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Brian Weber PT, DPT, FFMT, FAFS, NG360 GPS, FAAOMPT

Gregory S. Johnson PT, FFFMT, FAAOMPT

Coccygeal Internal Mobilization: Clinical Reasoning and Treatment for Diagnoses

Beyond the Pelvic Floor

My wife, Julie, for all her support Michelle Nesin: expertise on internal mobilization and editing Brent Yamashita: presentation development and editing Ryan Johnson presentation development and editing Gregg and Vicky Johnson: Developers of FMT AAOMPT for the opportunity to present this material

Thank You

History Associated Diagnosis/Dysfunctions Anatomy/Biomechanics Why the Coccyx Treatment◦ Precautions◦ Patient Education◦ Set Up ◦ Treatment procedure

Outline

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The first record of internal work on the coccyx was in 1859 by J. Y. Simpson M.D.

◦ For treatment he separated the coccyx from all the surrounding muscles, tendons, and ligaments, which was done subcutaneously, with a tenotomy knife

In 1937 Thiele described internal coccyx mobilization extending up to the piriformis in JAMA

A randomized single-blinded study in 2005 by Maigne evaluated intrarectal manipulation to treat coccydynia

◦ Good results were twice as frequent (borderline significant) in the treatment group compared to the control

History

Coccydynia Sacroiliac Pain Lumbar pain Pain with sitting Sciatica Neurotension◦ Flexion slump

(Maitland)◦ Extension slump

(Johnson) Trigger points not

accessible externally Coccyx◦ Not treatable

externally Sexual Dysfunctions Headaches

Visceral dysfunction (slow transit times)

Pelvic floor dysfunction Bowel or Bladder Dysfunction Dural Tension (Cervical retraction

test, Johnson) Shin splints Chronic hamstring strains,

especially Bilateral Chronic plantar fasciitis Upper Extremity Nerve Tension Decreased Cervical Rotation Decreased Shoulder elevation Decreased Trunk Rotation Decreased Hip Rotator Strength Decreased Trunk Forward Flexion Scoliosis Patellofemoral Pain Syndrome

(PFPS)

Associated Diagnosis/Dysfunctions

Consists of three to five coccygeal vertebrae (Woon 2013)◦ 3 (13%)◦ 4 segments (76%) ◦ 5 segments (11%)

Overall mean length◦ Women: 3.7 ± 0.7 cm ◦ Men and 4.2 ± 0.8 cm

The first coccygeal ◦ Largest segment ◦ Articulates with the

sacrum via a symphysialor synovial joint (Saluja, 1988)

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http://www.gustrength.com/anatomy:bones‐of‐the‐adult‐skeleton

Intercoccygeal JointsA. Fused jointsB. Intact Disks (similar to Lumbar Spine)C. Synovial JointsD. Symphysial joint

Balain B, et al. (2006);Maigne JY, et al. (1994)

A radiographic classification of the Coccyx: Potacchini et al

◦ Type I :(~70%) : the coccyx is curved slightly forward, apex pointing caudally

◦ Type II : (~15%) : the coccyx is curved more markedly anteriorly, apex pointing straight forward

◦ Type III : (~5%) : the coccyx is sharply angulated forward between the first and second or the second and third segments

◦ Type IV : (~10%) : the coccyx is subluxedanteriorly at the level of the sacrococcygeal joint or at the level of the first or second segment

◦ Type V: A coccyx with a retroverted tip (Woon et al. 2013)

Coccyx Angulations

• Flexed• Extended• Rotated• Side Bent• Anterior/Posterior Shear• Lateral Shear• Compressed

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Coccyx mobility in sitting: flexion (Maigne,1994)◦ Coccyx flexion: between 5 and 22 degrees

◦ During straining/ bowel movement, coccyx

extension: between 5 and 15 degrees

Postacchini: 120 asymptomatic subjects◦ Sacrococcygeal joint was mobile in 53 (63%)

◦ First intercoccygeal joint was mobile in 75 (90%)

◦ Second intercoccygeal joint was mobile in 47 (57%)

