Xiphoid Process Pain: Causes, Symptoms, & Treatments
What is Xiphoid Process Pain?
The xiphoid process area is located at the lower part of the sternum. Pain in this area is known as xiphoid process pain, xiphoid syndrome, xiphoidynia, or xiphoidalgia. Xiphoidalgia is characterized primarily by tenderness and dull pain in the xiphoid process area.
Xiphoid process pain is a subject of controversy. Some physicians claim that it is a rare disorder while others believe it is relatively common, albeit overlooked. While diagnosis is fairly straightforward, the condition is often misdiagnosed because its symptoms are similar to those of other diseases. The pain is due to a musculoskeletal disorder, but most of the symptoms of this condition mimic thoracic and abdominal diseases.
Referred pain, also called reflective pain, may also be present, which increases the likelihood of misdiagnosis. In cases of referred pain, the pain is felt at a location other than where the pain stimulus is actually located. In xiphoidalgia, the pain is sometimes referred to the shoulder area.
What is the Xiphoid Process?
This is a structure located at the lower border of the sternum. The sternum is the flat piece of bone in the middle of the chest where the ribs meet and are attached to. The xiphoid process is just a small spot but plays vital roles. It serves as a point of attachment to the various large muscles of the chest and the abdomen, the ligaments, and the rib cartilage.
The xiphoid process is also called the metasternum, xiphisternal bone, or the xiphosternum. It is a downward protrusion from the point where the lowermost rib and the sternum are connected. It is cartilaginous until the person reaches 40 years of age, after which it ossifies.
To locate the xiphoid bone, use your fingers to feel the lowermost rib over the side of your torso. Follow that rib towards the center of the chest, where it attaches to the sternum. At this point, locate for a small protruding bone below. That is the xiphoid process. It has a teardrop shape with a tiny hole in the middle.
What are the Symptoms?
The symptoms tend to be varied. The main symptom is pain in the lower section of the sternum. The pain felt is often described as dull and aching. The intensity varies, ranging from mild discomfort to severe pain.
Pain is typically made worse by turning and bending. Increased pressure over the area of the epigastrium (stomach region)after a large meal may also worsen the pain.
Applying pressure directly on the xiphoid process will cause the pain to radiate retrosternally or behind the sternum. The pain may also radiate towards the epigastrium. As mentioned, pain may also be referred, usually to the back and the shoulders. Referred pain symptom may get in the way of proper treatment because of the misdiagnosis it cases. It is still an enigma in the clinical setting though. Some patients suffer needlessly because of misdiagnosis and improper treatment.
The onset of pain is sudden. It may persist for weeks or months. Oftentimes, the pain will just go away without any intervention.
Other symptoms may or may not be present with the pain over the xiphoid process. Some people with this condition also experience the following symptoms:
- Pain in the epigastrium region
- Chest pain
- Discomfort in the chest area
- Pain radiating to the neck, shoulders, chest wall, arms and back
What are the Causes?
There are many possible causes of pain over the xiphoid area. The most common is direct injury to the xiphoid process. Note that xiphoid process is a musculoskeletal condition, and such an injury can be brought by various factors.
The most likely causes of xiphodynia are:
Trauma to the thoracic region
The xiphoid process can be easily fractured or dislocated through trauma. Trauma is injury acquired through external physical harm such as blunt trauma to the chest. Acceleration injury and lifting heavy weights especially if you are not used to doing so may also cause damage to the xiphoid process. It can also be caused by CPR or cardio-pulmonary resuscitation. CPR is usually administered in order to help restore flow of blood to the heart and the brain. It is meant to help the patient survive until help arrives. However, if you apply to much pressure on the chest area, or your hands are not in the correct position while you are performing chest compression, the xiphoid process could be damaged.
Other conditions and diseases
Certain conditions such as GERD or Gastro-esophageal reflux disease can cause damage to the esophagus, which is anatomically close to the xiphoid process. Because of their proximity, injury to the esophagus may result to pain in the also cause pain in the xiphoid process. GERD also triggers somato-visceral pain in the area due to symptoms like heartburn.
