What is the treatment for costochondritis?

Costochondritis: Diagnosis and Treatment

Diagnosis

Costochondritis is diagnosed clinically by finding reproducible chest wall pain with palpation over the costochondral or costosternal junctions, typically affecting the third through seventh ribs. 1

Clinical Examination

• Palpate the costochondral junctions and costosternal joints—tenderness that reproduces the patient's pain confirms the diagnosis 1
• The pain is typically localized, sharp, and worsens with movement or deep breathing 1
• In children, adolescents, and young adults with typical presentation, history and physical examination alone are sufficient for diagnosis 1

When to Pursue Additional Testing

• Patients over 35 years old require an electrocardiogram and possibly chest radiograph to exclude cardiac causes, as coronary artery disease is present in 3-6% of adults with chest wall tenderness 1
• Any patient with cardiovascular risk factors or cardiopulmonary symptoms needs cardiac workup before accepting the diagnosis of costochondritis 1
• If fever, purulent drainage, or systemic signs are present, consider infectious costochondritis and obtain imaging (CT/MRI) and cultures 2

Treatment Algorithm

First-Line Pharmacological Treatment

Start with NSAIDs at maximum tolerated and approved dosage, evaluating response after 2-4 weeks. 3

• Use oral NSAIDs at the lowest effective dose for the shortest duration to minimize risks 3
• Consider topical NSAIDs to reduce systemic side effects 3
• For patients with increased gastrointestinal risk, use either non-selective NSAIDs plus a gastroprotective agent, or a selective COX-2 inhibitor 3
• Monitor for gastrointestinal, hepatic, and cardiorenal toxicity, particularly in elderly patients and those with comorbidities 3

Adjunctive and Alternative Pharmacological Options

• Add acetaminophen (paracetamol) at regular dosing intervals as an alternative or adjunct when NSAIDs are insufficient, contraindicated, or poorly tolerated 3
• For persistent focal pain after 2-4 weeks of NSAIDs, consider local corticosteroid injections directed to the site of inflammation 3
• Short courses of oral prednisolone may be used as bridging therapy while awaiting effect of other agents, but avoid long-term systemic corticosteroids due to adverse effects and lack of evidence 3

Non-Pharmacological Interventions

Physical therapy with stretching exercises provides significant pain reduction and should be incorporated early in treatment. 4

• Stretching exercises targeting the chest wall show progressive significant improvement compared to standard care alone (p<0.001) 4
• Manual therapy directed at the cervicothoracic spine and ribcage, combined with therapeutic exercise, facilitates resolution of symptoms 5
• Rib manipulation and soft tissue mobilization techniques can be effective, particularly for atypical or prolonged cases 6
• Apply local heat or cold applications to the affected area 3
• Provide patient education about the benign, self-limiting nature of the condition 3

Treatment Progression

If inadequate response after 2-4 weeks:

• Switch to a different NSAID or add acetaminophen 3
• Initiate or intensify physical therapy with manual techniques and stretching 4, 5
• For focal areas of persistent tenderness, proceed with local corticosteroid injection 3

Important Caveats

• Costochondritis is typically self-limiting, resolving within several weeks, but can persist for months 4, 1
• Always exclude cardiac causes before finalizing the diagnosis, especially in older adults 1
• Infectious costochondritis requires entirely different management with antibiotics and possible surgical debridement—suspect this if there are systemic signs, fever, or purulent drainage 2
• Reassurance about the benign nature is therapeutic, as patients often fear cardiac disease 1