What is costochondritis and how is it treated?

Costochondritis: Definition and Treatment

Costochondritis is a condition characterized by inflammation of the costochondral junctions or chondrosternal joints of the anterior chest wall, with the hallmark physical finding being tenderness to palpation of the affected joints. 1, 2

Clinical Characteristics

• Costochondritis accounts for approximately 42% of all nontraumatic musculoskeletal chest wall pain 1, 2
• Pain is typically described as stinging (53%) or pressing (35.1%), and is commonly retrosternal (52%) or left-sided (69.2%) 1
• Symptoms often occur more than once daily (62.9%), with many patients experiencing chronic symptoms lasting >6 months (55.4%) 1
• The condition is usually self-limited and benign, though it must be distinguished from more serious causes of chest pain 3

Diagnosis

• The primary diagnostic criterion is reproducible pain with palpation of the affected costochondral joints 4
• For patients older than 35 years or with cardiac risk factors, an ECG should be obtained to rule out cardiac causes 2, 3
• Chest radiography may be useful as an initial imaging test to evaluate for specific etiologies that may simulate chest wall pain 2
• Ultrasound can be helpful in detecting costochondral abnormalities not visible on radiographs 2

Differential Diagnosis

• Serious causes of chest pain that must be ruled out include acute coronary syndrome, pulmonary embolism, aortic dissection, and esophageal rupture 4
• Tietze syndrome, which involves localized inflammation of at least one joint between the rib and costal cartilage, often with visible swelling 2
• Slipping rib syndrome, characterized by pain associated with ribs subluxing from the joint 2
• Anterior chest wall pain may be the first manifestation of axial spondyloarthritis in some patients 1, 4

Treatment

Pharmacological Management

• First-line treatment consists of 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, 4
• Low-dose colchicine may be added if symptoms persist despite NSAID therapy 1, 4
• Topical analgesics like lidocaine patches may provide localized pain relief with minimal systemic effects 1, 4

Non-Pharmacological Approaches

• Local application of heat or ice as part of the initial treatment 1, 4
• Stretching exercises have shown progressive significant improvement in patients with costochondritis compared to control groups 5
• Osteopathic manipulation techniques (OMT) may be useful in the treatment of rib dysfunction, especially in atypical costochondritis that doesn't resolve with standard treatment 6
• Patients should be advised to avoid activities that produce chest muscle overuse 3

Treatment Algorithm

1. Initial Management:

   • Start with NSAIDs for 1-2 weeks 1, 4
   • Apply local heat or ice 1, 4
   • Recommend activity modification to avoid chest wall strain 3

2. If inadequate response after 1-2 weeks:

   • Consider adding low-dose colchicine 1, 4
   • Try topical analgesics like lidocaine patches 1, 4
   • Consider referral for stretching exercises or physical therapy 5

3. For persistent symptoms (atypical costochondritis):

   • Consider manipulative therapy and soft tissue mobilization 6
   • Reassess to rule out other potential causes of persistent pain 1

Special Considerations

• Infectious costochondritis is rare but can occur, particularly in immunocompromised patients, and requires antibiotic treatment and possibly surgical debridement 7
• Alternative treatments such as external herbal medicines have been reported in case studies but require further research 8