What are the diagnostic criteria and treatment options for costochondritis?

Costochondritis Diagnosis and Treatment

Costochondritis is diagnosed by tenderness to palpation of the costochondral joints, which is the hallmark physical finding, and treatment primarily consists of NSAIDs for 1-2 weeks along with activity modification. 1

Diagnostic Criteria

• The primary diagnostic criterion is reproducible pain with palpation of the affected costochondral joints 2, 1
• Pain is typically described as stinging (53%) or pressing (35.1%), commonly located retrosternal (52%) or left-sided (69.2%) 1, 3
• Symptoms often occur more than once daily (62.9%), with many patients experiencing chronic symptoms lasting >6 months (55.4%) 1
• Most nontraumatic musculoskeletal chest wall pain (42%) is attributed to costochondritis 1, 3

Required Diagnostic Testing

• For patients older than 35 years or with cardiac risk factors, an ECG should be obtained to rule out cardiac causes 3, 4
• Chest radiography may be useful as an initial imaging test to evaluate for other potential causes of chest pain 3, 5
• In younger patients without cardiac risk factors, history and physical examination documenting reproducible pain by palpation over the costal cartilages are usually sufficient for diagnosis 4

Differential Diagnosis Considerations

• Tietze syndrome (includes visible swelling at the costochondral junction) 3
• Slipping rib syndrome (pain associated with ribs subluxing from the joint) 3
• SAPHO syndrome (synovitis, acne, pustulosis, hyperostosis, and osteitis) 3
• Serious causes of chest pain that must be ruled out include acute coronary syndrome, pulmonary embolism, aortic dissection, and esophageal rupture 2, 5

Treatment Options

Pharmacological Management

• First-line treatment: NSAIDs for 1-2 weeks for pleuritic-type pain or when there is an underlying inflammatory component 1, 4
• Acetaminophen can be used as an alternative if NSAIDs are contraindicated 1
• Low-dose colchicine may be added if symptoms persist despite NSAID therapy 1
• Topical analgesics like lidocaine patches may provide localized pain relief with minimal systemic effects 1

Non-Pharmacological Approaches

• Local application of heat or ice as part of the initial treatment 1, 4
• Activity modification to avoid movements that exacerbate pain 4
• Stretching exercises have shown progressive significant improvement in pain compared to control groups 6
• Manual therapy techniques including rib manipulation and soft tissue mobilization have demonstrated complete resolution of symptoms in case studies 7, 8
• Physical therapy utilizing an impairment-based approach including manual therapy and therapeutic exercise may facilitate resolution of costochondritis 8

Treatment Algorithm

1. Initial management:

   • NSAIDs for 1-2 weeks (if not contraindicated) 1, 4
   • Local application of heat or ice 1
   • Activity modification to avoid chest muscle overuse 4

2. If inadequate response after 1-2 weeks:

   • Consider adding low-dose colchicine 1
   • Consider topical analgesics like lidocaine patches 1
   • Refer for physical therapy with focus on stretching exercises and manual therapy 6, 8

3. For persistent cases (lasting >6 weeks):

   • Reassessment to rule out other potential causes 1
   • Consider specialized physical therapy techniques including rib manipulation and instrument-assisted soft tissue mobilization 7, 8

Important Caveats

• Costochondritis is usually self-limited and benign but must be distinguished from more serious causes of chest pain 4
• Coronary artery disease is present in 3-6% of adult patients with chest pain and chest wall tenderness to palpation 4
• Infectious costochondritis is rare but should be considered if there is purulent drainage, fever, or other signs of infection 9
• Anterior chest wall pain affects a significant percentage of those with axial spondyloarthritis and may be the first manifestation of disease in some patients 1, 3
• Atypical costochondritis (not self-resolving) is associated with high medical expenses and psychological burden on patients 7