What is the recommended treatment for costochondritis?

Treatment for Costochondritis

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

Pharmacological Management

• NSAIDs should be used at the lowest effective dose for the shortest possible period to minimize risks, with consideration of topical NSAIDs to reduce systemic side effects 1
• Acetaminophen (paracetamol) may be used as an alternative or adjunct for pain relief when NSAIDs are insufficient, contraindicated, or poorly tolerated 1
• For patients with increased gastrointestinal risk, use non-selective NSAIDs plus a gastroprotective agent, or a selective COX-2 inhibitor 1
• Local corticosteroid injections may be considered for persistent pain that doesn't respond to initial treatments 1
• Avoid long-term use of systemic corticosteroids due to potential adverse effects and lack of evidence supporting their use for this condition 1

Non-Pharmacological Interventions

• Local heat or cold applications to the affected area can provide symptomatic relief 1
• Stretching exercises have shown significant improvement in pain compared to control groups 2
• Physical therapy utilizing manual therapy and therapeutic exercise may facilitate resolution of costochondritis, particularly in cases that don't respond to medication alone 3
• Regular exercise and physical therapy should be considered as part of a comprehensive treatment plan 1

Treatment Algorithm

1. Initial treatment: NSAIDs at maximum tolerated dose for 2-4 weeks 1
2. If inadequate response: Consider switching to a different NSAID or adding acetaminophen 1
3. For persistent pain: Consider local corticosteroid injection for focal areas of tenderness 1
4. Adjunctive therapy: Implement stretching exercises and physical therapy, particularly for cases not responding to medication 2, 3

Important Considerations

• Costochondritis is usually self-limited but can persist for several weeks to months 4
• Monitor for gastrointestinal, liver, and cardiorenal toxicity with prolonged NSAID use, particularly in elderly patients and those with comorbidities 1
• Serious causes of chest pain should be ruled out prior to diagnosing costochondritis, as it is often a diagnosis of exclusion 5
• Patients older than 35 years, those with a history or risk of coronary artery disease, and any patient with cardiopulmonary symptoms should have an electrocardiograph and possibly a chest radiograph to rule out cardiac causes 4
• Advise patients to avoid activities that produce chest muscle overuse during the recovery period 4

Special Cases

• For atypical costochondritis (not self-resolving), consider referral to physical medicine and rehabilitation for manipulative therapy, instrument-assisted soft tissue mobilization, and stretching exercises 5
• Infectious costochondritis is rare but requires different management including antibiotics and possibly surgical debridement 6