The xiphoid process is the small, pointed piece of bone and cartilage at the very bottom of your breastbone, sitting right where your lower ribs meet in the center of your chest. Pain in this area, called xiphodynia or xiphoid syndrome, is surprisingly common but often misdiagnosed because it can mimic heart attacks, gallbladder trouble, and other serious conditions. The xiphoid itself is easy to overlook on imaging and in clinical exams, which means many people live with unexplained chest or upper abdominal pain for months before the actual cause is identified.
Where Exactly Is the Xiphoid Process
The xiphoid process is the smallest of the three parts that make up your sternum (breastbone). It sits just below the body of the sternum, roughly at the level of the pit of your stomach.1PubMed Central. Xiphoid Process Variations: A Review with an Extremely Unusual Case Report If you press your fingers into the soft spot where your rib cage comes together in the center, you are touching or very close to the xiphoid. Several important structures attach to it: the diaphragm, the rectus abdominis muscles of the abdomen, and the aponeurosis (connective tissue sheet) that links your abdominal wall muscles all converge there. That makes the xiphoid a surprisingly busy junction for a piece of anatomy most people never think about.
Unlike most bones, the xiphoid starts life as pure cartilage and only gradually turns to bone over decades. A comprehensive anatomical study found that about 85% of xiphoid processes contain a mix of cartilage and bone, with roughly 45% showing very little ossification and only about 15% being mostly or fully ossified.2PubMed. Revisiting morphology of morphology of xiphoid process of the sternum in human: a comprehensive anatomical study This means the xiphoid in a younger adult is far more flexible and cartilaginous than in someone over 60, which partly explains why the type of pain and injury risk changes with age.
Anatomical Variations Are the Rule, Not the Exception
One reason the xiphoid can be confusing on imaging and in clinical exams is that it comes in a remarkable range of shapes. A large CT-based study of living individuals found that the most common variation was a double-ended xiphoid, appearing in about 37% of people. A single hole (foramen) through the xiphoid showed up in roughly 26% of cases, and a small percentage of people had triple-ended tips or calcified ligaments around the area.3European Journal of Radiology. Frequency of sternal variations and anomalies in living individuals evaluated by MDCT A separate CT study reported similar numbers, with about 63% of people having a single-tipped xiphoid, a third having a double tip, and around 5% a triple tip.4PubMed. Anatomic evaluation of the xiphoid process with 64-row multidetector computed tomography
These variations are nearly always harmless and cause no symptoms on their own. But they matter clinically because a foramen through the xiphoid can be mistaken for a bone lesion on a scan, and an unusually angled or protruding tip can press against surrounding tissue and contribute to pain. Radiologists and emergency physicians who are not looking for xiphoid variants sometimes flag them as abnormalities, leading to unnecessary follow-up tests.
Why the Xiphoid Process Hurts
Xiphodynia, the medical term for xiphoid pain, can be broken into two broad categories. Primary xiphodynia comes from direct problems with the xiphoid itself or the joint connecting it to the rest of the sternum. Secondary xiphodynia develops as referred pain from a disease somewhere else in the chest or abdomen.5PubMed Central. Treatment and Management of Xiphoidalgia
The pain tends to radiate unpredictably, which is part of what makes it so tricky. People with xiphodynia often feel discomfort spreading to the chest, upper abdomen, throat, arms, or even the back of the head. That wide radiation pattern is why it so easily gets mistaken for a heart problem or a gastrointestinal condition.
Direct Trauma and Repetitive Strain
A blow to the chest, a seatbelt injury in a car accident, or even aggressive CPR can damage the xiphoid. Because the xiphoid is partly cartilaginous, it does not break as cleanly as a rib; it tends to bend, partially fracture, or detach at the joint connecting it to the sternum body. Lifting heavy objects repeatedly is another classic trigger. The rectus abdominis muscles pull on the xiphoid every time you strain your core, and over time that mechanical stress can inflame the attachment point. Sports that involve heavy overhead pressing, rowing, or repeated crunching motions are frequent culprits.
Inflammatory Conditions
The xiphisternal joint, where the xiphoid meets the rest of the breastbone, is a real joint with cartilage, and it can become inflamed in the same way a knee or hip joint does. Rheumatoid arthritis, ankylosing spondylitis, psoriatic arthritis, and osteoarthritis can all affect this joint and produce localized tenderness.5PubMed Central. Treatment and Management of Xiphoidalgia This type of xiphoid pain tends to be chronic, fluctuating with flares of the underlying arthritis.
