Costochondritis: Symptoms and Treatment Options
Costochondritis is characterized by tenderness to palpation of the costochondral joints, which is the hallmark physical finding, and is typically managed with a 1-2 week course of NSAIDs as first-line treatment. 1
Symptoms of Costochondritis
- Pain is typically reproducible with palpation of the affected costochondral joints, particularly involving ribs 3-7 1, 2
- Pain may be described as stinging (53%) or pressing (35.1%), and is commonly retrosternal (52%) or left-sided (69.2%) 3
- Symptoms often occur more than once daily (62.9%), with many patients experiencing chronic symptoms lasting >6 months (55.4%) 3
- Pain typically worsens with deep breathing, coughing, or movement, which is characteristic of pleuritic chest pain 2
- Most patients report anterior chest wall pain that is exacerbated by physical activity or specific movements 4
Diagnostic Approach
- Diagnosis is primarily clinical, based on reproducible tenderness over the costochondral junctions 1, 4
- For patients older than 35 years or with cardiac risk factors, an ECG should be obtained to rule out cardiac causes 2, 4
- Chest radiography may be useful as an initial imaging test to rule out other conditions that may mimic costochondritis 2
- It's crucial to distinguish costochondritis from serious causes of chest pain, as coronary artery disease is present in 3-6% of adult patients with chest pain and chest wall tenderness 4
- Ultrasound can be helpful in detecting costochondral abnormalities not visible on radiographs, with higher sensitivity than CT 2
Treatment Algorithm
First-line Treatment
- NSAIDs for 1-2 weeks for pain management and to address the inflammatory component 1, 4
- Acetaminophen can be used as an alternative if NSAIDs are contraindicated 1
- Local application of heat or ice packs can provide symptomatic relief 1
Second-line Treatment (if inadequate response to initial therapy)
- Consider adding low-dose colchicine if symptoms persist despite NSAID therapy 1
- Topical analgesics like lidocaine patches may provide localized pain relief with minimal systemic effects 1
- Stretching exercises have shown significant improvement in pain compared to conventional treatment alone 5
Physical Therapy Approaches
- Manual therapy and therapeutic exercise targeting the cervicothoracic spine and ribcage have shown promising results in case studies 6
- Instrument-assisted soft tissue mobilization (IASTM) and stretching may be beneficial for persistent cases 7
- Osteopathic manipulation techniques can be useful in treating rib dysfunction, especially in atypical costochondritis 7
Important Considerations and Caveats
- Most nontraumatic musculoskeletal chest wall pain (42%) is attributed to costochondritis 3
- Costochondritis is usually self-limited and benign but can last from several weeks to several months 6
- Atypical costochondritis (non-resolving) is associated with high medical expenses and psychological burden 7
- Anterior chest wall pain affects a significant percentage of those with axial spondyloarthritis and may be the first manifestation of disease in some patients 3
- Infectious costochondritis is rare but should be considered in patients with purulent discharge, fever, or other signs of infection 8
- Patients should be advised to avoid activities that produce chest muscle overuse during the recovery period 4