What is the management for costochondritis?

Management of Costochondritis

For costochondritis, a 1-2 week course of nonsteroidal anti-inflammatory drugs (NSAIDs) is the first-line treatment, with the addition of low-dose colchicine as needed for persistent symptoms. 1

Diagnosis

Costochondritis is characterized by:

• Chest wall pain that is reproducible with palpation over the costal cartilages
• Tenderness at the costochondral junctions or chondrosternal joints
• Absence of swelling, erythema, or warmth (which would suggest Tietze syndrome)

Important diagnostic considerations:

• Rule out cardiac causes in patients >35 years or with cardiac risk factors via ECG and possibly chest radiograph 2
• Diagnosis is primarily clinical and typically doesn't require imaging in young, healthy patients

Treatment Algorithm

First-Line Treatment

1. NSAIDs for 1-2 weeks 1, 2

   • Ibuprofen 400-600mg three times daily
   • Naproxen 250-500mg twice daily
   • Use the lowest effective dose for the shortest duration

2. Activity Modification

   • Avoid activities that exacerbate chest wall pain 2
   • Rest from activities causing chest muscle overuse

For Persistent Symptoms

1. Add low-dose colchicine if symptoms persist despite NSAID therapy 1

2. Consider acetaminophen (up to 3-4g/day) as an alternative for patients with contraindications to NSAIDs 3

3. Physical therapy interventions for persistent cases:

   • Stretching exercises have shown significant improvement in pain reduction 4
   • Manual therapy including rib manipulation and soft tissue mobilization 5, 6
   • Instrument-assisted soft tissue mobilization for myofascial pain 5

For Refractory Cases

1. Local heat application for symptomatic relief 3, 2

2. Consider referral to physical medicine and rehabilitation for cases not responding to initial management 5

Special Considerations

• Duration: Costochondritis is typically self-limiting but may last from several weeks to several months 6

• Atypical costochondritis (non-resolving) may benefit from:

  • Osteopathic manipulative techniques targeting rib dysfunction 5
  • Multimodal physical therapy approaches 6

• Monitoring: Follow-up to assess pain control and functional status, adjusting treatment as needed 3

Treatment Efficacy

• Physical therapy utilizing manual therapy and therapeutic exercise has shown promising results:

  • Mean pain reduction of 5.1 points on the numerical pain rating scale 6
  • Improved functional outcomes allowing return to previous activities 6

• Stretching exercises demonstrated progressive significant improvement compared to control groups in patients with persistent costochondritis 4

Pitfalls to Avoid

1. Misdiagnosis: Coronary artery disease is present in 3-6% of adult patients with chest pain and chest wall tenderness 2

2. Overtreatment: Avoid unnecessary imaging in young patients with typical presentation

3. Prolonged NSAID use: Monitor for gastrointestinal, cardiovascular, and renal adverse effects with extended NSAID therapy 3

4. Delayed referral: Consider physical therapy for cases not resolving within expected timeframes

By following this evidence-based approach, most patients with costochondritis can achieve symptom resolution and return to normal activities.