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.
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.