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 with stretching exercises for persistent 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, or consider topical NSAIDs to reduce side effects 1
• For patients with increased gastrointestinal risk, use either non-selective NSAIDs plus a gastroprotective agent, or a selective COX-2 inhibitor (COX-2 inhibitors reduce serious GI risk by 82% compared to non-selective NSAIDs, RR 0.18) 1
• Acetaminophen (paracetamol) should be used as an alternative or adjunct when NSAIDs are insufficient, contraindicated, or poorly tolerated 1

Non-Pharmacological Interventions

• Apply local heat or cold applications to the affected area as an adjunctive measure 1
• Implement stretching exercises targeting the costochondral junctions, which have demonstrated progressive significant improvement compared to controls (p<0.001) 2
• Consider manual therapy techniques including rib manipulation and soft tissue mobilization, particularly for atypical costochondritis that persists beyond typical self-limited course 3, 4
• Regular exercise and physical therapy should be incorporated as part of comprehensive management 1
• Advise temporary rest from activities that produce chest muscle overuse during the acute phase 1, 5

Treatment Algorithm for Inadequate Response

• If pain persists after 2-4 weeks of initial NSAID therapy, switch to a different NSAID or add acetaminophen 1
• For focal areas of persistent tenderness, consider local corticosteroid injections directed to the site of musculoskeletal inflammation 1
• Short courses of oral prednisolone may be used as bridging therapy while awaiting effect of other agents, but avoid long-term systemic corticosteroid use due to adverse effects and lack of evidence for axial pain 1

Critical Safety Monitoring

• Monitor for gastrointestinal, hepatic, and cardiorenal toxicity with prolonged NSAID use, particularly in elderly patients and those with comorbidities 1
• Non-selective NSAIDs carry a 5.36-fold increased risk of serious GI complications (95% CI: 1.79-16.10) 1

Important Clinical Pitfalls

• Rule out serious cardiac causes before diagnosing costochondritis, as coronary artery disease is present in 3-6% of adult patients with chest pain and chest wall tenderness 5
• Patients older than 35 years, those with cardiac risk factors, or any patient with cardiopulmonary symptoms require electrocardiogram and possibly chest radiograph before attributing symptoms to costochondritis 5
• Be aware that infectious costochondritis (though rare) requires entirely different management with antibiotics and possible surgical debridement 6
• Physical therapy referral should be considered for cases lasting beyond several weeks, as the mean duration before PT referral in one series was 6.3 months, yet resolution occurred after only 4.8 visits 4