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.
JS, a 25 year old female, presented to a chiropractic teaching clinic with a chief complaint of neck and upper back pain. Following the initial work-up, a diagnosis of neck pain of mechanical origin with an associated myofascial syndrome was made and a course of SMT, STT and exercises for the deep neck flexors undertaken. JS's symptoms were resolving well. During the course of a standard office visit it was noted that JS was being investigated for gastric ulcers because of a 3.5 year history of daily mild to severe and at times disabling abdominal pain with associated throat tightness. The pain would reach 8/10 in intensity and last for several hours. Repeated investigations including abdominal ultrasound, endoscopy, and tests for helicobacter pylori were all negative. JS's medical practitioner (GP) made a presumptive diagnosis of gastric ulcer disease and prescribed Cimetidine, then Lansoprazole and later Esomeprazole to no avail. JS was then advised by her GP to cease all medications and diagnosed functional dyspepsia. With persisting symptoms, the GP opted to prescribe an anti-depressant, Fluoxetine hydrochloride. JS's symptoms persisted and, in addition, she began to experience adverse effects to the Fluoxetine hydrochloride and so this was ceased. It was at this time that one of the authors (JKS) examined JS and discovered that both abdominal and throat symptoms were reproducible by direct pressure over the lateral aspect of her xiphoid process.\nA diagnosis of xiphodynia was established and a course of treatment involving 2 minutes of low-level laser therapy (LLLT) to an area of approximately 4 cm2 surrounding the xiphoid undertaken. A therapeutic trial of two laser treatments per week for up to four weeks was recommended. Progress was good. At the end of the third week JS reported significant decrease in frequency, duration and intensity of her abdominal pain. JS experienced days without any pain at all. In addition, the intensity of her pain was now reported as 3/10 maximum with duration of 30 minutes. Palpation of the xiphoid no longer reproduced abdominal pain although some throat tightness was still experienced. Two additional LLLT treatments were undertaken and JS was reviewed six weeks later at which time there was no tenderness over the xiphoid and JS reported infrequent very mild abdominal symptoms and no throat tightness. After reflecting upon her abdominal symptoms JS recalled that they began when she was working as a fruit-picker and had repeatedly performed awkward lifts of heavy crates. In order to lift and move the crates JS arched backward and used her abdomen to support the lift. This brought the edge of the crate into contact with her xiphoid process. The abdominal pain and throat tightness began the day following a particularly strenuous workday.