What is the treatment for costochondritis?

Treatment of Costochondritis

Start with NSAIDs at maximum tolerated dosage as first-line treatment, evaluate response after 2-4 weeks, and add physical therapy interventions including stretching exercises and manual therapy for persistent or refractory cases. 1

First-Line Pharmacological Management

• Initiate NSAIDs or COX-2 inhibitors at maximum tolerated and approved dosage as the primary treatment approach 1
• Use oral NSAIDs at the lowest effective dose for the shortest duration to minimize systemic risks 1
• Consider topical NSAIDs to reduce systemic side effects, particularly in patients with comorbidities 1
• For patients with increased gastrointestinal risk, use non-selective NSAIDs plus a gastroprotective agent, or switch to a selective COX-2 inhibitor 1

Alternative and Adjunctive Pharmacological Options

• Add acetaminophen (paracetamol) at regular dosing intervals when NSAIDs are insufficient, contraindicated, or poorly tolerated 1
• For persistent focal pain after 2-4 weeks of NSAIDs, consider local corticosteroid injections directed to the site of costochondral inflammation 1
• Short courses of oral prednisolone may be used as bridging therapy while awaiting effect of other agents 1
• Avoid long-term systemic corticosteroids due to potential adverse effects and lack of evidence supporting their use 1

Non-Pharmacological Interventions

• Incorporate stretching exercises targeting the costochondral junctions, which have demonstrated progressive significant improvement compared to conservative treatment alone 2
• Apply manual therapy techniques including rib manipulation and soft tissue mobilization, particularly for atypical costochondritis that does not self-resolve 3, 4
• Direct treatment at the cervicothoracic spine and ribcage using impairment-based examination approaches 4
• Apply local heat or cold applications to the affected area 1
• Recommend regular exercise and physical therapy as part of comprehensive management 1

Treatment Algorithm

Week 0-2:

• Start maximum tolerated NSAID dosing 1
• Initiate stretching exercises 2
• Apply local heat/cold 1
• Provide patient education about the benign, self-limiting nature of the condition 1, 5

Week 2-4:

• Evaluate treatment response 1
• If inadequate response, switch to a different NSAID or add acetaminophen 1
• Consider adding manual therapy and instrument-assisted soft tissue mobilization 3, 4

After 4 weeks (persistent symptoms):

• Consider local corticosteroid injection for focal areas of tenderness 1
• Intensify physical therapy interventions targeting cervicothoracic spine and ribcage 4

Critical Safety Monitoring

• Monitor for gastrointestinal, hepatic, and cardiorenal toxicity with prolonged NSAID use, especially in elderly patients and those with comorbidities 1
• Rule out serious cardiac causes before diagnosing costochondritis, particularly in patients over 35 years or those with cardiac risk factors 5
• Obtain electrocardiogram and possibly chest radiograph in older patients or those with cardiopulmonary symptoms 5

Important Caveats

• Costochondritis is typically self-limiting and resolves within weeks, but atypical cases persisting beyond this timeframe require more aggressive intervention 3, 5
• Physical therapy approaches (manual therapy, stretching) can provide clinically meaningful improvements with mean pain reductions of 5.1 points on NPRS after approximately 5 treatment sessions 4
• Infectious costochondritis is rare but requires surgical debridement and prolonged antibiotic therapy—suspect this if purulent drainage, fever, or systemic signs are present 6