What are the causes of xiphoid process pain?

Causes of Xiphoid Process Pain

The most common causes of xiphoid process pain include xiphodynia (a musculoskeletal condition affecting the xiphoid process), trauma, heterotopic ossification, and referred pain from gastrointestinal or cardiac conditions. 1

Primary Causes

• Xiphodynia/Xiphoidalgia - A musculoskeletal disorder characterized by pain radiating from an irritated xiphoid process that can travel to the chest, abdomen, throat, and arms 1
• Trauma - Direct injury to the xiphoid process, including fractures from chest compressions during CPR or other trauma 2
• Heterotopic ossification - Abnormal bone formation in the xiphoid process following trauma, such as after chest compressions 2
• Xiphoid process elongation - Abnormal lengthening of the xiphoid process, which can occur postoperatively after cardiac surgery 3

Secondary/Referred Causes

• Gastrointestinal disorders - GERD and other digestive conditions can present with pain in the xiphoid region 1
• Cardiac conditions - Angina pectoris and coronary artery disease may refer pain to the xiphoid area 1
• Gallbladder disease - Can present with pain that radiates to or is felt in the xiphoid region 1
• Esophageal disorders - Various esophageal conditions can cause pain perceived in the xiphoid area 4

Mechanical/Activity-Related Causes

• Repetitive pressure - Activities that cause repeated compression of the xiphoid process against a hard surface (e.g., surfing) 5
• Postoperative complications - Following median sternotomy, the xiphoid process may fracture, separate from the sternum, and become elongated due to traction from the rectus abdominis muscles 3

Diagnostic Approach

• The diagnosis of xiphoid process pain is primarily clinical, with reproduction of the patient's pain upon light palpation of the xiphoid process being highly suggestive 6
• Plain radiographs are recommended as the first imaging step to identify bone involvement or abnormalities of the xiphoid process 7
• Ultrasound can be used as a follow-up imaging modality with high sensitivity (94.1%) and specificity (99.7%) for evaluating soft tissue involvement 7
• CT imaging may be necessary to evaluate for xiphoid process elongation or heterotopic ossification 2

Management Options

• Conservative treatment - First-line approach for mild cases 1

  • Physical therapy
  • Anti-inflammatory medications
  • Activity modification

• Injection therapy - For moderate cases 6

  • Local anesthetic-steroid combination injections at the xiphoid trigger points
  • No more than 5-7 mL of solution should be injected
  • Can be curative in many cases

• Surgical intervention - For severe or refractory cases 5

  • Xiphoidectomy (surgical removal of the xiphoid process)
  • Particularly effective for cases involving abnormal xiphoid morphology or heterotopic ossification

Clinical Pearls and Pitfalls

• Xiphoid process pain is often misdiagnosed as cardiac or gastrointestinal in origin, leading to unnecessary testing and delayed treatment 1
• The diagnosis should be considered when a patient's chest or abdominal discomfort is reproduced with light pressure on the xiphoid process 6
• In patients who have undergone median sternotomy, a fractured or separated xiphoid process should be considered for resection to prevent elongation and subsequent pain 3
• Patients with persistent epigastric pain of unclear etiology should have their xiphoid process examined as a potential source 2