From the Guidelines
Costochondritis is diagnosed primarily through clinical evaluation after excluding other serious conditions, with diagnostic criteria including localized chest pain and tenderness upon palpation of the costal cartilages, especially between the second and fifth ribs, as noted in the 2021 AHA/ACC/ASE/CHEST/SAEM/SCCT/SCMR guideline for the evaluation and diagnosis of chest pain 1. The diagnostic process involves a thorough clinical evaluation to rule out other causes of chest pain, such as cardiac or pulmonary disease.
- Key diagnostic criteria include:
- Localized chest pain that worsens with movement or breathing
- Tenderness upon palpation of the costal cartilages, especially between the second and fifth ribs
- Absence of other causes for the symptoms, such as cardiac or pulmonary disease No specific imaging or laboratory tests confirm the diagnosis, though tests like ECG, chest X-ray, or cardiac enzymes may be ordered to rule out other conditions, as discussed in the context of evaluating chest pain in the 2022 ACR Appropriateness Criteria for chronic chest pain with a high probability of coronary artery disease 1.
Treatment Options
Treatment focuses on pain management, with first-line options including nonsteroidal anti-inflammatory drugs (NSAIDs) such as ibuprofen or naproxen for 1-2 weeks.
- First-line treatment options:
- NSAIDs: ibuprofen (400-800mg three times daily) or naproxen (500mg twice daily)
- Acetaminophen (650-1000mg every 6 hours) if NSAIDs are contraindicated For severe cases, local lidocaine injections or intercostal nerve blocks may provide relief.
- Additional treatment considerations:
- Heat or ice application to the affected area for 15-20 minutes several times daily
- Rest and activity modification, avoiding movements that exacerbate symptoms Most cases resolve within weeks to months with conservative management, though some patients experience recurrent or chronic symptoms, highlighting the importance of ongoing clinical evaluation and management, as implied by the guidelines for evaluating and managing chest pain 1.
From the Research
Diagnostic Criteria for Costochondritis
- Costochondritis is a self-limiting, poorly described, and benign condition that usually manifests as non-cardiac chest pain 2
- The symptoms usually tend to resolve in a couple of weeks, but serious causes of chest pain should be ruled out prior to diagnosing costochondritis, as it is often a diagnosis of exclusion 2, 3
- Palpation of the affected chondrosternal joints of the chest wall elicits tenderness, and history and physical examination of the chest that document reproducible pain by palpation over the costal cartilages are usually all that is needed to make the diagnosis in children, adolescents, and young adults 3
- Patients older than 35 years, those with a history or risk of coronary artery disease, and any patient with cardiopulmonary symptoms should have an electrocardiograph and possibly a chest radiograph 3
Treatment Options for Costochondritis
- Traditional practice is to treat with acetaminophen or anti-inflammatory medications where safe and appropriate, advise patients to avoid activities that produce chest muscle overuse, and provide reassurance 3
- A multimodal approach, including manipulative therapy, instrument-assisted soft tissue mobilization (IASTM), and stretching, can be useful in the treatment of rib dysfunction, especially in atypical costochondritis 2
- Physical therapy (PT) utilizing an impairment-based examination and treatment approach, including manual therapy and therapeutic exercise, may facilitate the resolution of costochondritis 4
- The addition of short-term oral corticosteroids has shown a clear benefit for use in improvement of pain and quality of life in patients with Tietze syndrome, a rare form of chest wall costochondritis with joint swelling 5
- In some cases, surgical management, including debridement and well-vascularized tissue coverage, may be necessary to ensure eradication of the disease 6