Are injections a recommended treatment for costochondritis?

Injections for Costochondritis: Evidence-Based Management

Intra-articular glucocorticoid injections may be considered as a bridging option for costochondritis when awaiting the effect of other treatments, but should not be used as first-line therapy. 1

First-Line Treatment Approach

• NSAIDs or COXIBs at maximum tolerated and approved dosage should be initiated as first-line treatment for costochondritis pain 1
• Treatment response should be evaluated after 2-4 weeks of NSAID therapy; if insufficient response occurs, consider NSAID/COXIB rotation or advancing to second-line treatment 1
• Physical therapy interventions including stretching exercises have shown significant improvement in costochondritis pain compared to control groups and should be incorporated into the treatment plan 2

Role of Injections in Costochondritis Management

• Intra-articular glucocorticoid injections can be considered as a bridging therapy while awaiting the effect of other agents, but are not recommended as primary treatment 1
• Local glucocorticoid injections may be beneficial for patients with persistent localized pain that is inadequately controlled with NSAIDs 1
• For patients with limited response to first-line treatments, local injections can be considered before escalating to systemic therapies 1

Evidence for Injection Efficacy

• Evidence supporting injections specifically for costochondritis is limited, with most recommendations extrapolated from studies on other musculoskeletal conditions 1
• Intra-articular corticosteroid injections have demonstrated short-term efficacy in similar conditions like knee osteoarthritis 1
• When performing injections, ultrasound guidance may help ensure accurate medication delivery into the affected costochondral junction 1

Important Considerations and Precautions

• Avoid long-term use of glucocorticoids (both injected and oral) due to potential adverse effects 1
• Patients with diabetes should be informed about the risk of transient increased glycemia following glucocorticoid injections, particularly from days 1-3 post-injection 1
• Patients should avoid overuse of the injected area for 24 hours following injection, though complete immobilization is not recommended 1

Alternative Treatment Options

• Oral corticosteroids may be considered for severe cases, with one study showing significant improvement in pain scores when short-term oral prednisolone was added to NSAID therapy in Tietze syndrome (a form of costochondritis with visible swelling) 3
• Active physical therapy interventions (supervised exercise) are preferred over passive interventions (massage, ultrasound, heat) 1
• Stretching exercises have demonstrated progressive significant improvement in costochondritis pain compared to control groups 2

Treatment Algorithm

1. Start with NSAIDs/COXIBs at maximum tolerated dose 1
2. Add physical therapy with emphasis on stretching exercises 2
3. If inadequate response after 2-4 weeks:
   • Consider NSAID rotation 1
   • Consider local glucocorticoid injection as a bridging therapy 1
4. For persistent cases:
   • Short course of oral corticosteroids may be considered 3
   • Avoid long-term steroid use 1

Special Considerations

• Rule out infectious costochondritis, which requires antibiotics and possibly surgical debridement rather than anti-inflammatory treatment 4
• In cases of atypical costochondritis that does not self-resolve, consider manipulative therapy and instrument-assisted soft tissue mobilization 5
• Surgical intervention (resection of affected cartilage) is rarely needed and reserved for severe refractory cases 6