Doug Montgomery: A 38-Year-Old Male With Anterior Chest Wall Pain Made Worse by Bending

Learning Objectives

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Learn the common causes of xiphodynia.
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Develop an understanding of the anatomy of the xiphoid.
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Develop an understanding of the differential diagnosis of xiphodynia.
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Learn the clinical presentation of xiphodynia.
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Learn how to examine the xiphoid process.
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Learn how to examine the xiphoid and xiphisternal joint.
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Learn how to use physical examination to identify xiphodynia.
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Develop an understanding of the treatment options for xiphodynia.

Doug Montgomery

Doug Montgomery is a 36-year-old truck driver with the chief complaint of, “I can’t exercise because my chest is killing me.” Doug stated that ever since he took a hit to the chest during martial arts training, he has been suffering from severe chest wall pain. In spite of Advil, topical analgesic balm, and ice packs, the pain has persisted. He noted that the pain was made worse whenever he bent over or coughed. He went on to say, “I keep getting my days and nights mixed up because every time I roll over, it wakes me up.” He said that he was afraid he would fall asleep while driving and kill himself or somebody else. I asked Doug if he ever had anything like this in the past, and he said, “Not really, just the usual back pain after driving over the road all day.” I asked if he was experiencing any other symptoms associated with the chest pain, such as sweating, palpitations, or pain into the jaw or left arm, and he shook his head no. I asked Doug about any fever, chills, or other constitutional symptoms, such as weight loss or night sweats, and he again shook his head no.

I then asked Doug to point with one finger to show me where it hurt the most. He pointed to the area just above his xiphoid process.

On physical examination, Doug was afebrile. His respirations were 16, his pulse was 66 and regular, and his blood pressure was 112/68. Doug’s head, eyes, ears, nose, throat (HEENT) exam was normal, as was his cardiopulmonary examination. Examination of the thyroid gland was normal and well muscled. His abdominal examination revealed no abnormal mass or organomegaly. There was no costovertebral angle (CVA) tenderness. There was no peripheral edema. His low back examination was unremarkable. Visual inspection of the anterior chest wall revealed visual prominence of the xyphoid process ( Fig. 3.1 ). There was no rubor, ecchymosis, or obvious infection. Palpation of the xiphoid process caused Doug to cry out in pain ( Fig. 3.2 ). A careful neurologic examination of the upper extremities was completely normal. Deep tendon reflexes were normal.

Key Clinical Points—What’s Important and What’s Not

The History

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History of the onset of xiphoid pain following a kick to the chest during martial arts training
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No numbness
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No weakness
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No history of previous chest wall trauma or chest pain
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No fever or chills

The Physical Examination

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Patient is afebrile
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Normal cardiovascular examination
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Pain on palpation of the xiphoid process (see Fig. 3.2 )

Other Findings of Note

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Normal HEENT examination
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Normal pulmonary examination
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Normal abdominal examination
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No peripheral edema
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Normal upper extremity neurologic examination, motor and sensory examination

What Tests Would You Like to Order?

The following tests were ordered:

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Plain radiographs of the sternum and xiphoid process
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Ultrasound of the xiphisternal joint

Test Results

The plain radiographs of the xiphoid revealed that the xiphoid process projected anteriorly at an angle of 133 degrees from the sternal body ( Fig. 3.3 ).