What is the treatment for costochondritis?

Treatment for Costochondritis

The first-line treatment for costochondritis is NSAIDs at maximum tolerated and approved dosage, with evaluation of treatment response after 2-4 weeks. 1

Pharmacological Management

• Start with NSAIDs/COXIBs at maximum tolerated and approved dosage as first-line treatment 1
• Evaluate treatment response after 2-4 weeks; if sufficient response, continue and re-evaluate at 12 weeks 1
• Consider NSAID/COXIB rotation if insufficient response at 2-4 weeks 1
• Short courses of oral prednisolone or intra-articular glucocorticoid injections may be considered as bridging options while awaiting the effect of other agents 1
• Avoid long-term use of glucocorticoids due to potential adverse effects 1
• For pain relief, regular dosing of acetaminophen (paracetamol) may be needed as an alternative or adjunct 1
• Topical NSAIDs can be considered before oral NSAIDs to minimize systemic side effects 1
• Use oral NSAIDs at the lowest effective dose for the shortest possible period of time to minimize risks 1

Non-Pharmacological Interventions

• Provide patient education about the condition and lifestyle recommendations 1
• Consider physiotherapy, which has shown effectiveness in case studies 1, 2
• Apply local heat or cold applications to the affected area 1
• Implement stretching exercises, which have demonstrated significant pain reduction in patients with costochondritis 3
• Consider manual therapy techniques including rib manipulation and soft tissue mobilization, which have shown complete resolution of symptoms in some cases 4
• Recommend activity modification to avoid movements that exacerbate pain 5
• Consider instrument-assisted soft tissue mobilization (IASTM) for myofascial pain generators 4

Treatment Algorithm

1. Initial Management:

   • Start with NSAIDs at maximum tolerated dose 1
   • Implement non-pharmacological measures including local heat/cold, activity modification, and patient education 1

2. After 2-4 weeks, assess response:

   • If sufficient response: continue treatment and reassess at 12 weeks 1
   • If insufficient response: consider NSAID rotation or add second-line treatment 1

3. Second-line options:

   • Consider short-course oral prednisolone or intra-articular glucocorticoid injections 1
   • Refer for physical therapy with focus on manual therapy and stretching exercises 4, 2, 3

4. For persistent cases (atypical costochondritis):

   • Implement multimodal physical therapy approach including manipulative therapy, instrument-assisted soft tissue mobilization, and stretching 4, 2

Special Considerations

• Rule out more serious causes of chest pain before confirming diagnosis of costochondritis, especially in patients over 35 years or with cardiac risk factors 5
• Distinguish between non-infectious costochondritis (more common) and infectious costochondritis, which requires antibiotics and possibly surgical debridement 6
• Costochondritis is typically self-limiting but can persist for several weeks to months; persistent cases (atypical costochondritis) may require more aggressive physical therapy intervention 4, 5
• Monitor for gastrointestinal, liver, and cardiorenal toxicity with prolonged NSAID use, particularly in elderly patients and those with comorbidities 1

Treatment Efficacy

• Physical therapy utilizing manual therapy and therapeutic exercise has shown promising results with clinically meaningful improvements in pain and function 2
• Stretching exercises have demonstrated progressive significant improvement compared to control groups 3
• Complete resolution of symptoms has been reported after rib manipulation and soft tissue mobilization in some cases 4
• Traditional pharmacological treatment with NSAIDs is effective for most cases but may be insufficient for persistent symptoms 5, 3