What is the approach to treating costochondritis (inflammation of the cartilage that connects the ribs to the breastbone)?

Approach to Costochondritis

First-Line Treatment: NSAIDs

Start with NSAIDs or COX-2 inhibitors at the maximum tolerated and approved dosage for 1-2 weeks, supplemented with local heat or cold applications as needed. 1, 2

• Evaluate treatment response at 2-4 weeks; if sufficient response is achieved, continue therapy and consider tapering or switching to on-demand treatment with sustained improvement at 12 weeks 1
• If inadequate response after 2-4 weeks, consider switching to a different NSAID or adding acetaminophen 1
• Use topical NSAIDs as an alternative to minimize systemic side effects, particularly in patients with gastrointestinal or cardiovascular concerns 1, 2

NSAID Safety Considerations

• For patients with increased gastrointestinal risk, use non-selective NSAIDs plus a gastroprotective agent, or prescribe a selective COX-2 inhibitor 1
• Monitor for gastrointestinal, hepatic, and cardiorenal toxicity with prolonged use, especially in elderly patients and those with comorbidities 1, 2
• Use the lowest effective dose for the shortest possible period 1

Adjunctive Pharmacological Options

Acetaminophen

• Regular dosing of acetaminophen may be needed as an alternative or adjunct when NSAIDs are insufficient, contraindicated, or poorly tolerated 1, 2

Short-Course Corticosteroids

• Short courses of oral prednisolone or local corticosteroid injections directed to the specific costochondral junction may be considered as bridging options for persistent focal pain despite adequate NSAID therapy 1, 2
• Avoid long-term systemic corticosteroids due to lack of evidence supporting their use and significant adverse effect profile 1, 2

Colchicine

• For persistent inflammatory symptoms, consider adding low-dose colchicine 2

Non-Pharmacological Interventions

Physical Modalities

• Apply local heat or cold applications to the affected area for symptomatic relief 1, 2
• Consider physiotherapy as part of comprehensive management 1
• Stretching exercises have shown progressive significant improvement in pain reduction compared to controls (p<0.001) 3

Activity Modification

• Advise temporary rest during acute painful episodes 2
• Recommend avoiding activities that produce chest muscle overuse while maintaining general physical activity 2, 4
• Gradual return to activities as symptoms improve 2

Patient Education

• Provide reassurance that costochondritis is usually self-limited and benign 1, 4
• Educate patients about the condition, expected course, and lifestyle recommendations 1

Critical Diagnostic Considerations

Rule Out Serious Causes First

• In patients older than 35 years, those with cardiac risk factors, or any patient with cardiopulmonary symptoms, obtain an electrocardiogram and possibly chest radiograph before diagnosing costochondritis 4
• Coronary artery disease is present in 3-6% of adult patients with chest pain and chest wall tenderness to palpation 4
• Palpation of affected costochondral junctions should reproduce the pain to confirm diagnosis 4

Red Flags Requiring Further Investigation

• Fever, purulent drainage, or signs of infection suggest infectious costochondritis requiring cultures and antimicrobial therapy 5
• Persistent symptoms beyond typical self-limited course (>2 weeks) warrant re-evaluation 4, 6

Treatment Algorithm Summary

1. Initial 1-2 weeks: NSAIDs at maximum tolerated dose + local heat/cold + activity modification 1, 2
2. At 2-4 weeks: Assess response
   • Sufficient response: Continue therapy, re-evaluate at 12 weeks for potential tapering 1
   • Insufficient response: Switch NSAID or add acetaminophen 1
3. Persistent symptoms: Consider local corticosteroid injection to affected costochondral junction or add low-dose colchicine 1, 2
4. Throughout treatment: Incorporate stretching exercises and physical therapy 3

Common Pitfalls to Avoid

• Do not use long-term systemic corticosteroids, which lack evidence and carry significant adverse effects 1, 2
• Do not assume benign costochondritis in older adults or those with cardiac risk factors without appropriate cardiac workup 4
• Do not overlook infectious costochondritis in patients with diabetes, recent surgery, or signs of systemic infection 5