Coccydynia in primary care

Reply to the audit by Hourigan et al. of the Primary care awareness of coccydynia in Devon: I wonder why the authors did not give the general practitioners the option of choosing prolotherapy as a treatment for coccydynia. When the authors did their literature search, they must have noticed the 2008 paper by Khan et al. in which 37 patients with average visual analog scale (VAS) for pain of 8.5 were treated with 20% glucose (dextrose) and lignocaine. After the first treatment, the average pain VAS was reduced to 3.4 and 2.5 after the second injection. In eight patients who still had pain VAS of more than 4 after the second injection, a third injection was given 4 weeks later. Minimal or no improvement was noted in seven patients; the remaining 30 patients had good pain relief. The authors concluded that dextrose prolotherapy is an effective treatment option in patients with chronic, recalcitrant coccygodynia and should be used before undergoing coccygectomy. They suggest that randomized studies are needed to compare prolotherapy with local steroid injections. However, since there are no long-term (or short-term) side effects of glucose injections comparable to the skin atrophy and delayed long-term healing with steroid injections, it seems more logical to use the least harmful treatment first. In my practice I have not found it necessary to use radiological imaging. Localizing the strained ligaments by palpation is perfectly adequate, as strained enthuses are tender as well as painful. Treating all the painful points around the coccyx, including the tip, the sacrococcygeal joint and often also the sides, where some fibres of the sacrotuberous ligaments insert, with 20% glucose and 0.1% lignocaine, results in complete or adequate relief of pain within four treatments.