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 consider topical NSAIDs to minimize systemic side effects. 1

First-Line Pharmacological Management

• NSAIDs or COX-2 inhibitors should be initiated 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 adverse effects 1
• Topical NSAIDs are preferred when feasible to reduce systemic toxicity 1
• For patients with increased gastrointestinal risk, use either non-selective NSAIDs plus a gastroprotective agent, or a selective COX-2 inhibitor 1
• COX-2 selective inhibitors reduce serious GI complications with a relative risk of 0.18 (95% CI: 0.14-0.23) compared to non-selective NSAIDs 1

Alternative and Adjunctive Pharmacological Options

• Acetaminophen (paracetamol) should be used as an alternative or adjunct when NSAIDs are insufficient, contraindicated, or poorly tolerated 1, 2
• Regular dosing of acetaminophen may be necessary for adequate pain control 1

Treatment Algorithm for Inadequate Response

• If pain persists after 2-4 weeks of 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 inflammation 1
• Short courses of oral prednisolone or intra-articular glucocorticoid injections may serve as bridging therapy while awaiting effect of other agents 1
• Avoid long-term systemic corticosteroid use due to potential adverse effects and lack of evidence for axial pain 1

Non-Pharmacological Interventions

• Apply local heat or cold applications to the affected area 1
• Regular exercise and physical therapy should be incorporated as part of comprehensive treatment 1
• Stretching exercises targeting the costochondral junctions show progressive significant improvement compared to controls (p<0.001) 3
• Manual therapy techniques including rib manipulation and soft tissue mobilization may facilitate resolution, particularly in atypical cases lasting beyond several weeks 4, 5
• Advise patients to avoid activities that produce chest muscle overuse 2
• Provide patient education about the benign, self-limited nature of the condition 1

Safety Monitoring and Special Considerations

• 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 relative risk of 5.36 (95% CI: 1.79-16.10) for serious GI complications 1
• In patients older than 35 years or those with cardiac risk factors, rule out coronary artery disease before attributing chest pain solely to costochondritis 2
• Coronary artery disease is present in 3-6% of adult patients with chest pain and chest wall tenderness 2

Important Clinical Pitfall

• Costochondritis is a diagnosis of exclusion—serious cardiac causes must be ruled out first, especially in patients with cardiopulmonary symptoms or cardiac risk factors 2
• If infectious costochondritis is suspected (fever, purulent drainage, systemic symptoms), this requires surgical debridement and prolonged antibiotic therapy rather than standard anti-inflammatory treatment 6