What is the treatment for xiphoidalgia?

Treatment of Xiphoidalgia

The treatment of xiphoidalgia should begin with conservative management including local anesthetic-steroid injections, which are frequently curative for this musculoskeletal condition, with surgical xiphoidectomy reserved for refractory cases. 1

Diagnosis

• Diagnosis is confirmed when chest or abdominal discomfort is reproduced with light pressure on the xiphoid process 1
• Xiphoidalgia can mimic various thoracic and abdominal conditions, leading to delayed diagnosis and treatment 2
• Risk factors for secondary xiphoidalgia include GERD, gallbladder disease, angina pectoris, and coronary artery disease 2

Treatment Algorithm

First-Line Treatment: Conservative Management

• Local anesthetic-steroid injection:

  • Inject no more than 5-7 mL of solution directly into the xiphoid area 1
  • Results may be variable when multiple trigger points are present on the anterior chest wall 1
  • One study reported a patient achieving complete satisfaction with corticosteroid injections alone 3

• Oral medications:

  • NSAIDs may be helpful for pain management, similar to their use in other musculoskeletal pain conditions 4
  • For neuropathic components of pain, medications such as amitriptyline, gabapentin, or pregabalin could be considered 4

• Physical therapy:

  • Similar to other musculoskeletal conditions, stretching exercises and physical therapy modalities may provide relief 4
  • Heat application may help reduce local pain 4

Second-Line Treatment: Interventional Approaches

• Trigger point injections:

  • Can provide diagnostic confirmation and therapeutic benefit 5
  • In one case, a patient experienced 4 days of pain relief after a xiphoid trigger point injection 5

• Repeat injections:

  • Consider a series of injections over at least 6 months before considering surgical options 3

Third-Line Treatment: Surgical Management

• Xiphoidectomy:
  • Reserved for cases refractory to conservative management 3
  • Has shown excellent results with 100% of patients in one series reporting complete symptom resolution 3
  • Safe and effective procedure for severe, persistent cases 6
  • Particularly indicated in cases with anatomical abnormalities like "tack hammer deformity" or heterotopic ossification 1, 5

Special Considerations

• Xiphoidalgia can persist for years (up to 10 years in some reported cases) before appropriate treatment 3
• Comprehensive evaluation to rule out cardiac and other serious conditions is essential before attributing symptoms to xiphoidalgia 2
• Heterotopic ossification of the xiphoid process, which can occur after trauma (including CPR), may require surgical intervention 5

Treatment Efficacy

• In a case series of five patients with long-standing xiphoidalgia (up to 10 years), four ultimately underwent xiphoidectomy with 100% reporting complete symptom resolution 3
• One patient in this series achieved satisfactory results with conservative treatment alone 3
• Surgical treatment appears to be highly effective when conservative measures fail 3, 6

Common Pitfalls

• Misdiagnosis as cardiac, pulmonary, or gastrointestinal disease leading to unnecessary testing and delayed treatment 2
• Failure to perform a simple physical examination of the xiphoid process in patients with anterior chest or epigastric pain 1
• Inadequate duration of conservative treatment before considering surgical options 3
• Using excessive volume of injectate during local steroid injections (should not exceed 5-7 mL) 1