What are the management options for costochondritis?

Management of Costochondritis

Costochondritis should be managed primarily with NSAIDs for pain control, combined with stretching exercises which have demonstrated superior outcomes compared to NSAIDs alone, with manipulation therapy reserved for refractory cases.

Initial Conservative Management

The cornerstone of costochondritis treatment involves:

• NSAIDs as first-line therapy for reducing inflammation and pain, though their effectiveness as monotherapy is often limited 1
• Stretching exercises should be initiated early, as they produce progressive and significant pain improvement (p<0.001) compared to standard conservative treatment alone 1
• Local heat application can be used as an adjunctive measure 1
• Local splinting may provide symptomatic relief during acute phases 1

Physical Therapy Interventions for Persistent Cases

When symptoms persist beyond 2-3 weeks (atypical costochondritis), escalate to manual therapy:

• High-velocity low-amplitude thrust manipulation to the thoracic zygapophyseal joints, costotransverse, and costochondral joints can achieve complete resolution 2, 3
• Instrument-assisted soft tissue mobilization (IASTM) addresses myofascial pain generators effectively 3
• Ischemic compression and cross-fiber friction massage to the local area of pain 2
• Cryotherapy applied to affected areas 2
• Osteopathic manipulation techniques (OMT) for rib dysfunction, particularly when regional interdependence is suspected 3

Treatment Algorithm by Duration

Acute presentation (< 2 weeks):

• NSAIDs plus stretching exercises as initial therapy 1
• Local heat and splinting for symptom control 1

Subacute/persistent (2-8 weeks):

• Continue stretching exercises 1
• Add manipulation therapy to thoracic spine and costochondral joints 2
• Incorporate soft tissue mobilization techniques 3

Chronic/refractory (> 8 weeks):

• Multimodal approach combining manipulation, IASTM, and targeted exercises 3
• Consider acupuncture as adjunctive therapy 2

Critical Diagnostic Caveat

Rule out infectious costochondritis before initiating conservative management. Look specifically for:

• Fever, purulent drainage, or skin changes suggesting infection 4
• History of recent surgery, trauma, or immunocompromise (diabetes mellitus increases risk) 4
• Systemic signs of infection or positive blood cultures 4
• If infection suspected, obtain CT/MRI showing edema around costal cartilage and sternum, and initiate antibiotic therapy with surgical debridement as needed 4, 5

Expected Outcomes

• Stretching exercises: Progressive pain reduction over weeks with sustained benefit 1
• Manipulation therapy: Complete resolution possible within 3 treatment sessions for non-infectious cases 2, 3
• Typical course: Self-limiting within 2-3 weeks with appropriate conservative management 3
• Follow-up: Monitor for recurrence at 11 months, though recurrence is rare with appropriate treatment 2

Common Pitfalls to Avoid

• Do not rely solely on NSAIDs and local measures – this approach shows insufficient effectiveness compared to adding stretching exercises 1
• Do not delay manual therapy in cases not responding within 2-3 weeks, as atypical costochondritis carries high medical expenses and psychological burden 3
• Do not miss infectious costochondritis – always assess for signs of infection, particularly in diabetic or immunocompromised patients, as this requires surgical debridement and prolonged antibiotics rather than conservative management 4, 5
• Local steroid injections have insufficient effectiveness and should not be considered first-line 1