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Hello, I’m Dr. Sangchul Hwang, an autonomic nervous system researcher and therapist.
Patients come to the clinic with different diagnoses such as interstitial cystitis, pelvic floor dysfunction, anal sphincter syndrome, pudendal neuralgia, urethral syndrome, PGAD, ADHD, and autism spectrum. However, after seeing them in the clinic for a long time, there is a common thread that I see over and over again. They’re always tense in the pelvis, they have trouble sitting for long periods of time, and they have stiffness around the sacrum and tailbone. So I don’t just look at the symptomatic area, I look at the whole pelvis, including the sacrum and tailbone, as a system.
The meaning of the name Coccyx
The English name for the tailbone is Coccyx. The word comes from ancient Greek and means cuckoo. It got its name because when anatomists looked at the human body from the side, the way the tailbone bent forward looked like a cuckoo’s beak. It looks like just a small bone attached to the end of the spine, but it’s actually a very important structure that’s closely connected to pelvic function.
Why the Sacrum is Called the Sacred Bone
Just above the tailbone is the sacrum. The sacrum is a large, triangular-shaped bone that sits in the center of the pelvis and is responsible for transferring the weight of the upper body to the pelvis and legs. The name Sacrum comes from Latin and means sacred bone or holy bone. In ancient times, this area was thought to be deeply connected to reproduction, life, and lower body function, giving it special significance. The spinal cord runs through the cervical, thoracic, and lumbar vertebrae to the sacrum and tailbone, which together complete the last part of the spine and pelvis.
The sacrum and tailbone are one system
I don’t look at the sacrum and tailbone separately: the weight of the upper body travels down the spine and is transferred through the sacrum to the pelvis and legs, while the tailbone supports the back of the pelvic floor. Around the sacrum and tailbone are attached the pelvic floor muscles and various ligaments, as well as nerves associated with the bladder, rectum, anus, perineum, and genitals. Therefore, any tension or compression in these areas can lead to a variety of pelvic symptoms beyond simple tailbone pain.
Why the pelvic floor and tailbone are important
The pelvic floor muscles are a very important group of muscles that support the bladder, rectum, and genitals. Because these muscles are directly connected to the sacrum and tailbone, any tension or strain in the tissues around the tailbone can affect the function of the pelvic floor muscles. In fact, increased pelvic floor tension can cause nerves around the bladder and urethra to become sensitive and muscles around the anus to become overly tense, resulting in symptoms such as perineal pain, urinary discomfort, urge urinary retention, anal tightness, pelvic pain, and abnormal sensations around the genitals.
Commonalities Found in Patients with Interstitial Cystitis and Pelvic Floor Dysfunction
In my practice, I often see patients with interstitial cystitis or pelvic floor dysfunction who have difficulty sitting for long periods of time. I also often find that the pelvic floor muscles are overly tense or the tissues around the sacrum and tailbone are very stiff. Some patients report pain or pressure when urinating, even though a bladder examination reveals no abnormalities, and in these cases it is often necessary to evaluate the function of the entire pelvis, rather than just the bladder, to find the cause.
Anal sphincter syndrome and pudendal neuralgia are viewed from the same perspective.
Patients with diastasis recti complain of pain and pressure deep in the anus, and patients with pudendal neuralgia experience perineal pain, burning, or pins and needles. However, many of these patients may have persistent pelvic floor muscle contractures or repetitive irritation of the tissues around the sacrum and tailbone. Therefore, my approach is to evaluate and treat the entire pelvic structure, not just the nerve or muscle that is causing the symptoms.
Causes of persistent strain on the tailbone
There are many different causes of strain on the sacrum and tailbone. Some of the more common ones include those who have had severe hip injuries in the past, women who have given birth, those who have had pelvic surgery, and those who have a habit of sitting in hard chairs for long periods of time. Also, leaning to one side or sitting with your weight on your tailbone can cause constant pressure. The habit of unconsciously tensing the pelvic floor muscles constantly is also a significant contributor to increased tension in the muscles and ligaments around the sacrum and tailbone.
Autonomic Nervous System Abnormalities Common in People with ADHD and Autism
Recent studies have repeatedly reported autonomic nervous system dysfunction in individuals with ADHD and autism spectrum disorders. These include decreased heart rate variability (HRV), heart rate variability, skin conductance abnormalities, and altered pupillary responses. In ADHD patients, autonomic nervous system dysregulation is particularly prevalent in the regulation of arousal and maintenance of focus. Decreased heart rate variability and increased sympathetic nerve activity have also been reported in individuals on the autism spectrum, and these autonomic imbalances may also be associated with sensory hypersensitivity, increased stress response, and sleep problems.
The Link Between ADHD and Pelvic Alignment
Interestingly, some studies report that when analyzing the gait of children with ADHD, an increased pelvic anterior tilt was observed and that this angle was significantly associated with the severity of ADHD symptoms. Of course, we can’t attribute ADHD to pelvic problems alone, but I think it’s an important clue that brain function, autonomic nervous system, posture, pelvic alignment, and urination and defecation are connected, not separate.
Characteristics of the tailbone as seen in the clinic
In my practice, I see patients with a tailbone that is tilted to one side more than normal, and others with a tailbone that protrudes excessively long. In some cases, it protrudes posteriorly, causing direct compression when sitting, and in other cases, it curves excessively inward, causing repetitive irritation. Not all of these morphologies are painful, of course, but I think they can be important clues in patients with pelvic floor issues or autonomic nervous system overactivity because they are structures that can accumulate repetitive compression and irritation.
So I treat the tailbone
The reason I treat the tailbone is not just because of tailbone pain, but because the sacrum and tailbone are the central axis where the pelvic floor muscles, ligaments, nerves, and autonomic nervous system meet, and it’s a critical link that explains the commonalities I see over and over again in patients with different diagnoses, such as interstitial cystitis, levator ani syndrome, pudendal neuralgia, urethral syndrome, PGAD, ADHD, and autism spectrum. I don’t just treat the name of the condition, I look at the pelvis and spine, the autonomic nervous system, urinary and bowel function, and even the tailbone as one connected system, which is why I treat the tailbone today.
