What Causes a Crooked Xiphoid Process
A crooked xiphoid process is most commonly caused by normal anatomical variation present from birth, though it can also result from trauma (including surgical trauma), significant weight gain causing anterior displacement, or post-surgical distraction tissue neogenesis following median sternotomy. 1, 2
Primary Causes
Congenital Anatomical Variation
- The xiphoid process exhibits extensive natural variation in shape and orientation, including curved, deflected, bifid, trifid, broad, or thin configurations 1
- These variations are normal anatomical findings that can be mistaken for pathology or acquired deformities 1
- The xiphoid process is commonly misrepresented in textbooks as straight and fully ossified, but anatomical variations are actually quite common 1
Traumatic Causes
- Blunt or penetrating chest trauma can cause fracture or displacement of the xiphoid process 3
- Unaccustomed heavy lifting, repeated trauma to the area, and vigorous exercise can contribute to xiphoid displacement 2
- Surgical trauma during median sternotomy can fracture or separate the xiphoid from the sternum 4
Weight-Related Displacement
- Significant weight gain is a recognized cause of anterior displacement of the xiphoid process 2
- The mechanism involves increased anterior abdominal wall tension pulling on the xiphoid attachments 2
Post-Surgical Distraction Neogenesis
- Following median sternotomy, a fractured xiphoid process can undergo abnormal elongation through distraction tissue neogenesis 4
- The separated xiphoid is pulled inferiorly by the rectus abdominis muscles, causing elongation and eventual reconnection with the sternum in an abnormal position 4
- This can result in dramatic changes, with documented cases showing elongation from 3 cm to 6 cm over two years 4
Clinical Pitfalls
A critical pitfall is mistaking normal anatomical variation for pathology or acquired deformity 1. The xiphoid process naturally exhibits significant morphological diversity, and what appears "crooked" may simply represent the patient's baseline anatomy.
Another common error is pursuing extensive cardiac or gastrointestinal workup when the xiphoid itself is the source of symptoms 5, 6. If the crooked xiphoid is causing pain (xiphodynia), the diagnosis is confirmed when light palpation directly over the xiphoid process completely or nearly completely reproduces the patient's symptoms 7, 5.
Diagnostic Approach
- Initial evaluation should include plain radiographs to assess bone anatomy, identify fractures, and document the xiphoid configuration 8, 7
- Ultrasound provides excellent soft tissue evaluation with 94.1% sensitivity and 99.7% specificity for assessing any associated masses or soft tissue involvement 8, 7
- Physical examination should assess for tenderness, palpable prominence, and complete symptom reproduction with direct palpation 7, 5
When Intervention Is Needed
If the crooked xiphoid is asymptomatic, no treatment is required as anatomical variation is benign 1. However, if causing pain:
- Start with NSAIDs for 1-2 weeks as first-line therapy 7
- Progress to local anesthetic-steroid injection if NSAIDs fail, which is frequently curative 7, 5
- Reserve surgical xiphoidectomy for severe, refractory cases with anterior displacement causing persistent symptoms 2
In post-sternotomy patients with fractured xiphoid, consider prophylactic resection to prevent distraction neogenesis 4