What is the recommended treatment for costochondritis?

Treatment of Costochondritis

The recommended first-line treatment for costochondritis is nonsteroidal anti-inflammatory drugs (NSAIDs) at the maximum tolerated and approved dosage to reduce inflammation and pain. 1

Diagnosis and Clinical Features

Costochondritis is characterized by:

• Anterior chest wall pain at the costochondral or costosternal junctions
• Localized tenderness on palpation
• Pain that may be exacerbated by physical activity, deep breathing, or coughing
• Absence of swelling, redness, or warmth (which would suggest infectious costochondritis)

Treatment Algorithm

First-Line Treatment

1. NSAIDs:

   • Oral NSAIDs (ibuprofen, naproxen) at maximum tolerated dosage 1
   • Topical NSAIDs can be considered as an alternative with fewer systemic side effects 1
   • Duration: 1-2 weeks trial 1

2. Local Physical Interventions:

   • Local heat or cold applications to the affected area 1
   • Rest and avoidance of activities that exacerbate pain

Second-Line Treatment

If insufficient response to NSAIDs after 2-4 weeks:

1. Short course of oral corticosteroids or intra-articular corticosteroid injections may be considered as bridging options 1

2. Physical Therapy Interventions:

   • Stretching exercises targeting the chest wall and intercostal muscles 2
   • Manual therapy including soft tissue mobilization 3
   • Instrument-assisted soft tissue mobilization for persistent cases 3

Additional Supportive Measures

• Patient education about the benign and self-limiting nature of the condition
• Lifestyle modifications to avoid triggering activities
• Breathing exercises and relaxation techniques

Evidence for Treatment Efficacy

NSAIDs have demonstrated effectiveness in reducing inflammation and pain in costochondritis. A study showed that stretching exercises led to progressive significant improvement in patients with costochondritis compared to control groups 2. This suggests that physical therapy interventions can be valuable adjuncts to pharmacological treatment.

Manual therapy techniques including rib manipulation and soft tissue mobilization have shown promise in case reports, with complete resolution of symptoms in atypical costochondritis that did not respond to conventional treatment 3.

Important Considerations

• Differential Diagnosis: Before diagnosing costochondritis, it's crucial to rule out serious cardiac conditions, as costochondritis is often a diagnosis of exclusion 4
• Monitoring: Evaluate treatment response after 2-4 weeks to determine if modification of therapy is needed 1
• Duration: While costochondritis is typically self-limiting (resolving within weeks to months), some patients may develop chronic symptoms requiring longer-term management 4
• Caution with NSAIDs: Consider gastrointestinal, renal, and cardiovascular risks, particularly in elderly patients or those with comorbidities 1

Special Situations

• Infectious Costochondritis: This rare condition requires antibiotic therapy and possibly surgical debridement rather than standard costochondritis treatment 5
• Atypical Costochondritis: For cases that don't self-resolve, consider referral to physical medicine and rehabilitation for specialized manual therapy techniques 3
• Athletes: May require more aggressive management to facilitate return to sport activities 6

By following this treatment approach, most patients with costochondritis will experience significant improvement in symptoms and can return to normal activities within a few weeks to months.