What is the best treatment for costochondritis?

Best Treatment for Costochondritis

The best treatment for costochondritis is nonsteroidal anti-inflammatory drugs (NSAIDs) at maximum tolerated dosage for 1-2 weeks, combined with local heat or cold application and relative rest. 1

Pharmacological Management

First-line Treatment

• NSAIDs for 1-2 weeks at maximum tolerated dosage:
  • Options include ibuprofen, naproxen, diclofenac, or celecoxib 1
  • Should be taken regularly rather than as needed for better anti-inflammatory effect
  • Monitor for gastrointestinal, renal, and cardiovascular side effects, especially in elderly patients or those with comorbidities 1

Alternative Pharmacological Options

• Topical NSAIDs: Consider for patients who cannot tolerate oral NSAIDs or have contraindications 1
• Acetaminophen: Alternative if NSAIDs are ineffective or contraindicated 1
• Corticosteroids: Short course of oral corticosteroids or intra-articular corticosteroid injections may be considered if insufficient response to NSAIDs after 2-4 weeks 1

Non-Pharmacological Management

Heat and Cold Therapy

• Local heat: Apply heating pad for 15-20 minutes several times daily 1
• Cold therapy: Apply ice wrapped in a towel for 10-minute periods 1

Activity Modification

• Relative rest: Reduce activities that aggravate pain 1
• Avoid muscle overuse: Particularly activities that involve the chest wall 1

Stretching Exercises

• Stretching exercises have shown progressive significant improvement in pain compared to control groups 2
• Can be a useful adjunct to pharmacological management

Manual Therapy

• In cases of atypical costochondritis (not resolving with standard treatment), consider:
  • Manipulative therapy
  • Instrument-assisted soft tissue mobilization
  • Stretching to address myofascial pain generators 3

Treatment Evaluation and Follow-up

• Evaluate treatment response after 2-4 weeks 1
• If symptoms persist beyond 4-6 weeks despite appropriate treatment, consider further evaluation to rule out other causes 1
• Approximately 80% of patients improve within 12 months with proper treatment 1

Important Considerations

• Costochondritis is usually self-limited but can become chronic in some cases 4
• Before initiating treatment, serious causes of chest pain must be ruled out, including:
  • Acute coronary syndrome
  • Pulmonary embolism
  • Aortic dissection
  • Pneumothorax
  • Pericarditis
  • Pneumonia 1
• Patients older than 35 years or with cardiac risk factors should have appropriate cardiac evaluation before confirming the diagnosis of costochondritis 4

Treatment Algorithm

1. Confirm diagnosis (reproducible tenderness over costochondral junctions without swelling)
2. Start NSAIDs at maximum tolerated dose for 1-2 weeks
3. Apply local heat or cold therapy several times daily
4. Advise rest from aggravating activities
5. Add stretching exercises to treatment regimen
6. Reassess in 2-4 weeks:
   • If improved: Continue current management until resolution
   • If not improved: Consider alternative analgesics, corticosteroids, or manual therapy
7. If no improvement after 4-6 weeks: Reconsider diagnosis and evaluate for other causes