What is the recommended treatment for costochondritis?

Treatment of Costochondritis

A short course of nonsteroidal anti-inflammatory drugs (NSAIDs) is the first-line treatment for costochondritis, with the addition of low-dose colchicine as needed for cases with significant inflammatory component. 1

First-Line Pharmacological Treatment

NSAIDs

• Recommended as initial therapy for pain and inflammation management
• Use for 1-2 weeks as a trial 1
• Options include:
  • Ibuprofen (400-800 mg three times daily)
  • Naproxen (250-500 mg twice daily)
  • Other NSAIDs based on patient tolerance and risk factors

Important NSAID Considerations

• GI risk: For patients with increased gastrointestinal risk, consider:
  • Non-selective NSAIDs plus gastroprotective agent
  • Selective COX-2 inhibitor 1
• Cardiovascular risk: Choice of NSAID should account for cardiovascular risk factors 1
• Use lowest effective dose for shortest duration possible

Second-Line Treatments

Colchicine

• Add low-dose colchicine if symptoms persist despite NSAID therapy 1
• Particularly useful when there is a significant inflammatory component

Analgesics

• Consider for pain control when NSAIDs are:
  • Insufficient
  • Contraindicated
  • Poorly tolerated 1
• Options include:
  • Acetaminophen/paracetamol (up to 3-4g/day)
  • Opioids (reserved for severe cases)

Non-Pharmacological Approaches

Physical Therapy and Exercise

• Stretching exercises have shown significant improvement in costochondritis pain 2
• Consider referral to physical therapy for:
  • Manual therapy techniques
  • Therapeutic exercise
  • Soft tissue mobilization 3

Heat Application

• Local heat application may provide symptomatic relief 4
• Can be used as adjunct to pharmacological treatment

Activity Modification

• Avoid activities that exacerbate symptoms
• Modify movements that involve chest wall stress
• Gradually return to normal activities as symptoms improve

Special Considerations

Atypical or Persistent Costochondritis

• For cases not responding to standard treatment after 2-3 weeks:
  • Consider manual therapy techniques including rib manipulation 5
  • Instrument-assisted soft tissue mobilization may be beneficial 5
  • Re-evaluate diagnosis to rule out other conditions

Infectious Costochondritis

• Important to differentiate from non-infectious costochondritis
• Requires antibiotic therapy based on culture results
• May require surgical debridement in severe cases 6

Treatment Algorithm

1. Start with NSAIDs for 1-2 weeks
2. If inadequate response, add colchicine
3. Incorporate heat therapy and activity modification throughout treatment
4. For persistent symptoms beyond 2-3 weeks, refer to physical therapy
5. For severe or refractory pain, consider analgesics
6. If symptoms persist beyond 4-6 weeks, re-evaluate diagnosis and consider specialized interventions

Monitoring

• Assess pain control and functional status regularly
• Monitor for medication side effects, particularly with NSAIDs
• Adjust treatment based on response and tolerance

Most cases of costochondritis are self-limiting and resolve within weeks to months with appropriate treatment. The combination of pharmacological and non-pharmacological approaches typically provides effective symptom relief while the condition resolves.