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.
RH, a 21 year old female presented to a chiropractic teaching clinic with a chief complaint of neck and thoracic spinal pain which had been present for approximately 4 years since commencing her university studies and was aggravated by studying. RH experienced this pain about once per week and it lasted for 'a couple of days'. RH had a secondary complaint of headache, which began about the same time as her primary complaint. The headaches were described as a band of pain across her forehead along with an ache at the base of her skull and in her temples. Past medical history was unremarkable save for shingles in 2004. Routine physical examination was unremarkable. Following history and examination a working diagnosis of mid-back pain of mechanical origin with associated muscle hypertonicity was established and a course of chiropractic treatments proposed. Treatment included SMT to the spinal levels thought to have restricted motion, soft-tissue treatment to the musculature of the upper back and a recommendation for core stability exercises. On a subsequent visit RH reported that she could neither lie prone on the treatment table nor could she perform even the most basic core stability exercises because to do so would result in severe abdominal pain, throat tightness and headache. Following further questioning it was determined that RH had been experiencing this triad of symptoms since she was eight years old and had subsequently avoided any activity that placed pressure on her abdomen, such as sitting close to a table when studying or performing abdominal exercises. Medical investigation for her symptoms had yielded neither a diagnosis nor a treatment. RH traced her symptoms back to a ballet class when she was age eight years during which she was required to lie prone on a wooden floor and, while holding onto her ankle, attempt to touch her toes to her head. Palpation of the area surrounding RH's xiphoid reproduced her abdominal pain and throat tightness immediately with the headache beginning a few minutes later. These symptoms persisted for several hours. A diagnosis of xiphodynia was established and a course of LLLT suggested. Four treatments of 2 minutes each were administered. RH reported a lessening of her symptoms but not cessation. It was noted that, in order to reproduce the symptoms pressure had to be applied to the xiphoid for up to 20 seconds and that RH's symptoms would not begin for until two minutes after pressure was removed. A switch of modality to Ultrasound was commenced. Ultrasound was chosen because of its known effects on tissue repair [,]\nIn addition, RH was advised to use a topical anti-inflammatory gel over the xiphoid. Following four ultrasound treatments RH's symptoms persisted however they have subsided from 8/10 to 2–3/10 and she is content to continue with conservative care because she does not wish to receive an injection of corticosteroid to the area. RH was reviewed in April 2007 and related that she went overseas during the University summer break during which time her symptoms continued to subside. RH stated that her symptoms were mild and intermittent. At this point in time RH elected to have no examination or treatment of the xiphoid, instead opting to return for assessment and treatment if she experienced an exacerbation of symptoms.