Working Diagnosis:
Xiphodynia

Treatment:
The patient received an ultrasound guided 40 mg Kenalog/ 2 mL 1% Lidocaine injection of the xiphoid process Case Photo #1 . She was given a topical compound of gabapentin/diclofenac, cyclobenzaprine, baclofen, and bupivacaine. She was instructed to stop meloxicam and limit strenuous activity for 2 weeks.

Outcome:
The patient returned to the Sports Medicine Center 1 month and 4 months following her injection. She reported 97% improvement of her symptoms after this injection and resumed gardening without pain. She continues to be observed and could consider repeat injection if her symptoms recur.

Author's Comments:
Xiphodynia is a relatively rare cause of musculoskeletal pain in the chest, characterized by localized pain and tenderness over the xiphoid process. Symptoms can range from upper abdominal pain, chest pain, and sometimes throat and arm symptoms. It is frequently insidious in onset, but trauma may precipitate the syndrome. Acceleration/deceleration injuries, blunt trauma to the chest, and unaccustomed heavy lifting and aerobics can precipitate xiphodynia because of the muscular attachments Case Photo #2 . Diagnosis is dependent upon the reproduction of the patient�s symptoms completely or in part by moderate pressure on the xiphoid process and its adjacent structures. Although it often exists in the absence of other medical conditions, it has been demonstrated in conjunction with life-threatening disease. Generally is a self-limiting disorder to be treated with reassurance or with analgesics, topical heat and cold, and an elastic rib belt. The medical treatment of choice is an injection of a local anesthetic and steroid.

Editor's Comments:
This case demonstrates important musculoskeletal diagnosis to consider for those presenting with upper abdominal, chest or rib pain. In patients who present with abdominal pain, acute internal and life threatening processes must first be ruled out as was done in this case.

When considering musculoskeletal causes of upper abdominal, chest, or rib pain, one should also consider rib fractures or costochondritis as part of the differential in addition to those listed in the differential section above. Rib fractures may occur with primary trauma or may occur pathologically with any metabolic bone disorders or in the presence of malignancy.

Costochondritis is another common musculoskeletal disease that may cause pain at the upper abdominal, chest and rib regions, usually peri-xiphoid. It may occur after trauma, exertion/strain, post-infectiously/viral, or spontaneously.

Xiphodynia is an uncommon cause of musculoskeletal chest and abdominal pain. This case demonstrates the importance of awareness of this rare diagnosis in patients suspected with a musculoskeletal cause of chest or epigastric pain. Of note because the location of the pain may commonly occur in the mid-chest region, it often causes concern for myocardial ischemia/infarction. The symptoms, clinical presentation, diagnosis, and treatment of xiphodynia is discussed nicely above in the author comments.

References:
Speed C. Therapeutic ultrasound in soft tissue lesions.
Rheumatology. 2001;40:1331-1336.

Waldman S. Atlas of uncommon pain syndromes.
Philadelphia: Saunders; Elsevier 2003.

The sternum. A, Ventral view. B, Dorsal view. (Modified from Anson BJ (ed). Morris� Human Anatomy (12th ed). New York: McGraw-Hill, 1966.)

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