Treatment Recommendations for Costochondritis

First-line treatment for costochondritis is NSAIDs at maximum tolerated and approved dosage, with treatment response evaluated after 2-4 weeks. 1

Pharmacological Management

Start with oral NSAIDs at the lowest effective dose for the shortest possible period to minimize systemic risks, particularly gastrointestinal, hepatic, and cardiorenal toxicity 1
Consider topical NSAIDs to reduce systemic side effects while maintaining local anti-inflammatory action 1
For patients with increased gastrointestinal risk (elderly, history of peptic ulcer disease, concurrent corticosteroid use), use either:
- Non-selective NSAIDs plus a gastroprotective agent (proton pump inhibitor or H2-blocker), OR
- Selective COX-2 inhibitor 1
The risk reduction with COX-2 inhibitors versus non-selective NSAIDs is substantial (RR 0.18,95% CI: 0.14-0.23) 1

Use acetaminophen (paracetamol) at regular dosing intervals when NSAIDs are insufficient, contraindicated, or poorly tolerated 1
Acetaminophen can be added to NSAIDs if response is inadequate after 2-4 weeks 1

Local corticosteroid injections directed to the specific costochondral junction may be considered for persistent focal pain despite adequate NSAID therapy 1, 2
Short courses of oral prednisolone may serve as bridging therapy while awaiting effect of other agents 1
Avoid long-term systemic corticosteroids due to lack of evidence for axial/chest wall pain and significant adverse effect profile 1, 2

Apply local heat or cold applications to the affected costochondral area 1
Stretching exercises targeting the pectoralis muscles and chest wall demonstrate progressive significant improvement (p<0.001) compared to standard care alone 3
Regular exercise and physical therapy should be incorporated into the treatment plan 1

Provide education about the benign, self-limiting nature of costochondritis 1
Advise temporary avoidance of activities producing chest muscle overuse or repetitive movements 4

Initial approach (Weeks 0-4):

Start NSAID therapy at appropriate dose based on GI/cardiovascular risk profile 1
Add local heat/cold applications 1
Initiate stretching exercises 3
Provide reassurance about benign nature 4

If inadequate response after 2-4 weeks:

For refractory cases:

Refer for physical therapy with manual manipulation techniques and instrument-assisted soft tissue mobilization 5
Re-evaluate diagnosis to exclude infectious costochondritis or other serious pathology 6

Monitor for gastrointestinal, hepatic, and cardiorenal toxicity with prolonged NSAID use, particularly in elderly patients and those with comorbidities 1
The risk of serious GI complications with NSAIDs is significant (RR 5.36,95% CI: 1.79-16.10) 1

Patients older than 35 years or those with coronary artery disease risk factors require electrocardiogram and possibly chest radiograph before diagnosing costochondritis 4
Presence of fever, purulent drainage, or systemic symptoms suggests infectious costochondritis requiring antibiotics and possible surgical debridement 6
Cardiopulmonary symptoms warrant cardiac workup, as coronary artery disease is present in 3-6% of adult patients with chest pain and chest wall tenderness 4

Do not assume all anterior chest wall pain is benign costochondritis without appropriate cardiac risk stratification in adults over 35 years 4
Avoid long-term systemic corticosteroid therapy, which lacks evidence and carries significant adverse effects 1, 2
Do not overlook infectious costochondritis in patients with diabetes, recent surgery, or immunocompromise 6
NSAIDs alone may have insufficient effectiveness; combining with stretching exercises improves outcomes 3