Observations also showed that an enlarged xiphoid process increases the risk for xiphodynia. The risk increases if the xiphisternal angle is less than 160-degrees. Xiphoid syndrome pain can also be made worse by aerobics and heavy meals.
Oftentimes, xiphodyniaoccurs alone, without any other medical conditions. However, there are instances when it does develop with serious medical conditions such as angina pectoris, pericarditis, myocardial infarction, and other cardiac diseases.
Medical practitioners are advised to rule out these conditions when xiphodynia is present. Appropriate treatments should be initiated immediately. If symptoms persist despite efforts to give treatments for cardiac, thoracic or abdominal disorders, consider treating it as xiphodynia.
Breif Observation of Xiphoid Process Pain
Conditions leading to the problem
Trauma to the chest region can cause injury, dislocation or fracture to the cartilaginous xiphoid process
Injury or dislocation may come from lifting objects are excessively heavy.
It may also come from having the wrong body mechanics when lifting, turning or bending.
Other potential causes of trauma are blunt trauma to the chest and acceleration injury.
Eating heavy meals may also worsen the symptoms.
Improper application of cardiopulmonary resuscitation may also cause fractures in the xiphoid process
Improper hand placement during CPR can cause chest injuries. Placing the hand too low over the chest for CPR can fracture the sternum and the xiphoid. One indication is hearing or feeling a pop when compressing the chest. Fractured xiphoid process can develop into xiphoidalgia.
Too much pressure can also cause the xiphoid process to dislocate and fracture. The sternum and all the attached structures can withstand pressure, protecting the internal organs. However, it does have its own breaking point too.
This disease mainly causes damage to the esophagus' mucosal lining. GERD or gastroesophageal reflux disease is characterized by the reflux or backflow of gastric (stomach) acids into the esophagus. The acids erode the lining of the esophagus, digesting it.
The esophagus lies very near the xiphoid process. Eroded esophagus due to GERD is painful. That pain can also radiate to the adjacent xiphoid process.
How is Xiphoid Process Pain diagnosed?
Xiphodynia is mainly diagnosed by reproducing the symptoms. That means making the symptoms appear either partially or completely. To make this happen, moderate pressure is applied to the xiphoid process and nearby structures
The tests to diagnose Xiphodyniaare straightforward. The problem lies in the recognition that the pain felt over the area is from a problem involving the xiphoid process, not from chest or abdominal problems.
The first thing a doctor does when a patient comes in experiencing pain over the chest area is to rule out any thoracic or abdominal problems. These conditions can quickly make a turn for the worse. Early diagnosis and treatment is key to successful management and reduction of complications.
Once serious conditions are ruled out, the doctor will perform clinical examinations and order diagnostic procedures. During clinical examination, the doctor needs to obtain a detailed medical history. He will need to ask questions regarding recent accidents, any incident involving heavy lifting and strenuous activities. The patient will be asked if he has any history of or if he is currently suffering from any disease involving the thoracic and abdominal regions.
Physical examination follows. The doctor will palpate the area to look for any tenderness and pain in nearby structures. It is possible that the pain over the xiphoid process is pain reflected from internal organs such as the liver orby ulcers in the stomach.
Next, radiologic studies will be carried out. Imaging techniques such as X-rays and ultrasound will be utilized. These will show images of the xiphoid process, revealing if there are indeed injuries causing the pain.
There are other, more expensive radiologic imaging procedures such as CT scan and MRIs. These can give images that are more detailed. These can be helpful in detecting minute injuries that might be missed by X-rays and ultrasounds.
What Leads to Misdiagnosis?
There are many reasons that xiphoid process pain is widely misdiagnosed. The main one, as previously mentioned, is the similarity of its symptoms to a wide variety of other diseases. Another reason is that the area where the pain occurs is also the same area where pain is felt when the patient is suffering from more serious conditions. This region is where pain from angina, MI (myocardial infarction), and gall bladder stones is felt.
Doctors are often more focused on diagnosing and treating more serious diseases compared to trying to find injuries in the xiphoid process. When doctors find nothing that indicates the presence of these serious conditions, they typically do not proceed with further tests for xiphoid process pain.
What About a Lump in the Sternum?
