What is the treatment for costochondritis?

Treatment of Costochondritis

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

First-Line Pharmacological Management

NSAIDs are the cornerstone of treatment for costochondritis. The American College of Cardiology and American College of Rheumatology recommend initiating NSAIDs at the maximum tolerated and approved dosage for 1-2 weeks. 1, 2

• Use oral NSAIDs (such as ibuprofen or naproxen) at the lowest effective dose for the shortest possible period to minimize gastrointestinal, renal, and cardiovascular risks. 2
• Evaluate treatment response after 2-4 weeks; if inadequate, consider switching to a different NSAID. 2
• Topical NSAIDs may be used as an alternative to minimize systemic side effects, particularly in patients with concerns about gastrointestinal or cardiovascular toxicity. 1, 2

Adjunctive Non-Pharmacological Interventions

• 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

Second-Line Options for Persistent Symptoms

If symptoms persist beyond 2-4 weeks despite NSAIDs, escalate treatment systematically:

• Add low-dose colchicine for persistent inflammatory symptoms. 1
• Consider local corticosteroid injections directed to the site of costochondral inflammation for focal areas of persistent tenderness. 2
• Short courses of oral prednisolone may be used as a bridging option while awaiting the effect of other agents, but avoid long-term glucocorticoid use due to adverse effects. 2

Alternative Analgesics

• Use acetaminophen (paracetamol) at regular dosing intervals as an alternative or adjunct when NSAIDs are contraindicated, insufficient, or poorly tolerated. 1, 2

Physical Therapy Considerations

• Manual therapy directed at the cervicothoracic spine and ribcage, combined with therapeutic exercise and stretching, may facilitate resolution in cases lasting several months. 3, 4
• Stretching exercises targeting the costochondral junctions have shown progressive significant improvement compared to controls. 4

Special Population Considerations

In elderly patients or those with comorbidities, carefully weigh NSAID risks:

• For patients with increased gastrointestinal risk, use non-selective NSAIDs plus a gastroprotective agent (such as a proton pump inhibitor), or use a selective COX-2 inhibitor. 2
• Selective COX-2 inhibitors reduce serious gastrointestinal risk with a relative risk of 0.18 compared to non-selective NSAIDs. 2
• In patients with contraindications to NSAIDs, prioritize acetaminophen and physical therapy interventions. 1
• Monitor for gastrointestinal, hepatic, and cardiorenal toxicity with prolonged NSAID use, particularly in elderly patients. 2

Critical Diagnostic Caveat

Before treating as costochondritis, rule out serious cardiac causes. 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 electrocardiography and possibly chest radiography before initiating treatment. 5