Initial Treatment for Costochondritis
The initial treatment for costochondritis should be nonsteroidal anti-inflammatory drugs (NSAIDs) at maximum tolerated dosage for 1-2 weeks to reduce inflammation and pain. 1
Diagnosis and Confirmation
Costochondritis is characterized by:
- Tenderness of costochondral joints
- Localized chest pain reproduced by palpation
- Absence of swelling, redness, or warmth (distinguishing it from Tietze syndrome)
- No abnormalities on imaging studies
Before initiating treatment, it's essential to rule out serious causes of chest pain such as acute coronary syndrome, pulmonary embolism, pneumothorax, and pericarditis through appropriate evaluation 2, 1.
Pharmacological Management
First-Line Treatment:
- NSAIDs for 1-2 weeks at maximum tolerated dosage 1
- Options include ibuprofen, naproxen, diclofenac, and celecoxib
- Continue for up to 2 weeks to adequately reduce inflammation
- Monitor for gastrointestinal, renal, and cardiovascular side effects, particularly in elderly patients or those with comorbidities
Alternative Pharmacological Options:
- Topical NSAIDs: Consider as an alternative with fewer systemic side effects 1
- Acetaminophen: Can be used if NSAIDs are contraindicated or ineffective 1
- Non-acetylated salicylates: Consider in small doses if both NSAIDs and acetaminophen are ineffective 1
- Corticosteroids: A short course of oral corticosteroids or intra-articular corticosteroid injections may be considered if there is insufficient response to NSAIDs after 2-4 weeks 1
Non-Pharmacological Management
Local heat or cold application 1:
- Heat: Apply heating pad for 15-20 minutes several times daily
- Cold: Apply ice wrapped in a towel for 10-minute periods
Activity modification 1:
- Relative rest
- Avoid activities that aggravate pain
- Reduce activities involving muscle overuse
Stretching exercises: May provide significant improvement in pain compared to conventional treatment alone 3
Manual therapy: In cases of persistent symptoms, consider referral for techniques such as rib manipulation and soft tissue mobilization 4
Follow-up and Treatment Evaluation
- 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 typically self-limiting but can become chronic in some cases 5
- Long-term use of NSAIDs should be avoided due to potential risks 1
- In a prospective analysis, costochondritis was found in 30% of emergency department patients with chest pain, with a higher frequency among women 6
- After one year, approximately 55% of patients may still experience some chest pain, though only about one-third will still have definite costochondritis 6
Remember that while costochondritis is usually benign, proper diagnosis is crucial to exclude more serious conditions that may present with similar symptoms.