◦ Only 7% had completely fused coccygeal segments

Coccyx Mobility

Woon and Maigne:101 Patients with Coccydynia

Sacrococcygeal joint: 27% Fused

Intercoccygeal joint◦ C1/2 (first) 17% Fused

◦ C2/3 (second) 47% Fused

◦ C3/4 (third) 78% Fused

Tip of the coccyx demonstrate minimal side bend (mean of 6 degrees)◦ (Woon 2013)

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Nervous System◦ Dural attachment

Ligaments◦ 7 attach to the coccyx

Fascia

Muscles◦ 6 attach directly to the coccyx

http://www.backandneck.ca/tail-bone-injuries/

Rufus Weaver, anatomist, 1892

Positional Mal-alignments and motion fixations of

the coccyx from trauma places sustained tension

through the Filum Terminale and Dura, simulating

Tethered Cord Syndrome in the general population

(Wardlaw)

Proposal

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http://childrenshospital.org/az/Site1705/Images/Final_TetheredCord_lrg.gif

Signs and Symptoms

◦ Intermittent pain in the back of one or both legs and in the lower back

◦ Pain in a radicular distribution, elicited by a straight leg raise

◦ Increased abnormal sensations in the feet (numbness, tingling, burning)

◦ Sensory loss in a root distribution

◦ Muscle stiffness, weakness, or atrophy

◦ Progressive scoliosis

◦ Abnormal lower extremity reflexes

◦ Bladder problems

Sometimes erroneously referred to as the coccygeal ligament

Anchor for the spinal cord

Distally, fuses with the periosteum of the dorsal aspect of the coccyx or sacrum (Tubbs, 2005)

Consists largely of fibrous tissue containing smooth muscle, blood vessels, and peripheral nerves (Tubbs, 2005)

Filum Terminale

http://www.ktif.info/coccyx_illustrations.asp

Spinal Cord◦ Lengthen approximately 30% from spinal

extension to spinal flexion (Troup 1986)

Filum Terminale◦ Stretches to allow cranial movement of the spinal

cord with flexion

◦ Pulls the spinal cord to normal position when returning from a flexion

◦ Decreased mobility leads to increased stretch to the spinal cord instead of the filum

Spinal Motion

http://www.ktif.info/coccyx_illustrations.asp

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A connective tissue link between the rectus capitis posterior minor muscle (RCPMi) and the cervical dura mater (Hack 1995)

◦ High density of muscle spindle (Peck 1984)

Action◦ Active when the head is translated forward at the

AO joint (McPartland and Brodeur 1997)

◦ May prevent in-folding of the dura mater during cervical extension (Hack et al.1995)

Testing◦ Cervical Retraction Test (Johnson)

Myodural Bridge

http://www.massagetoday.com/archives/2005/07/06.html

Gentle traction at occiput

Drop Legs to one side than otherPositive Test

Head will be drawn inferior withleg rotation

Increase tension on the dura by extending the knees

KAHKESHANI AND WARD 2012

Dural Connection

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http://www.ktif.info/_documents/patients_before_after.pdf

Kemper and Wooley (1998) ◦ 50 Patients with or without coccydynia◦ Treatment: Internal coccyx manipulation

Results◦ Average treatment Duration 3.1 visits for females

4.3 visits for males

◦ 7.38 inch improvement in lumbar flexion

◦ Visual analogue Pain Scale (0-10) Pre: (4.66/10)

Post (0.66/10)

Anterior Longitudinal

Sacroccygeal ligaments◦ Extension of the ALL◦ Insertion first and sometimes the

second coccygeal vertebrae◦ Thicker over the sacrococcygeal joint

Anococcygeal Extends between the coccyx and

the external anal sphincter

Ligaments

Superficial◦ Sacral hiatus to dorsal surface of the coccyx◦ Corresponds to the ligamentum flava

Deep◦ Continuation of the posterior longitudinal ligament◦ Originates on the posterior fifth sacral segment◦ Inserts on the dorsal surface of the coccyx

Lateral◦ Up to 3 separate ligaments ◦ ILA to first coccygeal transverse processes◦ Attachments to the sacrotuberous and

sacrospinous ligament

Posterior Sacrococcygeal Ligament

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Sacrospinous Ligaments Attachments

◦ Lateral margins of the sacrum and coccyx

◦ Entire length is covered by the coccygeus muscle

◦ Laxity allows for excessive posterior innominate rotation

◦ Increased tension can pull the innominate into anterior rotation

(Woodley 2005)

