A 61-year-old male presented with complaints of nausea, abdominal pain, tenderness of the xiphoid process, and the feeling of “luxation” of the sternum, as if bones were sliding over each other as he describes. He quit smoking a few years earlier, which resulted in significant weight gain. The patient was an overweight mechanic (BMI 31.7 kg/m2), who worked on buses for which he often had to carry large tires. His current complaints however prevented him from being able to work. The symptoms were thought to be gastrooesophageal reflux, and the patient was analysed by a gastroenterologist who started treatment with a proton pump inhibitor. Upper gastrointestinal endoscopy revealed, apart from a small sliding diaphragmatic hernia (3 cm), no abnormalities. Cardiac pathology was ruled out by a cardiologist. Previously taken plain radiographs of the sternum before the weight gain showed a slight anterior displacement of the xiphoid process (). At three years after the onset of his complaints a second radiograph of the sternum was obtained, which showed progression of the anterior displacement of the xiphoid process (). This progression () was thought to be due to the patients' weight gain, causing anterior displacement as a result of pressure on the xiphoid process by the panniculus. A xiphoidectomy was performed. Postoperatively the patient experienced no more pain, and he could return to work. During eighteen months of follow-up, the patient reported none of the symptoms he complained of before.
DM, a 33 year old female presented to a chiropractic clinic with a chief complaint of neck pain and headaches following a motor vehicle accident and a secondary complaint of mid-dorsal pain. DM's primary complaint was diagnosed as Whiplash Associated Disorder (Grade II) (WAD II) and resolved following a course of spinal manipulative therapy (SMT), soft-tissue treatment (STT) and neck exercises. The onset of DM's second complaint of mid-dorsal pain was five years previously, following the difficult delivery of her first child. The pain had worsened following the birth of her second child, four years later. It was present every day, rated 7–8/10 at its worst and 3–4/10 at best. The mid-dorsal pain disturbed DM's sleep and physical activity aggravated the pain. Minor relief was obtained by application of moist heat over the painful thoracic area and stretching of the mid-back. Of note, DM had undergone a laparoscopic cholecystectomy between the pregnancies after which her mid-dorsal pain had completely abated for three weeks but then recurred. Aside from local tenderness in the mid-dorsal spine, physical examination was unremarkable. A course of manipulation and ultrasound to the mid-dorsal area was undertaken. Even though DM reported a feeling of increased mobility in her dorsal spine, the symptom of mid-back pain persisted. Because of the refractory nature of DM's mid-dorsal pain, re-assessment was performed. The reassessment included an abdominal examination because of the resolution of her symptoms following laparoscopic cholecystectomy. Examination revealed an exquisitely tender xiphoid process and reproduction of DM's mid-dorsal pain when pressure was applied to the left aspect of the xiphoid. A diagnosis of xiphodynia was established and a course of ultrasound (4 minutes, 2 watts/cm2, pulsed) undertaken over a two week period. Following five treatments DM's symptoms were significantly diminished but for unknown reasons, in the week between the fifth and sixth treatment, there was a relapse in mid-dorsal pain. At this point it was determined to refer her for an opinion from a Rheumatologist who performed a single injection of lidocaine and Celestone ™ to the spot found to be most tender to palpation in the xiphisternal area. DM's mid-dorsal pain resolved completely and has not returned in the intervening 9 years.