Treatment of Costochondritis
Start with a 1-2 week course of NSAIDs (such as ibuprofen or naproxen) at maximum tolerated dosage as first-line treatment, supplemented with local heat or cold applications as needed. 1, 2
First-Line Pharmacological Management
NSAIDs are the cornerstone of treatment and should be initiated at the lowest effective dose for the shortest duration necessary to minimize gastrointestinal, renal, and cardiovascular risks. 1, 2
For patients with increased gastrointestinal risk (elderly, history of ulcers, concurrent anticoagulation), use either:
- Non-selective NSAIDs plus a proton pump inhibitor or H2-blocker for gastroprotection, OR
- Selective COX-2 inhibitors, which reduce serious GI complications by 82% (RR 0.18,95% CI: 0.14-0.23) 2
Evaluate treatment response after 2-4 weeks; if inadequate, switch to a different NSAID or add acetaminophen. 2
Adjunctive Non-Pharmacological Measures
Apply local heat or cold to the affected costochondral junctions for symptomatic relief throughout the treatment course. 1, 2
Modify activities to avoid movements that exacerbate pain (such as heavy lifting or repetitive upper body motions), while maintaining general physical activity. 1
Stretching exercises targeting the chest wall muscles and costochondral junctions can provide significant pain reduction and should be incorporated into the treatment plan, as they have shown progressive improvement compared to standard care alone (p<0.001). 3
Treatment Algorithm for Persistent Symptoms
If symptoms persist beyond 2-4 weeks despite adequate NSAID therapy:
- Add low-dose colchicine for ongoing inflammatory symptoms 1
- Consider local corticosteroid injection directly into the tender costochondral junction for focal, persistent pain 2
- Refer for physical therapy or manual therapy techniques (rib manipulation, soft tissue mobilization) for refractory cases 4, 5
Avoid long-term systemic corticosteroids due to lack of evidence supporting efficacy and significant adverse effect profile. 2
Alternative Pain Management
For patients with NSAID contraindications (renal disease, active peptic ulcer, severe heart failure), use regular-dose acetaminophen as the primary analgesic. 1, 2
Topical NSAIDs may be considered to minimize systemic side effects, particularly in elderly patients or those with multiple comorbidities. 1, 2
Critical Safety Monitoring
Monitor for NSAID-related complications, especially in elderly patients: gastrointestinal bleeding (RR 5.36,95% CI: 1.79-16.10), renal dysfunction, and cardiovascular events with prolonged use. 1, 2
In patients over 35 years or those with cardiac risk factors presenting with chest pain, rule out coronary artery disease with electrocardiogram before attributing symptoms solely to costochondritis. 6
Important Clinical Pitfalls
Costochondritis is a diagnosis of exclusion—always rule out serious cardiac, pulmonary, and gastrointestinal causes of chest pain before initiating treatment, particularly in older adults. 6
If purulent drainage, fever, or systemic signs develop, consider infectious costochondritis (especially in diabetic or immunocompromised patients), which requires cultures and antibiotic therapy rather than NSAIDs alone. 7
Most cases are self-limiting and resolve within weeks, but atypical costochondritis persisting beyond 2-3 months warrants reassessment and consideration of alternative diagnoses or multimodal therapy including physical therapy interventions. 4