Attachments◦ Posterior portion of the iliac crest, the lower three sacral

vertebrae and the coccyx

Associated Ligaments◦ Dorsal sacroiliac ligaments

◦ Posterior sacrococcygeal ligament Direct attachment to the dura (Barral)

◦ Blends/fuses with the sacrospinous ligament

Nerves/Arteries◦ Cutaneous nerve and filaments of the coccygeal plexus

Sacrotuberous Ligaments

Anatomy Trains

Muscle attachments◦ Gluteus maximus Most direct connection

◦ Biceps femoris Hypothesized to stabilize the sacroiliac

joint via the sacrotuberous ligament

◦ Piriformis

◦ Obturator internus

◦ Semitendinosus/Semimembranosus

(Woodley 2005)

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Woon, 2012

http://www.tlcschool.com/the-enlightened-body-

blog/thoracolumbar-fascia-and-back-pain/ Anatomy Trains

1. Puborectalis

2. Pubococcygeus

3. Iliococcygeus

4. Coccygeus

5. Piriformis

6. Obturator Internus

Muscles

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U-shaped

Most medially levator ani muscle

Defecation

◦ Relaxation of the puborectalis

◦ Extension of the coccyx

Treatment indications

◦ Problems with defecation

◦ Pubic Symphysis Dysfunction

Puborectalis

Gluteus Minimus

Greater sciatic foramen

Obturator Internus Quadratus Femoris

Obturator Externus

Inferior gemellus

Obturator Internus

Superior gemellus

Piriformis

Lesser sciaticforamen

Muscles of the Hip and Pelvis

So why coccyx?◦ Nerve and Dural Tension

◦ Muscle length-tension relationship

◦ Ligament length-tension relationship

◦ Fascial Connections

Why Internal Mobilization?◦ Structures not assessable or treatable externally

◦ Nerve tension with strong pull to coccyx (especially flexion)

◦ Patient who has not been successfully with other treatments

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Theile 1937

Verify that this procedure is within the scope of your state’s practice act

This procedure requires explanation, permission, and tact

Be sure to give clear explanation of the procedure

Parents should always be present during examination and treatment of children

Avoid rectal examination during menstrual period

DO NOT force or pressure a reluctant patient

Bleeding Hemorrhoids

Patients who have been sexual abused

Be aware of patients with osteopenia and osteoporosis

Precautions

The most likely risk is irritation of the rectal lining◦ May cause mild, temporary bleeding

The more severe risk is that you tear the rectal lining

Increased pain or nerve symptoms

Autonomic Symptoms: Ganglion Pars◦ Instruct the patient on autonomic symptoms ◦ They need to inform you if symptoms occur

Change in temperature

Increased heart rate

Clamminess/feeling flush

Increased breathing rate

Increased sweating

Complications

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Request that the patient to empties their bladder prior to treatment

Verbal/nominal consent must be obtained from the patient

An informed-consent form for the patient to sign should be standard practice

Many clinicians choose to have an assistant in the room

◦ Assistance with neurotension

◦ Patient comfort and help them relax during the procedure

◦ To avoid/decrease likelihood of any possible liability issues

Patient Preparation

Side lying ◦ Bilateral hip flexion to 70-90 degrees

◦ Top leg flexed and bottom leg extended

◦ Patients placed with most involved side on top

Patient Position

Gloves and lubrication

◦ Make sure to use enough lubrication

Apply to glove and may also apply to rectal area

Warm up lubricate: improves patient comfort and relaxation

Finger Choice

◦ Use your index finger

◦ 3rd digit is the longest, but other fingers limit you depth of palpation

Sanitation

◦ Have a waste basket, tissues and hand sanitizer next to you

◦ Have tissues and waste basket for the patient to clean themselves

Set Up

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Patient comfort is First and Foremost

◦ If the patient feel uncomfortable at any time let them know they need to let you know

◦ Tell them that you will stop treatment and slowly remove your finger

Draping◦ Sheet should be placed on the table and another sheet to cover the patient

Set Up and Draping

Soft Tissue Mobilization◦ Boney contours◦ Muscle belly/trigger points

Functional Movement Patterns (FMP)

