Xiphodynia

Xiphodynia

An uncommon cause of anterior chest wall pain, xiphodynia is often misdiagnosed as pain of cardiac or upper abdominal origin. Xiphodynia syndrome is a constellation of symptoms consisting of severe intermittent anterior chest wall pain in the region of the xiphoid process that worsens with overeating, stooping, and bending.

The patient may report a nauseated feeling associated with the pain of xiphodynia syndrome. This xiphisternal joint seems to serve as the nidus of pain for xiphodynia syndrome.

The xiphisternal joint is often traumatized during acceleration/deceleration injuries and blunt trauma to the chest. With severe trauma, the joint may sublux or dislocate.

The xiphisternal joint also is susceptible to the development of arthritis, including osteoarthritis, rheumatoid arthritis, ankylosing spondylitis, Reiter syndrome, and psoriatic arthritis. The joint is subject to invasion by tumor from either primary malignancies, including thymoma or metastatic disease.

What are the Symptoms of Xiphodynia

Physical examination reveals that the pain of xiphodynia syndrome is reproduced with palpation or traction on the xiphoid. The xiphisternal joint may feel swollen.

Stooping or bending may reproduce the pain. Coughing may be difficult, and this may lead to inadequate pulmonary toilet in patients who have sustained trauma to the anterior chest wall. The xiphisternal joint and adjacent intercostal muscles also may be tender to palpation.

The patient may report a clicking sensation with movement of the joint. Furthermore, patients with a prominent xiphoid process on visual inspection indicating an xiphisternal angle less than 160 degrees are more prone to the development of xiphodynia.

How is xiphodynia diagnosed?

Plain radiographs are indicated in all patients with pain thought to be emanating from the xiphisternal joint to rule out occult bony pathological conditions, including tumor.

Based on the patient’s clinical presentation, additional tests, including complete blood cell count, prostate-specific antigen level, erythrocyte sedimentation rate, and antinuclear antibody testing, may be indicated. Computed tomography (CT), ultrasound imaging, or magnetic resonance imaging (MRI) of the joint is indicated if joint instability or an occult mass is suspected. The following injection technique serves as a diagnostic and therapeutic maneuver.

Differential Diagnosis

As with costochondritis, costosternal joint pain, devil’s grip, Tietze syndrome, and rib fractures, many patients with xiphodynia first seek medical attention because they believe they are having a heart attack. Patients also may believe they have ulcer or gallbladder disease. In contrast to most other causes of pain involving the chest wall that are musculoskeletal or neuropathic in origin, the pain of devil’s grip results from infection. The constitutional symptoms associated with devil’s grip may lead the clinician to consider pneumonia, empyema, and occasionally pulmonary embolus as the most likely diagnosis.

Treatment

Initial treatment of xiphodynia should include a combination of simple analgesics and nonsteroidal antiinflammatory drugs (NSAIDs) or cyclooxygenase-2 (COX-2) inhibitors. If these medications do not control the patient’s symptoms adequately, opioid analgesics may be added during the period of acute pain. Local application of heat and cold may be beneficial to provide symptomatic relief of the pain of xiphodynia. The use of an elastic rib belt may help provide symptomatic relief in some patients. For patients who do not respond to these treatment modalities, the injection of the xiphisternal joint using a local anesthetic and steroid may be a reasonable next step.

Complications and Pitfalls

The major problem in the care of patients thought to have xiphodynia is the failure to identify potentially serious pathology of the thorax or upper abdomen. The major complication of injection of the xiphisternal joint is pneumothorax if the needle is placed too laterally or deeply and invades the pleural space. Infection, although rare, can occur if strict aseptic technique is not followed. Trauma to the contents of the mediastinum is an ever-present possibility.

This complication can be greatly decreased if the clinician pays close attention to accurate needle placement.

Clinical Pearls

Patients with pain emanating from the xiphisternal joint often attribute their pain symptoms to a heart attack or ulcer disease.

Reassurance is required, although it should be remembered that this musculoskeletal pain syndrome, ulcer disease, and coronary artery disease can coexist.

The xiphoid process articulates with the sternum via the xiphisternal joint.

The xiphoid process is a plate of cartilaginous bone that becomes calcified in early adulthood.

The xiphisternal joint is strengthened by ligaments, but it can be subluxed or dislocated by blunt trauma to the anterior chest.

The xiphisternal joint is innervated by the T4-7 intercostal nerves and the phrenic nerve. It is thought that this innervation by the phrenic nerve is responsible for the referred pain associated with xiphodynia syndrome.

Tietze syndrome, which is painful enlargement of the upper costochondral cartilage associated with viral infections, can be confused with xiphisternal syndrome, although both respond to the injection technique described.

The use of physical modalities, including local heat and gentle range-of-motion exercises, should be introduced several days after the patient undergoes this injection technique for xiphisternal joint pain.

Vigorous exercises should be avoided because they would exacerbate the patient’s symptoms. Simple analgesics and NSAIDs may be used concurrently with this injection technique. Laboratory evaluation for collagen-vascular disease is indicated in patients with xiphisternal joint pain in whom other joints are involved.