A lump in the sternum may be felt in some people. This is often no cause for alarm. The lump is the xiphoid process protruding outwards due to a few factors.
Remember that itis not until a person is 40 years old that the cartilage hardens into bone. The xiphoid process is soft and can easily protrude.
Infants have a more prominent xiphoid process compared to adults. It is easily palpated over the lower sternal border. The lump of the xiphoid process becomes less palpable and visible as the baby grows older.
However, some people retain the protruding appearance of the xiphoid process. Some naturally have their xiphoid process develop in a protruding fashion. Some adults who have lost a lot of weight may easily see or feel their xiphoid process.
Obese people may also find a lump in their sternum. The excess visceral fat puts pressure on the internal organs. The internal organs push out against the ribcage. Since the xiphoid processis cartilaginous, it easily yields to the outward pressure. It will then look like a lump pushing out from the lower sternal border. This may not be visible until after the obese person loses some weight.
Another possible reason for a lump in the sternum is previous injury. The xiphoid process may not have been able to heal properly. Instead, it protruded outwards and can be felt as a lump in the sternal region.
Some lumps in the sternum might be an indication of a serious condition. It may be a tumor from a developing bone cancer (e.g., osteosarcoma, multiple myeloma), leukemia or lymphoma. It may be an indication of a developing bone weakness due to nutritional deficiency conditions such as rickets and scurvy. It is important to have all possibilities ruled out. Consult a health care provider for any lump felt over the sternum before deciding that it is a self-limiting, non-life threatening condition
Are There Complications?
By itself, the injury to the xiphoid process generally does not cause any further damage to the internal organs. This depends on the extent of injury sustained.
Severe injury to the xiphoid process may lead to complications. In xiphoidalgia, nausea and vomiting are among the leading complications. An injured xiphoid process can be a source of irritation to the adjacent structures and organs. One in particular is the stomach, which is located just beneath the xiphoid. This irritation can lead to nausea and vomiting, and if these symptoms persist, they may lead to more problems. They can lead to imbalance in electrolytes, malnutrition, and dehydration.
A fractured xiphoid process may also cause damage to the nearby liver. The upper border of the liver lies directly below the xiphoid. A large enough fracture can cause sections of the xiphoid to puncture the liver. This can lead to bleeding and a life-threatening situation.
Pain can also affect general well-being. It can cause irritability and alter your mood. In addition, a person in pain is less able to focus. Pain may even interfere with day-to-day activities, and thatcould lead to emotional and mental changes. Socialization could be hampered. In addition to being irritable, a person becomes impatient and less eager to be with others. This can lead to social isolation, depression, and declining self-esteem.
What is the Importance of the Xiphoid Process?
Physiologically speaking, the xiphoid process acts as a point of attachment to a number of muscles. These muscles help control the movement of the ribcage. It plays an indirect role in stabilizing the lower ribs. These also play a part in other types of movement involving the thoracic and abdominal cavities.
The muscles of the diaphragm are also attached to the xiphoid process. This makes up the floor of the ribcage. This has an important role to play in the respiratory process.
In the clinical setting, the xiphoid process acts as a landmark. It is used as a guide in locating certain anatomical positions. For example, it is used in determining the:
- upper margin of the liver
- diaphragm's central tendon
- heart's lower margin
- anterior thoracic cage's lower border
The xiphoid also acts as a vital landmark during certain medical procedures. Examples include:
- Pericardial Tap: This procedure is also known as pericardiocentesis. This removes excess fluids that have accumulated within the sac or membrane that covers the heart (pericardium). Fluid in this area can be very dangerous because it will hinder effective heart contractions. This condition can be caused by several factors. Among the common causes are trauma to the chest and heart conditions.
The xiphoid process serves as a point of reference on where to safely insert the needle for this procedure. It helps reduce the likelihood of getting the lungs punctured.
- CPR: Locating the xiphoid process is the first step in performing cardiac compressions. Find the xiphoid process by feeling the lower section of the sternum. Place 2 fingers above the xiphoid process. Then, place the heel of the hand right above the finger closest towards the head of the person to be given CPR.
That is the optimal location. If you go above or below that point, the compressions will not be sufficient to keep blood moving to the heart.
How is it Treated?