◦ Active patient movements

Breathing

Unilateral or bilateral hip rotation

Pelvic Tilts

Pelvic floor contractions

Hip Motion

Knee Motion

Treatment Techniques

Functional Mobilization (FM)◦ Resisted movements

Nerve Mobilization (Direct treatment to the nerve)

◦ Lateral mobility

◦ Longitudinal mobility

Nerve place on tension with Lower extremity motion

Block segment being pulled/shifted by the nerve tension

Treatment Techniques

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Prior to initiation

◦ Visual confirmation of the rectum is recommended

Gently spread the buttocks with your free hand

Finger facing posterior towards coccyx

There are 2 anal sphincters

◦ Voluntary external sphincter muscles

◦ Involuntary internal sphincter muscles

Initiation of Mobilization

If trigger points (TrPs) are present, insertion of the finger can be distressful even when done very carefully

Entering the rectum

◦ Have patient gently bear down

◦ As they relax enter deeper into the rectum

◦ May also have patient initiate posterior depression of the pelvis

DO NOT use force to enter deeper

Internal hemorrhoids can perpetuate TrPs

◦ Perform a 360 degree assessment and treatment

Initiation of Mobilization

Located inferior to tip of the coccyx at the level of the external anal sphincter

Restrictions will resist ability to move

to higher structures

Treatment ◦ 360 degree STM

Key structure ◦ Constipation

◦ Pubic symphysis dysfunctions

Puborectalis

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Rectal Cancer◦ Signs and Symptoms Diarrhea Constipation Not being able to completely empty the bowel Change in the size or shape of stools (narrower) Bloody stool (either bright red or very dark)

• The symptoms of rectal cancer are similar to other bowel diseases, like ulcerative colitis, Crohn's disease

• These diseases usually demonstrate periods of symptom remission

• If you feel a hard button like area over the tissues of the rectum refer the patient to their primary physician to rule out the presence of cancer

Red Flag

In 2012 Joguet et al looked at the anatomy of the digital rectal examination to improved teaching methods and consistency with palpation for medical students

These bone landmarks are less consistent for internal organ palpation

We will utilize the palpation guidelines as a general rule

◦ Remember

Coccyx length is variable

Coccyx angulations does vary

Index finger length is variable

Patient size and structure can influence palpation

Levels of Palpation

The first level (the tip of the index on the tip of the coccyx)

Assess tip of coccyx Flexion Extension Side bend

Pelvic Floor

Level One Palpation

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Assess Pelvic Active◦ Have your patient actively squeeze their rectum around your finger

Assess along the margin of the coccyx◦ Lateral◦ Inferior

Levator ani may feel like a firm sheet of muscle Soft tissue mobilization of these structures very helpful prior to positional

corrections of the coccyx

Treatment

STM

FMP

FM

Levator Ani

Coccyx Flexion Type III : (~5%) coccyx is sharply angulated forward

Only the rectal wall between finger and coccyx

Spring test to the coccyx to check mobility

Flexion may occur at any of the mobile joints

Treatment

Anterior to posterior mobilization

May apply traction

FMP and FM

If no motion is present proceed

to the next structure

Distal inter-phalangeal articulation placed on the tip of coccyx

Sacrococcygeal Joint

Anterior Longitudinal Ligament

Sacroccygeal ligaments

Anterior

Lateral

Level Two Palpation

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Palpation◦ Mainly at level 2

◦ Most of the muscle lies anterior to the sacrospinous ligament

◦ Gluteus maximus coccyx attachment similar to the cocccygeus

Treatment STM

FMP

FM

Sacroccygeal

◦ All cross sacrococcygeal joint

Treatment

◦ Lateral Mobility

◦ Longitudinal mobility

◦ STM

◦ FMP

◦ FM

Shears Anterior shears

◦ Sacrococcygeal

◦ Individual vertebrae of the Coccyx

Lateral shear

◦ Sacrococcygeal

◦ Individual vertebrae of the Coccyx

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Sacrococcygeal joint◦ Traction is applied with the internal hand and also the external hand

◦ Anterior to posterior mobilization◦ Dysfunction may be central (pure shear) or lateral (rotation)

