What is the best treatment for costochondritis?

Treatment of Costochondritis

Start with NSAIDs at maximum tolerated dosage as first-line treatment for 2-4 weeks, using the lowest effective dose for the shortest duration, and add local heat/cold applications and stretching exercises for optimal pain relief. 1

First-Line Pharmacological Management

• Begin with NSAIDs or COX-2 inhibitors at maximum tolerated and approved dosage, evaluating treatment response after 2-4 weeks 1
• Use oral NSAIDs at the lowest effective dose for the shortest possible period to minimize systemic risks 1
• Consider topical NSAIDs as an alternative to minimize systemic side effects, particularly for localized pain 1
• Regular dosing of acetaminophen (paracetamol) may be needed as an alternative or adjunct when NSAIDs are insufficient, contraindicated, or poorly tolerated 1, 2

Gastroprotection Strategy

• For patients with increased gastrointestinal risk, use non-selective NSAIDs plus a gastroprotective agent (proton pump inhibitor), or prescribe a selective COX-2 inhibitor 1
• COX-2 selective inhibitors reduce serious GI complications with relative risk of 0.18 compared to non-selective NSAIDs 1
• Monitor for gastrointestinal, liver, and cardiorenal toxicity with prolonged NSAID use, particularly in elderly patients and those with comorbidities 1

Non-Pharmacological Interventions

• Apply local heat or cold applications to the affected costochondral junctions 1
• Implement stretching exercises targeting the chest wall, which have demonstrated progressive significant improvement in pain compared to controls (p<0.001) 3
• Consider osteopathic manipulation techniques (OMT) and instrument-assisted soft tissue mobilization for persistent cases, as case reports show complete resolution with rib manipulation 4
• Advise temporary rest from activities that produce chest muscle overuse during the acute phase 1, 2
• Provide patient education about the benign, self-limiting nature of the condition to reduce psychological burden 1, 2

Second-Line Options for Persistent Pain

If inadequate response after 2-4 weeks of NSAIDs:

• Consider switching to a different NSAID or adding acetaminophen 1
• Local corticosteroid injections directed to the specific costochondral junction may be considered for persistent focal pain despite adequate NSAID therapy 1
• Short courses of oral prednisolone may be used as bridging therapy while awaiting the effect of other agents 1

Critical Safety Considerations and Pitfalls

• Avoid long-term systemic corticosteroids due to lack of evidence supporting their use for chest wall pain and significant adverse effect profile 1
• Rule out serious cardiac causes before diagnosing costochondritis, especially in patients older than 35 years, those with cardiac risk factors, or any patient with cardiopulmonary symptoms—obtain electrocardiogram and possibly chest radiograph 2
• Coronary artery disease is present in 3-6% of adult patients with chest pain and chest wall tenderness to palpation 2
• Distinguish from infectious costochondritis (rare), which requires antibiotics and potentially surgical debridement rather than NSAIDs alone 5
• The diagnosis relies on reproducible pain by palpation over the costal cartilages in the absence of other findings 2