What are the management options for costochondritis?

Management of Costochondritis

Costochondritis should be managed primarily with NSAIDs and stretching exercises, as this combination provides superior pain relief compared to NSAIDs alone, with stretching exercises showing progressive significant improvement (p<0.001).

Initial Assessment and Diagnosis

Costochondritis is a diagnosis of exclusion requiring you to first rule out cardiac, pulmonary, and gastrointestinal causes of chest pain through appropriate testing (ECG, cardiac enzymes, imaging as indicated) 1. The condition presents as painful inflammation at the costochondral or costosternal junction, typically affecting the third through seventh ribs 2.

Key diagnostic features to identify:

• Focal tenderness at costochondral or costosternal junctions on palpation 1
• Reproducible pain with direct pressure over affected areas 2
• Pain exacerbated by movement, deep breathing, or coughing 3
• Absence of systemic signs of infection (fever, elevated inflammatory markers) in typical cases 3

Primary Treatment Algorithm

First-Line Therapy: NSAIDs Plus Stretching Exercises

NSAIDs combined with stretching exercises should be your initial approach, as this demonstrates statistically significant progressive improvement compared to NSAIDs alone 2. The stretching protocol involves exercises targeting the affected costochondral junctions, performed regularly 2.

Adjunctive Conservative Measures

For patients requiring additional symptom control beyond NSAIDs and stretching:

• Local heat application to the affected area 2
• Local splinting for severe cases 2
• Cryotherapy applied to the painful region 4

Second-Line Interventions for Refractory Cases

Manual Therapy Approaches

When conservative management fails after 2-3 weeks, consider manual therapy techniques 4, 1:

• High-velocity low-amplitude thrust manipulation to thoracic zygapophyseal joints, costotransverse, and costochondral joints 4
• Instrument-assisted soft tissue mobilization (IASTM) to address myofascial pain generators 1
• Cross-fiber friction massage techniques 4
• Ischemic compression to tender points 4

This multimodal manual therapy approach achieved complete resolution in documented cases with 11-month follow-up showing no recurrence 4.

Acupuncture

Acupuncture to the local area of pain can be incorporated as an adjunctive treatment 4.

Local Injections

Local injection of anesthetic or corticosteroid can be considered, though evidence suggests insufficient effectiveness as monotherapy 2.

Critical Red Flags Requiring Different Management

Infectious Costochondritis

You must distinguish infectious costochondritis from typical costochondritis, as management differs dramatically 3:

Suspect infection when:

• Purulent drainage or fistula formation present 3
• Fever or systemic signs of infection 3
• History of recent thoracic surgery or adjacent infection 3
• Diabetes mellitus or immunocompromised state 3
• CT showing edema around costal cartilage and sternum with cartilage distraction 3
• MRI with fat-suppressed T2 showing high-intensity signal in affected areas 3

Infectious costochondritis requires:

• Blood and wound cultures to identify organism 3
• Prolonged antibiotic therapy (typically 4-6 weeks total) 3
• Surgical debridement of affected costal cartilage and sternum when medical therapy fails 3, 5
• Well-vascularized tissue coverage (pectoralis major, latissimus dorsi, or rectus abdominis muscle flaps) for large defects after debridement 5

Common Pitfalls to Avoid

• Never assume chest pain is costochondritis without ruling out life-threatening cardiac causes first 1
• Do not rely solely on NSAIDs when stretching exercises provide additional significant benefit 2
• Do not continue ineffective conservative therapy beyond 2-3 weeks without escalating to manual therapy or considering alternative diagnoses 4, 1
• Never miss infectious costochondritis, as it requires surgical debridement rather than conservative management 3, 5
• Avoid inadequate debridement in infectious cases, as this is the single most important factor for eradication 5

Expected Timeline and Follow-Up

Typical costochondritis is self-limiting and resolves within several weeks with appropriate conservative management 1. Atypical costochondritis persisting beyond this timeframe warrants escalation to manual therapy techniques 1. For infectious cases treated surgically, follow-up should extend at least 11 months to monitor for recurrence 3.