Treatment

◦ FMP

◦ FM

If no motion is present proceed to the next structure

Level Three Palpation Proximal interphalangeal articulation placed on the tip

of the coccyx

◦ Sacrospinous Ligament

◦ Sacrotuberous ligament

◦ Obturator internus muscle

◦ Ischial spine

◦ Pudendal nerve

Attachment◦ Superior and lateral to sacrococcygeal joint

◦ Fibers run medial to lateral with slight inferior angulations to the ischial spine

◦ Majority covered by the fibers of the coccygeus muscle

Motion restrictions and tenderness if dysfunctional

Important to treat at ischial tuberosity◦ STM◦ FMP◦ FM

Sacrospinous Ligaments

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Palpation

◦ Posterior to the sacrospinous ligament

◦ Vertical Fibers

◦ Easiest to palpated superior and inferior to the sacrospinous ligament

◦ Often tender and demonstrate restricted mobility

Treatment

◦ STM

◦ FMP

◦ FM

Palpation

◦ Round and string-like

◦ Always keep same diameter with palpation

◦ Landmarks Cocccygeus muscle

Sacrospinous Ligament

Ischial tuberosity

Treatment

◦ STM Medial to lateral mobility

Longitudinal mobility

Pudendal Nerve

AA First Labs

Formed by folding of the obturator internus fascia

Follow the nerve anterior and inferior

Just superior to ischial tuberosity

Treatment

◦ STM

Medial to lateral mobility

Longitudinal mobility

http://web.uni-plovdiv.bg/stu1104541018/docs/res/skandalakis'%20surgical%20anatomy%20-%202004/Chapter%2028_%20Pelvis%20and%20Perineum.htm

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Oburator Internus

http://lucy.stanford.edu/img/img7.jpg

Palpation◦ Level 3

◦ Turn finger to face anterior lateral to anteriolateral wall of the lesser pelvis

◦ Inferior to the pubic bone

◦ Verify by resisting external rotation of the hip

Treatment STM

Critical to examine just caudal to the tip of the ischial spine

Most likely place for trigger points according to Travell and Simons

• Metacarpophalangeal articulation comes into contact

with the tip of the coccyx

• Piriformis

• Sacral plexus

Level Four Palpation

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Anterior to the coccygeus muscle Anterior aspect of the piriformis Round and string-like Always keep same diameter with palpation◦ STM Medial to lateral mobility Longitudinal mobility

Sacral Nerves

Palpation

◦ Cranial to the sacrospinous

◦ Usually can palpate inferior/medial edge of the muscle

◦ Verify palpation with resisted hip abduct

◦ If tender will often reproduce patient’s pain in a sciatic distribution

Treatment

◦ STM

◦ FMP

◦ FM

Piriformis

http://www.pudendal.com/

Review of Palpation

Travell and Simons

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Following mechanical treatment assess nerve tension

Nerve consist of 50- 90% connective tissue

Beware of being too aggressive

Clear out nerve restrictions distal prior to

performing nerve mobilization at the coccyx

Decreased likelihood of exacerbation

Very powerful treatment in decreasing

pain, improving function and preventing recidivism

Pressure placed on coccyx

Assistant brings hip into flexion until tension is perceived in the leg or coccyx

Block coccyx movement

◦ Flexion

◦ Anterior shear

Perform flossing

Assistant resists

hip extension

Nerve manipulation

Blocking for Nerve Tension

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The uterus is located immediately dorsal (and usually somewhat anterior/superior) to the urinary bladder

When assessing the ovaries and uterus if you feel masses and growths must make a referral to an OBGYN

Uterus

Treatment

◦ Level 2

◦ Turn finger to face anterior

If the uterus is retroverted you will feel a hard round mass which prevents your finger from moving forward

◦ When in a normal position the uterus give little resistance to digital pressure

◦ Treatment

◦ Assess mobility in all directions

Uterus

Inserted finger in a downwards angle as if pointing to the umbilicus

Pressing on the prostate gland should not hurt, although it may make you feel like you need to urinate

Consistency

◦ Rubbery and firm

◦ Smooth surface

◦ Palpable sulcus between right and left lobes

◦ There should not be any tenderness

◦ There should be no nodules

Prostate

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The prostate ("one who stands before", "protector“) Slightly larger than a walnut Tenderness◦ Prostatitis, a temporary inflammation, no surface changes

