The Os Trigonum Syndrome

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Key Words: os trigonum syndrome (AND treatment NOT surgery, AND physical therapy), posterior ankle impingement, ballet dancers

Definition/Description

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Clinically Relevant Anatomy

The coccyx, also known as the tailbone, is a small triangular bone that is usually formed by fusion of the four rudimentary coccygeal vertebrae, although in some people there may be one less or one more. The coccygeal vertebra 1 (Co1) may remain separate from the fused group, but with increasing age Co1 often fuses with the sacrum and the remaining coccygeal vertebrae usually fuse to form a single bone. (level of evidence D)
The forward movement of coccyx is performed actively by the M. levator ani, and the backward movement of coccyx is passively caused by relaxation of these muscles. The coccyx also provides the site of attachment for the M. gluteus maximus as well as the M. levator ani, which is responsible for voluntary control of bladder and bowel. (level of evidence B) The coccyx does not participate with the other vertebrae in support of body weight when standing, however when sitting it may flex anteriorly, indicating that it’s receiving some weight. ( level of evidence D)i

The coccyx is part of the sacrococcygeal joint, an cartilaginous joint with an IV disc. Fibrocartilage and ligaments join the apex of the sacrum to the base of the coccyx. The anterior and posterior sacrococcygeal ligaments are long strands that reinforce the joint. (level of evidence D)
The coccyx is also attached with the margin of the anus by the anococcygeal ligament. (level of evidence D)iii

Epidemiology /Etiology

Fracture of the coccyx often arise after a fall on the buttock, most prevalent a fall of the stairs on the tailbone, or by an impact directly applied. (level of evidence D) An especially difficult childbirth occasionally injures the mother’s coccyx. ( level of evidence D)

Characteristics/Clinical Presentation

1. GENERAL SYMPTOMS
General symptoms that appear are (level of evidence D)iv,vii,viii :
• Pain that increases in severity when sitting or getting up from a chair
• Provoked pain over the tailbone
• Bruising or swelling in the tailbone area
• Bowel movements and straining are often painful
• There are no neurological signs

An important number of people suffer from long lasting pains over the coccyx following trauma (with or without fracture of the coccyx), better known as cocydynia.(level of evidence D)

2. CLINICAL PRESENTATION IN PATIENTS WITH SPINAL CORD INJURY
Patients with SCI, suffering from painful symptoms in the low back, gluteal, hip and thigh region, have coccyx fracture with a frequency of 34,6%. Patients who had coccyx fracture have higher pain scores when compared with those who don’t have any fracture, however the difference is only statistical significant regarding Sensory Pain Index (SPI) and total McGill scores.( level of evidence C)

Diagnostic Procedures

1. MEDICAL DIAGNOSIS
A plain radiography or MRI is necessary to confirm the diagnose of a coccyx fracture. (level of evidence D)

2. CLINICAL DIAGNOSIS
The diagnose is made after rectal examination. (level of evidence D)iv By passing the finger up the rectum and then pressing the bone backwards and forward, the unnatural degree of motion will then be felt. Related to the age and sex of the patient must be remembered that in the female this bone naturally possesses more motion than in the male, and that in youth a degree of motion, that does not exist at a later period of life, is present, allowing the ossification being less complete. However the free motion of the bone is taken as a symptom. (level of evidence D)

Outcome Measures

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Examination

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Medical Management

1. COCCYGEOPLASTY
By applying the novel techniques that are used in vertebroplasty and sacroplasty, coccygeoplasty is introduced as a new percutaneous treatment modality for fractures of the coccyx. This procedure can be helpful for patients with refractory pain resulting from a fracture of the coccyx and can be performed quickly and safely with high-resolution c-arm fluoroscopy. The coccygeal fracture treated with an injection of polymethylmethacrylate cement can provide early symptom relief. Although the promising results, an experience with a larger patient population is warranted. ( level of evidence C)

2. COCCYGECTOMY
Literature reports suggest that coccygectomy, partial or total removal of the coccyx, has been beneficial with success rates as high as 60-91%. However, coccygectomy is a more invasive procedure, with a common complication rate as high as 22%, and is usually associated with perineal contamination of the wound. Other complications could include persistent bleeding from the hemorrhoidal venous complex of the rectum. (level of evidence C)ix

Physical Therapy Management

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Key Research

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Resources

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Clinical Bottom Line

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Recent Related Research (from Pubmed)

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References

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MOORE K.L., DALLEY A.F., AGUR A.M.R., Clinically oriented anatomy: chapter 3: Pelvis and perineum, Wolters Kluwer health, sixth edition, 2010, pag. 451-452, level of evidence D
YU-TSAI T., LI-WEN T., CHENG-HSIU L., SHIH-WEI C., The influence of human coccyx in body weight shifting, medicine and science in sport and exercise, 2011, Volume 43, Number 5, pag. 494-496, level of evidence B
MOORE K.L., DALLEY A.F., AGUR A.M.R., Clinically oriented anatomy: chapter 3: Pelvis and perineum, Wolters Kluwer health, sixth edition, 2010, pag. 332, level of evidence D
HAARMAN H.J.Th.M., Klinische traumatologie, Elsevier gezondheidszorg, 2006, pag. 117, level of evidence D
MOORE K.L., DALLEY A.F., AGUR A.M.R., Clinically oriented anatomy: chapter 3: Pelvis and perineum, Wolters Kluwer health, sixth edition, 2010, pag. 461, level of evidence D
TEKIN L. et al., Coccyx fracture in patients with spinal cord injury, European journal of physical and rehabilitation medicine, March 2010, Volume 46, Number 1, pag. 43-46, level of evidence C
RAISSAKI M.T.,Fracture dislocation of the sacro-coccygeal joint: MRI evaluation, Pediatric radiology, March 1999, pag. 642-643, level of evidence D
LONSDALE E.F., A practical treatise on fractures, Walton and Mitchell printers, 1838, pag. 269-270, level of evidence D
MIYAMOTO K. et al., Exposure to pulsed low intensity ultrasound stimulates extracellular matrix metabolism of bovine intervertebral dosc cells cultured in alginate beads, Spine, November 2005, level of evidence B
EBNEZAR J., Essentials of orthopaedics for physiotherapist, Jaypee, 2003, pag. 174, level of evidence D
DEAN L.M. et al., Coccygeoplasty : treatment for fractures of the coccyx, J. Vasc. Interv. Radiol, 2006, pag. 909-912, level of evidence C
COOPER G., HERRERA J.E., Manual of musculoskeletal medicine, Wolters kluwer, Lippincott Williams & Wilkins, 2008, pag. 144, level of evidence D