What are the recommended treatment options and patient education for costochondritis?

Treatment and Patient Education for Costochondritis

Costochondritis should be treated primarily with NSAIDs at maximum tolerated doses, combined with patient education about the self-limiting nature of the condition, and supplemented with stretching exercises and manual therapy techniques targeting the cervicothoracic spine and ribcage.

Initial Management and Pharmacologic Treatment

• Start NSAIDs as first-line therapy at the maximum tolerated and approved dosage for adults, as this represents the standard anti-inflammatory approach for musculoskeletal chest wall inflammation 1.
• Evaluate treatment response at 2-4 weeks; if insufficient response occurs, consider rotating to a different NSAID or adding adjunctive therapies 1.
• Oral acetaminophen can be recommended as an alternative analgesic for pain improvement, particularly in patients with NSAID contraindications 1.
• Avoid long-term glucocorticoid use, though short courses of oral prednisolone or local glucocorticoid injections may be considered as bridging options for severe pain 1.

Physical Therapy and Manual Interventions

• Stretching exercises show progressive significant improvement in costochondritis pain compared to conservative treatment alone and should be prescribed as a core component of therapy 2.
• Manual therapy directed at the cervicothoracic spine and ribcage, including rib manipulation and instrument-assisted soft tissue mobilization (IASTM), can facilitate complete resolution of symptoms, particularly in atypical or prolonged cases 3, 4.
• Physiotherapy should be considered throughout all treatment stages, with an impairment-based examination approach targeting regional interdependence and myofascial pain generators 1, 4.
• Treatment typically requires 4-5 physical therapy sessions to achieve clinically meaningful changes, with mean pain reduction of 5 points on the numerical pain rating scale 4.

Patient Education: Critical Components

Educate patients that costochondritis is a self-limiting, benign condition that typically resolves within several weeks to months, though some cases may persist longer 3.

Key Educational Points:

• Reassure patients this is NOT a cardiac condition after serious causes of chest pain have been ruled out, as costochondritis is often a diagnosis of exclusion 3.
• Explain that the condition represents inflammation at the costochondral or costosternal junction without infection (unless infectious etiology is confirmed) 5, 6.
• Inform patients they should expect gradual improvement, with systemic symptoms (if present) resolving before local chest wall pain 1.
• Advise patients to avoid activities that exacerbate symptoms, particularly heavy lifting, repetitive movements, and severe coughing 5.
• Provide lifestyle recommendations including activity modification during the acute phase 1.

Monitoring and Follow-up:

• Schedule follow-up at 2-4 weeks initially to assess treatment response 1.
• If symptoms worsen or fail to improve after 2-4 weeks of appropriate treatment, re-evaluate for alternative diagnoses or consider atypical costochondritis 3.
• Patients with prolonged symptoms beyond several months warrant referral to physical medicine and rehabilitation or physical therapy for multimodal treatment 3, 4.

Important Caveats and Red Flags

• Always rule out serious cardiac, pulmonary, and gastrointestinal causes before diagnosing costochondritis, as it remains a diagnosis of exclusion 3.
• Be aware of potential neurovascular complications in patients with anterior chest wall involvement 1.
• Infectious costochondritis is rare but requires different management: if purulent drainage, fever, or systemic signs are present, obtain cultures and consider infectious etiology requiring antibiotics and potentially surgical debridement 5.
• Patients with diabetes mellitus may be at higher risk for infectious complications and require closer monitoring 5.
• If costochondritis does not self-resolve within expected timeframes (several weeks to months), it becomes "atypical costochondritis" and is associated with high medical expenses and psychological burden, warranting more aggressive multimodal treatment 3.

Treatment Algorithm

1. Initial presentation: NSAIDs at maximum tolerated dose + patient education + activity modification
2. 2-4 week evaluation:
   • Sufficient response → Continue treatment, re-evaluate at 12 weeks
   • Insufficient response → Consider NSAID rotation OR add stretching exercises and manual therapy
3. Persistent symptoms (>2-3 months): Refer to physical therapy for impairment-based examination and treatment including manual therapy, stretching, and therapeutic exercise 4
4. Refractory cases: Consider short-course oral prednisolone or local glucocorticoid injection as bridging therapy 1