What is the treatment for costochondritis?

Treatment of Costochondritis

Start with a 1-2 week course of NSAIDs at the lowest effective dose as first-line treatment, combined with local heat or ice application and patient education about activity modification. 1, 2

Initial Pharmacological Management

First-Line Treatment: NSAIDs

• NSAIDs or COX-2 inhibitors (Coxibs) are the cornerstone of pharmacological treatment, prescribed at maximum tolerated and approved dosage with evaluation of treatment response after 2-4 weeks 2
• Use oral NSAIDs at the lowest effective dose for the shortest possible period to minimize cardiovascular, gastrointestinal, and renal risks 1, 2
• For patients with increased gastrointestinal risk, use either non-selective NSAIDs plus a gastroprotective agent, or a selective COX-2 inhibitor (COX-2 inhibitors reduce serious GI risk with RR 0.18,95% CI: 0.14-0.23) 2
• Consider topical NSAIDs to minimize systemic side effects, particularly in elderly patients or those with comorbidities 2

Alternative Analgesics

• Acetaminophen (paracetamol) should be used as an alternative or adjunct when NSAIDs are contraindicated, insufficient, or poorly tolerated 1, 2
• Regular dosing of acetaminophen may be needed for adequate pain control 2
• Topical analgesics like lidocaine patches may provide localized pain relief with minimal systemic effects 1

Non-Pharmacological Interventions

Physical Modalities

• Apply local heat or ice packs to the affected costochondral junctions as part of initial treatment 1, 2
• Advise patients to avoid activities that produce chest muscle overuse or repetitive movements 3

Exercise and Physical Therapy

• Stretching exercises have shown progressive significant improvement in pain compared to control groups (p<0.001) and can be a useful adjunct to pharmacological treatment 4
• Regular exercise and physical therapy should be considered as part of a comprehensive treatment plan 2
• Osteopathic manipulation techniques (OMT) and instrument-assisted soft tissue mobilization may be beneficial for atypical costochondritis that does not self-resolve 5

Second-Line and Adjunctive Treatments

When Initial Treatment Fails (After 2-4 Weeks)

• If inadequate response after 2-4 weeks, switch to a different NSAID or add acetaminophen 2
• Low-dose colchicine may be added if symptoms persist despite NSAID therapy 1

Local Corticosteroid Injections

• For focal areas of persistent tenderness despite adequate NSAID therapy, local corticosteroid injections directed to the specific costochondral junction may be considered 1, 2
• Short courses of intra-articular glucocorticoid injections may serve as bridging options while awaiting the effect of other agents 2

Critical Safety Considerations and Pitfalls

What to Avoid

• Avoid long-term use of systemic glucocorticoids due to lack of evidence for axial pain and significant adverse effect profile 2
• Monitor for gastrointestinal, liver, and cardiorenal toxicity with prolonged NSAID use, particularly in elderly patients and those with comorbidities 2

Diagnostic Vigilance

• For patients older than 35 years or with cardiac risk factors, obtain an ECG to rule out cardiac causes before diagnosing costochondritis 6, 3
• Coronary artery disease is present in 3-6% of adult patients with chest pain and chest wall tenderness to palpation 3
• Reassess patients with persistent pain to rule out other potential causes, including Tietze syndrome, slipping rib syndrome, or infectious costochondritis 1, 6

Special Populations

• For patients with axial spondyloarthritis, anterior chest wall pain may be the first manifestation of disease and requires rheumatology collaboration 1, 6
• Infectious costochondritis (though rare) requires debridement and antibiotic therapy rather than standard anti-inflammatory treatment 7

Treatment Algorithm Summary

1. Week 0-2: NSAIDs (or COX-2 inhibitors) + local heat/ice + activity modification + patient education 1, 2
2. Week 2-4: If inadequate response, switch NSAIDs or add acetaminophen; consider adding low-dose colchicine 1, 2
3. Week 4+: For persistent focal pain, consider local corticosteroid injection to affected costochondral junction 1, 2
4. Throughout: Incorporate stretching exercises and physical therapy as tolerated 2, 4