What is the treatment for costochondritis?

Treatment for Costochondritis

Start with NSAIDs at maximum tolerated and approved dosage as first-line treatment, evaluate response after 2-4 weeks, and consider topical NSAIDs to minimize systemic side effects. 1

First-Line Pharmacological Management

• NSAIDs/COXIBs represent the cornerstone of treatment and should be initiated at maximum tolerated doses, with treatment response assessed at 2-4 weeks 1
• Use oral NSAIDs at the lowest effective dose for the shortest duration to minimize adverse effects 1
• Topical NSAIDs are preferred when possible to reduce systemic side effects, particularly gastrointestinal, hepatic, and cardiorenal toxicity 1
• Acetaminophen (paracetamol) should be used as an alternative or adjunct when NSAIDs are insufficient, contraindicated, or poorly tolerated 1

Special Population Considerations

For patients at increased gastrointestinal risk (age ≥60 years, history of peptic ulcer disease, concurrent corticosteroid or anticoagulant use):

• Use non-selective NSAIDs plus a gastroprotective agent, OR 1
• Use selective COX-2 inhibitors 1
• Monitor closely for gastrointestinal, liver, and cardiorenal toxicity, especially in elderly patients with comorbidities 1

Treatment Algorithm for Inadequate Response

If pain persists after 2-4 weeks of initial NSAID therapy:

• Switch to a different NSAID, OR 1
• Add acetaminophen to the existing regimen 1
• For focal areas of persistent tenderness, consider local corticosteroid injection directly to the site of musculoskeletal inflammation 1

Corticosteroid Use

• Short courses of oral prednisolone or intra-articular glucocorticoid injections may serve as bridging options while awaiting the effect of other agents 1
• Avoid long-term systemic corticosteroids due to potential adverse effects and lack of evidence supporting their use for axial pain 1

Non-Pharmacological Interventions

• Apply local heat or cold applications to the affected area 1
• Implement stretching exercises targeting the costochondral junctions, which have demonstrated progressive significant improvement compared to controls (p<0.001) 2
• Regular exercise and physical therapy should be incorporated as part of comprehensive treatment 1
• Manual therapy techniques including rib manipulation and soft tissue mobilization may facilitate resolution, particularly in atypical cases that don't self-resolve 3, 4
• Provide patient education about the benign, self-limiting nature of the condition and lifestyle modifications 1

Critical Pitfalls to Avoid

• Always rule out serious cardiac causes before diagnosing costochondritis, especially in patients over 35 years or those with cardiac risk factors—coronary artery disease is present in 3-6% of adult patients with chest pain and chest wall tenderness 5
• Do not use long-term glucocorticoids, as evidence does not support their efficacy and adverse effects are significant 1
• Avoid prolonged NSAID use without gastroprotection in high-risk patients 1
• Recognize that infectious costochondritis (though rare) requires antibiotic therapy and potentially surgical debridement, not just anti-inflammatory treatment 6