Attending Physician Long Beach Veterans Affairs Medical Center Orange, California, United States
Case Diagnosis: Chronic Xiphodynia
Case Description: A 78 year-old man presented to clinic with chest pain secondary to chronic xiphodynia after attempting to catch his falling motorcycle several years prior. Pain was localized to xiphoid/substernal region without radiation. Exam showed tenderness to palpation over xiphoid process. Chest CT showed mild pectus deformity and anterior bowing of the inferior sternal tip. Cardiac workup was previously negative. Prior treatment included referral to outside pain clinic who ordered PT, topical analgesics, gabapentin, and acupuncture with limited improvement. Rheumatology consult was done who recommended NSAIDS. Patient stated to be suicidal at one point due to the inability to have intercourse with his spouse due to the pain. Due to continued symptoms the patient underwent three peri-xiphoid dextrose prolotherapy injections, one month apart. He noted 100% improvement by the second injection. Pain reoccurred but was minimal for the third injection.
Discussion: Xiphodynia is a hypersensitivity pain syndrome of the xiphoid process often precipitated by blunt trauma, acceleration/deceleration injuries. Since this condition is often a diagnosis of exclusion and can mimic life-threatening comorbidities, diseases like acute coronary syndrome, pulmonary embolism, angina must first be ruled out. Initial treatments are typically conservative including physical therapy, topical analgesics, NSAIDs, and elastic rib belt. More invasive techniques such as local steroid injections, pulsed radiofrequency ablation, or xiphoidectomy have been utilized. The syndrome is typically self-limiting but symptoms may become chronic. Prolotherapy is a regenerative injection technique that stimulates a local inflammatory cascade to release growth factors/collagen deposition, inducing tissue healing and restoration. This case demonstrates a patient with chronic xiphodynia successfully treated with dextrose prolotherapy.
Conclusions: Xiphodynia may be disabling, severely impact one’s function and quality of life. In patients with localized xiphodynia, dextrose prolotherapy is a safe, minimally invasive procedure that can be considered prior to more invasive treatments.