What is the initial treatment for costochondritis?

Initial Treatment for Costochondritis

The first-line treatment for costochondritis is a short course of nonsteroidal anti-inflammatory drugs (NSAIDs) for 1-2 weeks, along with temporary rest and application of ice or cool packs to the affected area. 1, 2

Diagnosis and Clinical Features

Costochondritis is characterized by:

• Localized pain and tenderness at the costochondral or chondrosternal junctions
• Pain typically affects the 3rd to 7th ribs
• Pain reproducible with palpation of the affected area
• Absence of swelling, redness, or warmth (distinguishes from infectious causes)

Treatment Algorithm

First-Line Treatment

1. Non-pharmacological approaches:

   • Application of ice or cool packs to the affected area 1
   • Temporary rest and activity modification to avoid movements that exacerbate pain 2
   • Avoid activities that produce chest muscle overuse 2

2. Pharmacological treatment:

   • NSAIDs for 1-2 weeks 1, 2
     • Options include ibuprofen, naproxen, or diclofenac
     • Use the lowest effective dose for the shortest duration
     • Consider gastroprotective agents if risk factors for GI complications exist 1
   • Acetaminophen as an alternative if NSAIDs are contraindicated 2

Second-Line Treatment

For patients who fail to respond to initial treatment:

1. Local therapy options:

   • Intra-articular corticosteroid injection for persistent pain 1
   • Consider topical NSAIDs as an alternative with lower systemic absorption 3

2. Physical therapy approaches:

   • Stretching exercises for the chest wall 4
   • Instrument-assisted soft tissue mobilization 5
   • Manual therapy techniques for rib dysfunction 5

For Refractory Cases

• Low-dose colchicine may be considered for severe cases unresponsive to NSAIDs or steroids 6
• Short tapering course of oral corticosteroids for severe inflammation 1

Special Considerations

Elderly Patients and Those with Comorbidities

• Use caution with NSAIDs due to increased risk of adverse effects
• Consider acetaminophen as first-line therapy
• Topical NSAIDs may be safer alternatives 3

Differential Diagnosis

Before treating for costochondritis, rule out serious causes of chest pain:

• Cardiac conditions (especially in patients >35 years or with cardiac risk factors) 2
• Infectious costochondritis (characterized by swelling, redness, purulent discharge) 7
• Other musculoskeletal conditions

Monitoring and Follow-up

• Assess response to treatment within 1-2 weeks
• If symptoms persist beyond 2-3 weeks or worsen, consider further evaluation
• For patients >35 years or with cardiac risk factors, consider ECG and possibly chest radiograph 2

Common Pitfalls to Avoid

1. Failing to rule out cardiac causes of chest pain, especially in older adults or those with risk factors
2. Prolonged use of NSAIDs without appropriate monitoring for adverse effects
3. Overuse of corticosteroids for a condition that is typically self-limiting
4. Inadequate patient education about activity modification and expected course of illness

Costochondritis is usually self-limiting, with most cases resolving within weeks to months. Providing reassurance to patients about the benign nature of the condition is an important aspect of management.