What is the recommended treatment for costochondritis in adults?

Treatment for Costochondritis in Adults

The recommended first-line treatment for costochondritis in adults is non-steroidal anti-inflammatory drugs (NSAIDs) at maximum tolerated and approved dosage, along with physical therapy interventions including stretching exercises and local heat or cold applications. 1, 2

Pharmacological Management

First-Line Treatment

• NSAIDs should be started at maximum tolerated and approved dosage for adults with active costochondritis 3
• Acetaminophen (paracetamol) can be used for pain relief, with regular dosing as needed 3
• Topical NSAIDs should be considered before oral NSAIDs, particularly for mild to moderate pain 3, 4

Second-Line Treatment

• If NSAIDs are insufficient after 2-4 weeks, consider NSAID rotation or advancing to second-line treatment 3
• Oral NSAIDs or COX-2 inhibitors should be used at the lowest effective dose for the shortest possible period of time 3, 4
• When prescribing oral NSAIDs/COX-2 inhibitors, add a proton pump inhibitor for gastroprotection 3, 4

Additional Considerations

• Short courses of oral prednisolone or intra-articular glucocorticoid injections may be considered as bridging options in cases of severe pain 3
• Avoid long-term use of systemic glucocorticoids 3
• In cases of isolated active inflammation, locally administered parenteral glucocorticoids may be considered 3

Non-Pharmacological Management

Physical Therapy

• Physical therapy is strongly recommended for costochondritis treatment 3, 5
• Stretching exercises have shown significant improvement in costochondritis pain compared to control groups 2
• Manual therapy techniques including rib manipulation and soft tissue mobilization have demonstrated complete resolution of symptoms in some cases 5, 6

Heat and Cold Applications

• Local heat or cold applications can provide temporary pain relief 3
• These can be used as adjuncts to pharmacological treatment 3, 7

Activity Modification

• Advise patients to avoid activities that produce chest muscle overuse 1
• Pacing activities (avoiding "peaks" and "troughs") is recommended 3

Treatment Algorithm

1. Initial Management (0-2 weeks)

   • Start NSAIDs at maximum tolerated dose 3
   • Begin stretching exercises and physical therapy 2, 6
   • Apply local heat or cold for symptomatic relief 3
   • Provide reassurance about the benign nature of the condition 1

2. Evaluation at 2-4 weeks

   • If sufficient response: continue current treatment and re-evaluate at 12 weeks 3
   • If insufficient response: consider NSAID rotation or add second-line treatment 3

3. Second-Line Options (if needed)

   • Consider physical therapy with manual techniques including rib manipulation 5, 6
   • Consider local glucocorticoid injection for severe cases 3
   • Evaluate for possible referral to specialist if symptoms persist beyond 3 months 5

Important Considerations

• Costochondritis is usually self-limited but can persist for several weeks to months 1, 6
• Rule out serious causes of chest pain before diagnosing costochondritis, as it is often a diagnosis of exclusion 5, 1
• Patients older than 35 years or those with risk factors for coronary artery disease should have appropriate cardiac evaluation 1
• Infectious costochondritis is rare but should be considered if there is purulent drainage, fever, or other signs of infection 8
• Physical therapy utilizing an impairment-based examination and treatment approach has shown promising results in case series, with patients returning to normal activities after an average of 4-5 sessions 6