What causes pain in the xiphoid process area?

Xiphoid Process Pain: Causes and Management

Primary Causes

Xiphoid process pain (xiphodynia) is most commonly caused by direct trauma, repetitive microtrauma, or inflammation of the xiphisternal joint and surrounding structures. 1 The condition can also develop secondary to gastroesophageal reflux disease (GERD), gallbladder disease, angina pectoris, and coronary artery disease. 1

Specific Etiologies to Consider:

• Occupational trauma: Chronic repeated microtrauma from sustained pressure or friction on the anterior chest wall, particularly in workers who place objects against their sternum (e.g., carpenters pushing wood into cutting machines) 2
• Post-surgical complications: Elongation or fracture of the xiphoid process following median sternotomy, which can occur through distraction tissue neogenesis when the fractured xiphoid is pulled inferiorly by rectus abdominis muscles 3
• Inflammatory conditions: Xiphisternal joint irritation causing pain that radiates to chest, abdomen, throat, and arms 1
• Pericardial pathology: In trauma settings, blunt injury to the area bordered by the clavicular line, bilateral nipple lines, and costal margins may indicate pericardial tamponade 4

Diagnostic Approach

The hallmark diagnostic finding is complete or near-complete reproduction of the patient's pain with light palpation directly over the xiphoid process. 5, 6 This distinguishes xiphodynia from cardiac, gastrointestinal, or other thoracic pathology.

Critical Examination Findings:

• Tender, hard, possibly palpable mass in the epigastric region 5
• Pain described as stinging or pressing, typically retrosternal or left-sided 5
• Immobile swelling with minimal protrusion under the skin 2

Imaging Strategy:

• Plain radiographs first: Initial imaging to identify bone involvement, anatomical variations, or fractures of the xiphoid process 5, 7
• Ultrasound for soft tissue evaluation: High sensitivity (94.1%) and specificity (99.7%) for evaluating palpable masses or soft tissue involvement 7, 8
• Consider esophageal evaluation: Esophageal disorders can cause referred pain to the xiphoid area 7

Important caveat: Cardiac causes must be ruled out first in patients with chest pain and cardiac risk factors before attributing symptoms to xiphodynia. 5

Treatment Algorithm

First-Line Conservative Management:

Prescribe NSAIDs for 1-2 weeks as initial pharmacological therapy. 5 This addresses the inflammatory component of xiphodynia.

• Alternative if NSAIDs contraindicated: Acetaminophen 5
• Adjunctive non-pharmacological measures: Ice packs or heat application to the affected area 5
• Occupational modification: Avoid sustained pressure or friction on the anterior chest wall and sternum 2

Second-Line Treatment for Refractory Cases:

Local anesthetic-steroid injection is reserved for symptoms persisting despite NSAID therapy. 5, 6

• Injection technique: Use no more than 5-7 mL of anesthetic-steroid combination solution 6
• Expected outcome: Local injection is frequently curative 6
• Limitation: Results are variable when multiple trigger points exist on the anterior chest wall 6

Additional Options:

• Low-dose colchicine: Add if symptoms persist despite NSAID therapy 5
• Topical lidocaine patches: For localized pain relief with minimal systemic effects 5

Surgical Intervention:

Xiphoidectomy should be considered for severe, refractory cases unresponsive to conservative management and injections. 1, 9

• Surgical outcomes: 94% of patients experience improvement, with 63% becoming completely pain-free at mean 34-month follow-up 9
• Safety profile: No surgery-related complications reported in case series 9
• Specific indication: Tack hammer deformity of the xiphoid has been successfully treated with surgical excision 6
• Post-surgical consideration: In cases of fractured or amputated xiphoid after median sternotomy, complete resection should be performed to prevent neogenesis and elongation 3

Clinical Pitfalls to Avoid

• Delayed diagnosis: Anterior chest pain commonly misleads physicians toward cardiac workup, prolonging time to appropriate treatment 1
• Incomplete injection: Using inadequate volume or technique reduces efficacy of local anesthetic-steroid injection 6
• Missed occupational history: Failure to identify repetitive microtrauma as the underlying cause prevents effective prevention strategies 2
• Incomplete xiphoid resection: Leaving fractured xiphoid fragments after sternotomy can lead to distraction neogenesis and recurrent symptoms 3