Prostate cancer can cause the surface of the prostate to become hard and bumpy

Refer to primary physician

Prostate

Females: anterior and inferior to the uterus and anterior to the vagina

Males: anterior and superior to the prostate

Internal treatment following unsuccessful external treatment

Much easier to palpate with an empty bladder

STM: Puborectalis prior to internal pubic symphysis treatment

Posterior Shears◦ Mobilize the posterior pubic symphysis

Pubic Symphysis

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Slowly remove your finger

Ask the patient to contract the pelvic floor◦ This prevents them from feeling like they are having a

bowel movement

Educate the patient on the possibility of bleeding and that a small amount is normal

Leave the room and have tissues and waste basket close to patient for clean up

Ending the Procedure

Levator Ani Muscles: Level 1/2: anterior and lateral to coccyx

Tip of the Coccyx: Level 1: posterior to rectum

Sacrococcygeal Joint Level 2: posterior to rectum

Sacrospinous and Sacrotuberous Ligaments: Level 3: lateral to rectum

Pudendal Nerve: Level 2/3: lateral to rectum

Obturator Internus: Level 2/3: anterior/lateral to rectum

Sacral nerve Root: Level 4: posterior of rectum, anterior to piriformis

Piriformis: Level 4: posterior of rectum and sacral nerves

Prostate or Uterus: Level 2 to 3: anterior to rectum

Pubic symphysis: Level: Most anterior to rectum

Review of Palpation

Case Study

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Questions

Anatomy Trains. Second Addition. Churchill Livingston. 2009. Dissection 5. Pelvis and Perineum. www.emory.edu/ANATOMY/AnatomyManual/pelvis.html FRANTISEK T, MIROSLAV T. SHORTENING OF THE PELVIC FLOOR MUSCLES INFLUENCEST HE POSITION

OF THE SACRAL BONE and CAUSES ASYMETRICAL MOVEMENT OF THE SACROILIAC JOINTS. The Journal of Orthopaedic Medicine 22(2)200O.

Fisher K. Ani Muscle Overactivity Management of Dyspareunia and Associated Levator. PHYS THER. 2007; 87:935-941.

Grieve, G. Modern Manual Therapy of the Vertebral Column. Churchill Livingstone. 1986. Hack GD, Hallgren RC. 2004. Chronic headache relief after section of suboccipital muscle dural connections: A

case report. Headache 44:84–89. Hack GD, Koritzer RT, Robinson WL, Hallgren RC, Greenman PE. 1995. Anatomic relation between the rectus

capitis posterior minor muscle and the dura mater. Spine 20:2484–2486. Heller M. The Coccyx Revisited: External and Internal Exam Correction Procedures. 2011. Coccyx.org http://www.cancercenter.com/colorectal-cancer/symptoms/tab/rectal-cancer-symptoms/ Joguet E, Robert R, Labat J, Riant T, Gue´rineau M, Hamel O, Louppe J. Anatomical basis of digital

rectal examination. Surg Radiol Anat (2012) 34:73–79. Krishnan H. Anatomy of Rectum. Slideshare. May 21, 2011 Kahkeshani, K. Ward, P. Connection Between the Spinal Dura Mater and Suboccipital Musculature: Evidence for

the Myodural Bridge and a Route for Its Dissection—A Review. Clinical Anatomy 25:415–422 (2012). Maigne J, Chatellier G. Comparison of Three Manual Coccydynia Treatments: A Pilot Study. SPINE

Volume 26, Number 20, pp E479–E484. Marios Loukas, Robert G Louis Jr, Barry Hallner, Ankmalika A Gupta and Dorothy White. (2006)

"Anatomical and surgical considerations of the sacrotuberous ligament and its relevance in pudendal nerve entrapment syndrome" Surg Radiol Anat 28(2): 163-169

McPartland JM, Brodeur RR, Hallgren RC. 1997. Chronic neck pain,standing balance, and suboccipital muscle atrophy—A pilot study. J Manipulative Physiol Ther 20:24–29.

References

PPeck D, Buxton DF, Nitz A. 1984. A comparison of spindle concentrations in large and small muscles acting in parallel combinations. J Morphol 180:243–252.

Pecina, M, Krmpotic J, Markiewitz A. Tunnel Syndromes. 3rd Edition. CRC Press 2010. Prendergast S, Weiss J. PT and PNE. Advance for Physical Therapists. 2004. Vol. 15, Issue 21. Page 47. Postacchini F, Massobrio M. Radiologic Study of Asymptomatic Patients Idiopathic coccygodynia.

