Management of Costochondritis

Start with a 1-2 week course of NSAIDs as first-line treatment, supplemented with local heat or cold applications and activity modification. 1

Initial Pharmacological Management

NSAIDs are the cornerstone of treatment and should be initiated at the lowest effective dose for the shortest duration necessary 1, 2
Specific options include ibuprofen or naproxen at appropriate dosing for 1-2 weeks initially 1
For patients with gastrointestinal risk factors, use non-selective NSAIDs plus a gastroprotective agent, or alternatively a selective COX-2 inhibitor 2
Topical NSAIDs may be considered as an alternative to oral formulations, particularly for patients concerned about systemic side effects 1, 2

Apply local heat or cold applications to the affected costochondral area for symptomatic relief 1, 2
Modify activities to avoid movements that exacerbate pain while maintaining general physical activity 1
Rest during acute painful episodes, followed by gradual return to normal activities as symptoms improve 1
Stretching exercises targeting the chest wall may provide significant pain relief, with one study showing progressive improvement compared to controls (p<0.001) 3

If symptoms persist after 2-4 weeks of initial NSAID therapy:

Add low-dose colchicine for persistent inflammatory symptoms 1
Consider switching to a different NSAID if the initial agent was ineffective 2
For patients with NSAID contraindications or insufficient response, use acetaminophen (paracetamol) at regular dosing as an alternative or adjunct 1, 2
Local corticosteroid injections directed to the site of costochondral inflammation may be considered for focal areas of persistent tenderness 2
Avoid long-term systemic corticosteroids due to potential adverse effects and lack of supporting evidence 2

Manual therapy techniques including rib manipulation and soft tissue mobilization can be effective, particularly for atypical costochondritis that fails to self-resolve 4, 5
An impairment-based examination and treatment approach targeting the cervicothoracic spine and ribcage showed clinically meaningful improvements, with mean pain reduction of 5.1 points on the NPRS scale 5
Regular exercise and physical therapy should be incorporated as part of comprehensive management 2

Before diagnosing costochondritis, cardiac causes must be excluded, particularly in patients over 35 years, those with cardiac risk factors, or any patient with cardiopulmonary symptoms 6, 7
An ECG should be obtained within 10 minutes for acute chest pain presentations, and cardiac troponin measured as soon as possible if acute coronary syndrome is suspected 6
Tenderness to palpation of the costochondral joints is the key diagnostic finding that distinguishes costochondritis from cardiac causes 6
Monitor for NSAID-related gastrointestinal, renal, and cardiovascular toxicity, especially in elderly patients and those with comorbidities 1, 2

In elderly patients or those with multiple comorbidities, carefully weigh the risks and benefits of NSAIDs before prescribing 1, 2
For patients with absolute contraindications to NSAIDs, prioritize acetaminophen and physical therapy interventions 1
Be aware that infectious costochondritis (though rare) requires entirely different management with antibiotics and possible surgical debridement, particularly in immunocompromised or diabetic patients 8