What are the treatment recommendations for patients with costochondritis?

Treatment Recommendations for Costochondritis

NSAIDs are the first-line treatment for costochondritis, used at the lowest effective dose for the shortest possible period to minimize adverse effects. 1

Pharmacological Management

First-Line Treatment

• NSAIDs should be used at maximum tolerated and approved dosage, with treatment response evaluated after 2-4 weeks 1
• Consider topical NSAIDs to minimize systemic side effects, especially in patients with increased gastrointestinal risk 1
• For patients with increased gastrointestinal risk, use non-selective NSAIDs plus a gastroprotective agent, or a selective COX-2 inhibitor 2, 1
• Monitor for gastrointestinal, liver, and cardiorenal toxicity with prolonged NSAID use, particularly in elderly patients and those with comorbidities 1

Alternative or Adjunct Pain Relief

• Acetaminophen (paracetamol) may be needed as an alternative or adjunct for pain relief when NSAIDs are insufficient, contraindicated, or poorly tolerated 2, 1
• Regular dosing of acetaminophen may be required for adequate pain control 1

Additional Options

• Short courses of oral prednisolone may be considered as a bridging option while awaiting the effect of other agents 1
• Local corticosteroid injections directed to the site of musculoskeletal inflammation may be considered for persistent pain 2, 1
• Avoid long-term use of systemic corticosteroids due to potential adverse effects and lack of evidence supporting their use for axial pain 2, 1

Non-Pharmacological Interventions

Physical Therapy and Exercise

• Regular exercise and physical therapy should be considered as part of a comprehensive treatment plan 2, 1
• Stretching exercises have shown progressive significant improvement in pain compared to control groups 3
• Manual therapy and therapeutic exercise targeting the cervicothoracic spine and ribcage may facilitate resolution of symptoms 4
• Rest from activities that exacerbate symptoms, particularly those involving chest muscle overuse 5

Supportive Measures

• Apply local heat or cold applications to the affected area for symptomatic relief 1
• Patient education about the condition, including its typically self-limiting nature 1

Treatment Algorithm

1. Initial Management (Weeks 1-4):

   • Start with NSAIDs at maximum tolerated dose 1
   • Add local heat/cold application as needed 1
   • Begin gentle stretching exercises 3
   • Avoid activities that exacerbate pain 5

2. If Inadequate Response After 2-4 Weeks:

   • Consider switching to different NSAID or adding acetaminophen 2, 1
   • Refer for physical therapy with manual therapy and targeted exercises 4
   • Consider local corticosteroid injection for focal areas of tenderness 2, 1

3. For Persistent Cases (Atypical Costochondritis):

   • Consider short course of oral prednisolone as a bridging therapy 1
   • Intensify physical therapy with manipulation techniques and soft tissue mobilization 6
   • Rule out infectious causes if symptoms persist beyond 3 months, especially in patients with risk factors like diabetes 7

Special Considerations

• Costochondritis is usually self-limited but can persist for several weeks to months 5
• Ensure serious causes of chest pain are ruled out before confirming diagnosis, especially in patients over 35 or with cardiac risk factors 5
• Infectious costochondritis is rare but should be considered in cases with purulent drainage, fever, or failure to respond to standard treatment 7