Analysis of fifty-one operative cases and a radiographic study of the normal coccyx. The Journal of bone and joint surgery. American volume. 1983 Oct; 65(8): 1116-1124

SIMPSON J.Y. On coccyodynia, and the diseases and deformities of the coccyx: CLINICAL LECTURES ON THE DISEASES OF WOMEN, LECTURE 17. Medical Times and Gazette. 1859, 40: 1-7.

THIELE, G. .COCCYGODYNIA AND PAIN IN THE SUPERIOR GLUTEAL REGION. JAMA. 1937;109(16):1271-1275.

Travell J, Simons D. Myofascial Pain and Dysfunction: The Trigger Point Manual. The Lower Extremities. Williams and Wilkins 1992.

Visceral Manipulation. Barral JP. Eastland Press. 1989. Vleeming, A., R. Stoeckart, et al. (1989). "The sacrotuberous ligament: a conceptual approach to its dynamic role

in stabilizing the sacroiliac joint." Clinical Biomechanics 4(4): 200-203. Weiss J. Pelvic Floor Myofascial Trigger Points: Manual Therapy for Interstitial Cystisitis and the Urgency-

Frequency Syndrome. Vol. 166, 2226-2231. Dec 2001. Wikipedia, the free encyclopedia Wilensky T. The levator ani, coccygeus and piriformis muscles. Agents in the causation of coccygodynia, superior

gluteal pain and sciatic syndrome. American Journal of Surgery. 1943. 59: 44-9. Witmer, L. Navigating Anorectal Anatomy: Terms, Planes, Spaces, Structures. Department of Biomedical

Sciences. College of Osteopathic Medicine . Ohio University.

Woodley SJ, Kennedy E, Mercer SR. (2005). Anatomy in practice: the sacrotuberous ligament. New Zealand Journal ofPhysiotherapy 33(3) 91-94.

All pictures contained in this presentation are from the internet unless otherwise noted.

References continued

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INFORMED CONSENT FOR ASSESSMENT OF COCCYX/PELVIC FLOOR DYSFUNCTIONS I understand that it may be beneficial for my therapist to perform a coccyx assessment and muscle assessment of the pelvic floor, initially and periodically to assess joint mobility, muscle strength, length, range of motion and scar mobility. Palpation of these muscles is most direct and accessible if done via the rectum. Coccyx/Pelvic floor dysfunctions include low back pain, SI pain, nerve tension, pelvic pain syndromes, urinary incontinence, fecal incontinence, dyspareunia, or pain with intercourse, pain from an episiotomy or scarring, vulvodynia, vestibulitis, or other similar complications. Evaluation of my condition may include observation, joint mobilization, soft tissue mobilization and nerve mobilization. I understand that I have the option to have a chaperone during evaluation & treatment that may include internal procedures. I will_____ will not_____ bring a chaperone to subsequent visits. If I opt for a chaperone, internal assessment, if allowed, will be deferred until the next visit when the chaperone is present. I understand that the benefits of the rectal assessment will be explained to me. I understand that if I am uncomfortable with the assessment or treatment procedures AT ANY TIME, I will inform my therapist and the procedure will be discussed with me. A decision will be made to either continue internal assessment/treatment or suspend it. External treatments may still be utilized. The therapist will explain all these treatment procedures to me and I may choose to not participate with all or part of the treatment plan.

I understand that no guarantees have been or can be provided to me regarding success of therapy. I have read or had read to me the foregoing and any questions, which may have occurred to me, have been answered to my satisfaction. I understand the risks, benefits, and alternatives of the treatment. Based on the information I have received from the therapist, I voluntarily agree to standard assessment and muscular treatment techniques of the pelvic area.__________________________ _______Patient’s Signature Date__________________________ _______Physical Therapist’s Signature Date__________________________(if applicable) Patient’s Legal Representative/Guardian/Parent __________________________ Relationship to Patient

If you are pregnant, have an infection of any kind, have vaginal dryness, are less than six weeks postpartum, post surgery, have severe pelvic pain, sensitivity to KY jelly, vaginal creams or latex, please inform the therapist prior to the pelvic floor assessment.