What is the management for a patient with stabbing chest pain of musculoskeletal origin, such as costochondritis?

Management of Musculoskeletal Chest Pain (Costochondritis)

For confirmed musculoskeletal chest pain such as costochondritis, initiate treatment with NSAIDs (e.g., ibuprofen) at the lowest effective dose for the shortest duration necessary, combined with activity modification and reassurance after excluding life-threatening cardiac and pulmonary causes. 1, 2

Initial Critical Step: Exclude Life-Threatening Causes

Before treating as costochondritis, you must rule out serious pathology:

• Perform a focused cardiovascular examination to identify ACS, aortic dissection, pulmonary embolism, or esophageal rupture 1
• Obtain an ECG immediately (within 10 minutes if in ED setting) to exclude STEMI, pericarditis patterns, or signs of PE 1
• Order chest radiography to evaluate for pneumothorax, pneumonia, pleural effusion, or widened mediastinum 1
• Measure cardiac troponin in acute presentations to exclude myocardial injury 1

Critical Pitfall to Avoid

Do not assume chest wall tenderness excludes cardiac disease—7% of patients with reproducible chest wall pain on palpation still have acute coronary syndrome. 3 While chest tenderness markedly reduces the probability of ACS, it does not eliminate it entirely 1

Confirming the Diagnosis

Costochondritis is characterized by:

• Tenderness of costochondral joints on palpation 1
• Sharp, stabbing pain that worsens with respiration, coughing, or movement 1, 4
• Pain reproduced by palpation of the affected area 5
• Normal ECG, cardiac biomarkers, and chest imaging 1, 5

First-Line Pharmacologic Management

NSAIDs are the primary treatment:

• Ibuprofen 400-800 mg orally every 6-8 hours with food 2
• Use the lowest effective dose for the shortest duration to minimize cardiovascular and gastrointestinal risks 2
• Maximum duration should not exceed 10 days without physician reassessment 2

NSAID Safety Considerations

Monitor for and counsel patients about:

• Cardiovascular risks: NSAIDs increase risk of heart attack and stroke, particularly with higher doses and longer duration 2
• Gastrointestinal risks: Risk of bleeding, ulcers, and perforation increases with prolonged use, especially in patients >60 years, those with prior GI bleeding, or concurrent use of corticosteroids or anticoagulants 2
• Contraindications: Do not use in patients with aspirin-sensitive asthma, immediately before/after CABG surgery, or after recent MI unless specifically indicated 2
• Pregnancy: Avoid after 30 weeks gestation; use between 20-30 weeks requires monitoring for oligohydramnios 2

Non-Pharmacologic Management

Activity modification and physical interventions:

• Avoid activities that exacerbate pain (heavy lifting, repetitive movements, severe coughing) 6
• Apply local heat or ice to the affected area for symptomatic relief 7
• Consider osteopathic manipulation techniques (OMT) or physical therapy for persistent cases, including rib manipulation and soft tissue mobilization 7
• Stretching exercises may address myofascial pain generators 7

Management of Refractory Cases

For costochondritis unresponsive to NSAIDs after 2-4 weeks:

• Consider colchicine as an alternative anti-inflammatory agent, particularly in severe cases unresponsive to traditional management 8
• Refer to Physical Medicine and Rehabilitation for multimodal approach including manipulative therapy and instrument-assisted soft tissue mobilization 7
• Reassess for infectious costochondritis if fever, purulent drainage, or systemic symptoms develop—this requires antibiotics and potentially surgical debridement 6

Red Flags Requiring Immediate Reassessment

• Fever or systemic symptoms: Consider infectious costochondritis or other serious infection 6
• Purulent drainage or skin changes: May indicate abscess formation requiring incision and drainage 6
• Progressive worsening despite treatment: Warrants imaging (CT or MRI) to exclude osteomyelitis or other structural pathology 6
• New cardiac symptoms: Repeat troponin and ECG to exclude evolving ACS 1

Patient Education and Follow-Up

Provide clear counseling:

• Reassure that costochondritis is benign and self-limiting in most cases, typically resolving within weeks 7, 5
• Warn about NSAID side effects: Stop medication and seek care immediately for signs of GI bleeding (black stools, vomiting blood), chest pain, shortness of breath, or allergic reactions 2
• Set expectations: Approximately 55% of patients may still have some chest pain at 1 year, though definite costochondritis persists in only one-third 5
• Schedule follow-up in 2-4 weeks if symptoms persist to reassess diagnosis and consider alternative treatments 7

Special Populations

Post-COVID-19 patients:

• Maintain high clinical suspicion for post-COVID costochondritis in patients with recent COVID-19 infection presenting with severe musculoskeletal chest pain 8
• Consider colchicine early if unresponsive to NSAIDs or steroids to prevent unnecessary steroid treatment and frequent ED visits 8

Diabetic patients:

• Monitor closely for infectious complications as diabetes increases risk of infectious costochondritis and sternal osteomyelitis 6