Gastrointestinal and Cardiac Links
Some of the most underappreciated causes of xiphoid pain have nothing to do with the bone itself. Gastroesophageal reflux disease (GERD) is a major risk factor, particularly in older men. Gallbladder disease and coronary artery disease can also produce secondary xiphodynia. One review specifically identified elderly men with GERD or high cholesterol (putting them at greater risk for heart disease) as the population most prone to developing secondary xiphoid pain.6Orthopedic Reviews. Treatment and Management of Xiphoidalgia In these cases, treating the GERD or managing the cardiac condition often reduces or eliminates the xiphoid tenderness, because the xiphoid was never the primary problem.
Why Xiphoid Pain Gets Misdiagnosed So Often
The biggest clinical concern with xiphodynia is not the condition itself but what it can look like. The pain sits in a zone shared by the heart, the esophagus, the upper stomach, and the gallbladder. A person who shows up in an emergency room with sharp pain just below the breastbone, radiating to the chest and arm, is going to get worked up for a heart attack before anyone pokes the xiphoid to see if it is tender. That is appropriate, since missing a heart attack is far more dangerous than missing xiphodynia. But it means that xiphodynia is diagnosed only after serious conditions have been ruled out.7PubMed Central. Xiphodynia as an Unusual Cause of Chest Pain: A Case Series
The diagnostic process typically involves an EKG, blood work to check cardiac enzymes, and often a chest X-ray or CT scan. If those come back normal, the clinician may then consider musculoskeletal causes. The physical exam finding that clinches the diagnosis is simple: pressing on the xiphoid reproduces the pain. A CT scan may also show the xiphoid angling forward or backward at an unusual degree, though a case-control study found that the xiphisternal angle alone was not significantly different between people with xiphodynia and controls. Instead, researchers observed that in about 70% of cases, the xiphoid process curves forward and then backward in an S-shaped pattern.8medRxiv. A case-control study evaluating CT signs of xiphoid process associated with xiphodynia
To strengthen the diagnosis when the clinical picture is ambiguous, some practitioners use a diagnostic injection: a local anesthetic is injected near the xiphoid, and if the pain disappears, the xiphoid is confirmed as the source.7PubMed Central. Xiphodynia as an Unusual Cause of Chest Pain: A Case Series This approach both confirms the diagnosis and provides temporary relief.
The Psychological Weight of Unexplained Chest Pain
People who live with undiagnosed xiphoid pain often go through a frustrating cycle. The pain feels cardiac, so they seek emergency care. Tests come back normal. They are told nothing is wrong and sent home, only to have the pain return. This pattern can take a real psychological toll. Research on noncardiac chest pain, the broader category that includes xiphodynia, has found that psychological disorders have been reported in up to 79% of patients with chest pain of noncardiac origin. Those patients showed significantly higher rates of panic disorder, major depression, and phobias compared to patients whose chest pain turned out to have a cardiac cause.9PubMed Central. The Role of Psychological Factors in Noncardiac Chest Pain of Esophageal Origin
That does not mean the pain is “all in your head.” It means living with recurring, unexplained chest pain is deeply anxiety-provoking, and the anxiety can amplify the pain perception. Getting an accurate diagnosis of xiphodynia, even though it is a relatively minor musculoskeletal condition, can break that cycle and significantly reduce the distress.
How Xiphoid Pain Is Treated
Treatment follows a step-by-step approach, starting with the least invasive option and escalating only if needed.
Pain Relief and Anti-Inflammatory Medication
The first line of treatment is straightforward: over-the-counter pain relievers like ibuprofen or naproxen to reduce both pain and inflammation. Heat or ice applied over the area can help. Avoiding activities that worsen the pain, whether that is heavy lifting, certain exercises, or prolonged slouching, is an obvious but easy-to-overlook step. For most people, this is enough. Unfortunately, conservative treatment does not always provide lasting improvement.10PubMed Central. A case series: xiphoidectomy for xiphodynia, a rare thoracic wall disorder
Steroid and Anesthetic Injections
When oral medications are not enough, a local injection combining an anesthetic with a corticosteroid is often the next step. The injection is placed directly into the tender area around the xiphoid. This approach can be both diagnostic and therapeutic: if the injection eliminates the pain, it confirms the xiphoid as the source, and the steroid component can provide weeks to months of relief. A classic case series noted that local injection with an anesthetic-steroid combination is frequently curative, though results are more variable when multiple tender spots are present across the chest wall.11PubMed. Xiphodynia: a report of three cases Some people need a single injection; others may require a repeat course.
