What is the recommended treatment for inflammation of the sternum and costal cartilage?

Treatment of Inflammation of the Sternum and Costal Cartilage

For inflammation of the sternum and costal cartilage, NSAIDs should be used as first-line treatment at maximum tolerated doses, with local corticosteroid injections considered for persistent cases, while avoiding long-term systemic corticosteroids. 1

Diagnosis and Classification

Before initiating treatment, it's important to establish the correct diagnosis:

Common Causes of Sternal/Costal Cartilage Inflammation:

• Chronic Non-bacterial Osteitis (CNO) - inflammatory bone condition affecting sternum/ribs
• Costochondritis - inflammation of costochondral junctions without swelling
• Tietze's Syndrome - costochondritis with visible swelling at the affected joint
• Axial Spondyloarthritis - can involve anterior chest wall

Key Diagnostic Considerations:

• Localized tenderness over costochondral junctions (typically ribs 2-5)
• Reproducible pain with palpation
• Possible swelling in Tietze's syndrome
• Rule out cardiac causes in patients >35 or with cardiac risk factors 2

Treatment Algorithm

First-Line Treatment:

1. NSAIDs at maximum tolerated dose 1
   • Continue for 2-4 weeks to assess response
   • If good response, continue for up to 12 weeks
   • Consider continuous use if symptoms persist, otherwise on-demand
   • Monitor for GI and cardiovascular side effects

Second-Line Options (if NSAIDs insufficient):

1. Local corticosteroid injections 1

   • Directed to the specific site of inflammation
   • Particularly effective for focal inflammation
   • Caution: avoid repeated injections due to risk of tissue atrophy

2. Short-course oral corticosteroids (for severe cases, particularly Tietze's syndrome)

   • Consider prednisolone regimen (40mg daily for 1 week, then 20mg daily for 1 week, then 10mg daily for 1 week) 3
   • Evidence shows significant pain reduction (65.4% vs 46.7% with NSAIDs alone) 3
   • CAUTION: Avoid long-term systemic corticosteroid use 1

Adjunctive Treatments:

1. Physical therapy and stretching exercises 1, 4

   • Stretching exercises have shown significant improvement in pain 4
   • Maintain range of motion and functional capacity

2. Simple analgesics 1

   • Paracetamol/acetaminophen for residual pain
   • Opioid-like medications only if other treatments fail

Special Considerations

For Refractory Cases:

• Consider referral to rheumatology if symptoms persist despite adequate treatment
• For CNO cases with insufficient response to NSAIDs and local treatments, consider:
  • Intravenous bisphosphonates (IVBP) or TNF inhibitors (TNFi) 1
  • Evaluate response after 3-6 months

Complications to Monitor:

• Be aware of neurovascular complications in patients with anterior chest wall involvement 1
• Monitor for vertebral fractures in patients with spinal involvement 1

Pitfalls to Avoid:

1. Missing serious underlying conditions

   • Always rule out cardiac causes in at-risk patients
   • Consider infectious causes if fever or systemic symptoms present 1

2. Inappropriate treatment

   • Avoid long-term systemic corticosteroids 1
   • Don't rely solely on analgesics without addressing inflammation

3. Inadequate follow-up

   • Reassess at 2-4 weeks after initiating NSAIDs 1
   • Monitor for treatment response based on pain reduction and functional improvement

The evidence strongly supports NSAIDs as first-line therapy with local corticosteroid injections for persistent cases. While short-term oral corticosteroids may benefit severe cases like Tietze's syndrome, long-term systemic corticosteroid use should be avoided due to unfavorable risk-benefit profile.