Xiphoid process pain is a widely considered as a self-limiting condition. It does not need any aggressive medical management. Treatment is typically focused on underlying causes. For example, if the pain is associated with cardiac conditions, treatment will be focused on the cardiac condition. Physicians also have to ensure that vital internal organs won't be harmed by damage to the xiphoid process, such as in the case of fracture.
In the absence of associated conditions, treatment is focused on managing pain.Mild analgesics could be prescribed given until pain disappears. These are over-the-counter medications given as first line of pain management. Non-steroidal anti-inflammatory drugs (NSAIDs) are also part of the first line of pain management for xiphoid process pain.
Conservative measures such as heat and cold therapy may also work. This involves alternately applying hot compress and cold packs over the painful, swollen area. This will help promote blood flow that supports healing and reduction of inflammation.
Before resorting to xiphoid injections, the physician may opt to try conservative physical therapies. Short course treatments may include application of low-level laser or use of ultrasound. However, there is not enough evidence that establishes the effectiveness of such methods.
A compromised xiphoid process may cause nearby structures to compensate. This may lead to further injuries or to the dislocation of the xiphoid process. In these cases, wearing an elastic rib belt can help. The belt supports the injured structures, reducing the strain during movement. It also applies pressure over the sternal area to reduce the pain. The belt also helps keep structures in their proper alignment during movement.
If pain persists or does not respond to NSAIDs and analgesics, stronger painkillers may be prescribed. Opioid analgesics may be given to control pain. Corticosteroids are given to reduce both pain and inflammation.
If pain is severe, local anesthetics (e.g., lidocaine) and corticosteroids may be given. These medications are injected directly on the xiphoid process. This treatment option may help get rid of the pain. However, it comes with risks. Xiphoid injections carry risks for complications such as peritoneal perforation (puncture of the peritoneum or membrane covering the abdominal cavity), infection, pleural perforation (puncture of the membranes covering the lungs) and pneumothorax (air within the pleural cavity).
Aside from medications, people suffering from xiphoid process pain are also advised to refrain from lifting heavy objects. Large and heavy meals should also be avoided while the xiphoid process and attached muscles heal.
Physiotherapy applied on the chest muscles may also help in reducing pain. Focus is placed on the muscles attached to the xiphoid process. This treatment helps in soothing the pain and relieving tenderness. Gentle exercise proves to be beneficial in improving mobility. At the start of physiotherapy, physicians may recommend pain medication. Manipulating the muscles may initially increase pain but is needed in order to improve mobility.
For pain associated with GERD, making dietary changes to the symptoms of GERD might be helpful. This may lead to the reduction of pain in the xiphoid process.
If none of the mentioned treatment methods work, the last resort is surgical removal of the xiphoid process or xiphoidectomy.
The xiphoid process is an important structure and has clinical significance. However, its function is not critical. Removal will not have a huge impact on overall health and bodily functions.
The procedure is complex and requires the skills of a specialist. The entire xiphoid process is not necessarily removed. Most often, removal of the protruding portion of the xiphoid is enough to treat the pain and other symptoms.
Do you have xiphoid process pain?
- Broyles, R. "The Location and Purpose of the Xiphoid Process." BrightHub. Updated: 11/29/2009. Retrieved Jan. 8, 2017.
- Simpson, J.K. and Hawken, E. Xiphodynia: "A diagnostic conundrum." Retrieved Jan. 8, 2017.
- "Xiphoid Process." Wikipedia. Retrieved Jan. 8, 2017.
- Mehmet Mihmanlı, Hakan Mustafa Köksal, Uygar Demir, and Rıza Gürhan Işıl. "Benefits of xiphoidectomy in total gastrectomy." Retrieved Jan. 8, 2017.
- By Mayo Clinic Staff. "GERD." Retrieved Jan. 8, 2017.
This content is accurate and true to the best of the author’s knowledge and does not substitute for diagnosis, prognosis, treatment, prescription, and/or dietary advice from a licensed health professional. Drugs, supplements, and natural remedies may have dangerous side effects. If pregnant or nursing, consult with a qualified provider on an individual basis. Seek immediate help if you are experiencing a medical emergency.