Surgical Removal of the Xiphoid
For the minority of patients whose pain persists despite medications and injections over at least a year, xiphoidectomy, the surgical removal of the xiphoid process, becomes an option. This sounds dramatic, but the xiphoid is not structurally essential in adults, and the procedure is relatively small as surgeries go. A study of 19 patients who underwent xiphoidectomy found no surgery-related complications, and 94% reported improvement afterward, with about 63% becoming completely pain-free over an average follow-up of nearly three years.12PubMed Central. Operative results after xiphoidectomy in patients with xiphodynia
Results are not universally positive, though. A separate study of ten patients found significant pain relief in eight, but two patients who had previously undergone open-heart surgery (sternotomy) did not benefit from the xiphoidectomy. The researchers concluded that while a protruding xiphoid with an angle below 160 degrees is a good indicator that surgery will help, patients who have already had major chest surgery are less likely to see improvement.13PubMed. Xiphoidectomy for Intractable Xiphodynia This makes sense: prior surgery can create scar tissue and altered anatomy that contribute to pain independently of the xiphoid.
When to Worry and When to Relax
The practical question most people with xiphoid tenderness have is whether they should be concerned. The honest answer depends on context. If you can press on the bony tip at the bottom of your breastbone and that pressure exactly reproduces your pain, you are most likely dealing with xiphoid-related discomfort. If the pain came on after a specific injury, a period of heavy lifting, or a new exercise regimen, the connection is even clearer.
You should seek prompt medical evaluation if the pain came on suddenly without clear cause, is accompanied by shortness of breath or dizziness, radiates to the jaw or left arm in a pattern consistent with cardiac symptoms, or is associated with fever. These features do not automatically mean something serious is happening, but they overlap enough with heart and abdominal emergencies that ruling them out first is always the right call. Once those have been excluded, bringing up the possibility of xiphodynia to your doctor can save you from the frustrating cycle of repeat ER visits with no diagnosis.
Why You Might Suddenly Notice Your Xiphoid for the First Time
A surprisingly common scenario is a person who one day notices a hard lump at the bottom of their breastbone and panics, thinking it is a tumor or growth. What they have actually discovered is their own xiphoid process, which has always been there but was never prominent enough to feel through the skin before. Weight loss, changes in posture, aging-related shifts in cartilage stiffness, or simply never having pressed on that spot before can all create this “new lump” experience. The xiphoid can angle outward as the cartilage ossifies with age, becoming more prominent. In people who are lean, it can protrude visibly under the skin.
This discovery leads to a lot of imaging and doctor visits that ultimately end with reassurance. The lump is normal anatomy. If it is not painful, nothing needs to be done about it. If it has become painful along with becoming more prominent, the evaluation and treatment steps described above apply. But the xiphoid itself, even an unusually protruding one, is not a sign of disease.
CPR and the Xiphoid
If you have ever taken a CPR class, you were probably taught to find the xiphoid process before positioning your hands for chest compressions. The reason is that pressing directly on the xiphoid during CPR can fracture it or drive it into the liver, which sits just behind and below. Proper hand placement for chest compressions is on the lower half of the sternum body, above the xiphoid. Sternum fractures during CPR are not rare, occurring in roughly 30% of patients in one post-mortem imaging study, with the most common fracture location being the mid-sternum between the third and fourth ribs.14PubMed Central. CPR related injuries of the chest wall: direct and indirect fractures The xiphoid is more vulnerable than the main sternum body because of its cartilaginous composition, and damage to it during resuscitation can lead to lingering xiphoid pain in survivors.
For CPR providers, the takeaway is simple: landmark correctly by finding the notch at the top of the sternum or the xiphoid at the bottom and placing the heel of your hand in the center. Avoid the xiphoid itself. For CPR survivors experiencing persistent chest discomfort weeks or months after resuscitation, xiphoid injury is worth mentioning to a doctor, as it can be treated.