Imaging for Xiphoid Process Pain
Plain radiographs should be the initial imaging study for patients presenting with xiphoid process pain, followed by ultrasound if further evaluation is needed. 1, 2
Initial Imaging Approach
- Plain radiographs (chest/sternum) are recommended as the first-line imaging modality to identify bone involvement or abnormalities of the xiphoid process 1, 2
- Radiographs help visualize anatomical variations, fractures, elongation, or other structural abnormalities of the xiphoid process 1, 3
- Radiographs can detect changes in the xiphoid process length or angulation, which may contribute to pain (normal xiphosternal angle is approximately 172° ± 15°) 4
Secondary Imaging
- Ultrasound should be used as the next imaging step after radiographs, with high sensitivity (94.1%) and specificity (99.7%) for evaluating soft tissue involvement around the xiphoid process 1, 2
- Ultrasound can help differentiate between xiphoid process abnormalities and surrounding soft tissue pathology 1
- Ultrasound is particularly useful for evaluating superficial soft tissue masses and can serve as an effective triage tool 1
Advanced Imaging Considerations
- CT imaging may be considered if radiographs and ultrasound are inconclusive or if more detailed evaluation of bone and surrounding structures is needed 3, 5
- CT can provide detailed visualization of the xiphoid process anatomy, including precise measurements of the xiphosternal angle and detection of abnormal elongation 4, 5
- MRI without IV contrast may be appropriate if soft tissue pathology is suspected and ultrasound is non-diagnostic 6
Clinical Pearls and Pitfalls
- Xiphoid process pain (xiphodynia) can mimic cardiac, pulmonary, or gastrointestinal conditions, leading to unnecessary extensive workups 7, 8
- The xiphoid process serves as an important anatomical landmark during ultrasound examination but should not be confused with pathology 1
- Occupational history is important as chronic repeated microtrauma to the sternum can contribute to xiphoid syndrome 8
- Xiphoid process abnormalities that may cause pain include prominence, elongation, or abnormal angulation 3, 4, 5
Special Considerations
- In patients with history of cardiac surgery via median sternotomy, radiographs can identify potential post-surgical complications such as abnormal elongation of the xiphoid process 3
- For patients with persistent symptoms despite normal initial imaging, further evaluation with CT may be warranted to assess for subtle abnormalities in the xiphosternal angle 4, 5