Xiphoid Process Pain: Causes and Management
Xiphoid process pain (xiphodynia) is a musculoskeletal condition diagnosed by reproducible tenderness on palpation of the xiphoid process, and should be treated initially with NSAIDs for 1-2 weeks, with local anesthetic-steroid injection reserved for refractory cases. 1, 2, 3
Diagnostic Approach
Clinical Diagnosis
- The hallmark finding is tenderness to palpation directly over the xiphoid process that reproduces the patient's pain 1, 3
- Pain may radiate to the chest, abdomen, throat, or arms, mimicking cardiac or gastrointestinal pathology 2
- Patients often describe the pain as stinging (53%) or pressing (35.1%), typically retrosternal or left-sided 1
- On examination, a tender, hard mass may be palpable in the epigastric region 4, 5
Important Differential Considerations
- Rule out cardiac causes first in patients presenting with chest pain, particularly those with risk factors for coronary disease 6
- Pain that is reproducible with palpation, varies with respiration or body position, and is well-localized suggests a musculoskeletal rather than cardiac etiology 6
- Secondary xiphoidalgia can be associated with GERD, gallbladder disease, or coronary artery disease 2
Imaging Strategy
- Plain radiographs are the first imaging step to identify bone involvement or anatomical variations of the xiphoid process 7
- Ultrasound has high sensitivity (94.1%) and specificity (99.7%) for evaluating soft tissue masses if a mass is palpable 7
- MRI without contrast may be appropriate if soft tissue pathology is suspected and ultrasound is non-diagnostic 7
- CT is generally not necessary for initial evaluation but may reveal anatomical variations such as an enlarged xiphoid process 5
Treatment Algorithm
First-Line Management
- Prescribe NSAIDs for 1-2 weeks as initial pharmacological therapy 1
- Apply ice packs or heat to the affected area as adjunctive non-pharmacological treatment 1
- Advise avoidance of pressure or friction on the anterior chest wall, particularly in occupational settings involving repetitive chest trauma 4
- Use acetaminophen as an alternative if NSAIDs are contraindicated 1
Second-Line Management for Persistent Symptoms
- Add low-dose colchicine if symptoms persist despite NSAID therapy 1
- Consider topical analgesics such as lidocaine patches for localized pain relief with minimal systemic effects 1
Third-Line Management for Refractory Cases
- Local injection with anesthetic-steroid combination is frequently curative for refractory xiphodynia 3
- Use no more than 5-7 mL of solution for injection 3
- Results are variable when multiple trigger points are present on the anterior chest wall 3
Surgical Management
- Xiphoidectomy (surgical excision) is reserved for severe, refractory cases that fail conservative management and injections 2, 3
- Surgical excision has been successfully used for "tack hammer deformity" of the xiphoid 3
- In cases of fractured or amputated xiphoid process after median sternotomy, the xiphoid should be resected to avoid neogenesis and elongation 8
Common Pitfalls and Caveats
Diagnostic Pitfalls
- Xiphodynia is frequently misdiagnosed as cardiac disease, leading to prolonged duration of pain before appropriate treatment 2
- The anterior chest location commonly misleads physicians into pursuing cardiac workup rather than considering musculoskeletal causes 2
- Occupational history is critical—chronic repeated microtraumas from work activities (e.g., carpentry) can cause xiphoid syndrome 4
Treatment Considerations
- Reassess patients with persistent pain to rule out other potential causes 1
- Injection therapy results are less predictable when multiple trigger points are identified 3
- Postoperative elongation of the xiphoid process can occur after cardiac surgery due to distraction tissue neogenesis 8