What is the treatment for costochondritis?

Treatment for Costochondritis

First-line treatment for costochondritis is NSAIDs at maximum tolerated dosage for 2-4 weeks, combined with activity modification and reassurance, with topical NSAIDs preferred when possible to minimize systemic side effects. 1

Initial Pharmacological Management

• Start with NSAIDs/COXIBs at maximum tolerated and approved dosage as first-line treatment, evaluating response after 2-4 weeks 1
• Use oral NSAIDs at the lowest effective dose for the shortest possible period to minimize risks 1
• Consider topical NSAIDs as preferred option to minimize systemic side effects, particularly gastrointestinal, hepatic, and cardiorenal toxicity 1
• For patients with increased gastrointestinal risk, use either non-selective NSAIDs plus a gastroprotective agent, or a selective COX-2 inhibitor 1
• Regular dosing of acetaminophen (paracetamol) may be needed as an alternative or adjunct when NSAIDs are insufficient, contraindicated, or poorly tolerated 1

Treatment Algorithm for Inadequate Response

• If inadequate response after 2-4 weeks, consider switching to a different NSAID or adding acetaminophen 1
• For persistent focal pain at specific costochondral junctions despite adequate NSAID therapy, local corticosteroid injections directed to the site may be considered 1
• Short courses of oral prednisolone may be considered as bridging options while awaiting the effect of other agents 1
• Avoid long-term use of systemic glucocorticoids due to lack of evidence and significant adverse effect profile 1

Non-Pharmacological Interventions

• Apply local heat or cold applications to the affected area 1
• Stretching exercises show progressive significant improvement compared to control groups (p<0.001) and can be a useful adjunct treatment 2
• Regular exercise and physical therapy should be considered as part of comprehensive treatment, with impairment-based manual therapy and therapeutic exercise facilitating resolution 1, 3
• Provide patient education about the benign, self-limited nature of the condition and lifestyle recommendations 1
• Advise patients to avoid activities that produce chest muscle overuse 4

Critical Safety Considerations

• Monitor for gastrointestinal, liver, and cardiorenal toxicity with prolonged NSAID use, particularly in elderly patients and those with comorbidities 1
• In patients older than 35 years, those with history or risk of coronary artery disease, or any patient with cardiopulmonary symptoms, obtain electrocardiogram and possibly chest radiograph to rule out cardiac causes before attributing symptoms to costochondritis 4
• Coronary artery disease is present in 3-6% of adult patients with chest pain and chest wall tenderness to palpation 4

Common Pitfalls to Avoid

• Do not use long-term systemic corticosteroids - they lack evidence for axial/chest wall pain and carry significant adverse effects 1
• Do not assume all anterior chest wall pain is benign costochondritis without appropriate cardiac evaluation in at-risk populations 4
• Recognize that infectious costochondritis is rare but requires different management with antibiotics and possible surgical debridement; suspect if there is purulent drainage, fever, or failure to respond to standard treatment 5