Management of Costochondritis
Costochondritis should be managed primarily with NSAIDs and stretching exercises, as stretching has demonstrated significant pain reduction compared to conservative treatment alone, with manual therapy and exercise directed at the cervicothoracic spine reserved for cases that fail to self-resolve within several weeks.
Initial Assessment and Diagnosis
- Rule out serious cardiac and infectious causes first before diagnosing costochondritis, as it remains a diagnosis of exclusion 1
- Look for focal tenderness at costochondral or costosternal junctions (typically ribs 3-7) on physical examination 2, 3
- Obtain blood cultures and imaging (CT/MRI) if purulent drainage, fever, or systemic signs suggest infectious costochondritis, which requires entirely different management 4
- Normal laboratory values, ECG, and imaging studies support the diagnosis of non-infectious costochondritis 1
First-Line Treatment Algorithm
Conservative Management (Weeks 0-4)
- Start NSAIDs for pain control and inflammation reduction 2
- Initiate stretching exercises immediately, as these provide progressive significant improvement (p<0.001) compared to NSAIDs alone 2
- Apply local heat as adjunctive therapy 2
- Consider local splinting for severe cases 2
Persistent Cases (Beyond 4-8 Weeks)
- Refer to physical therapy for impairment-based examination and treatment when symptoms persist beyond several weeks 3
- Manual therapy directed at the cervicothoracic spine and ribcage should be implemented 3
- Osteopathic manipulation techniques (OMT) including rib manipulation can address regional interdependence 1
- Instrument-assisted soft tissue mobilization (IASTM) targets myofascial pain generators 1
- Therapeutic exercise programs complement manual therapy 3
Expected Outcomes and Treatment Duration
- Most cases self-resolve within several weeks with conservative management 1
- Physical therapy typically requires 4-5 sessions over 6-8 weeks for atypical (non-resolving) costochondritis 3
- Clinically meaningful improvements include: NPRS reduction of 5+ points, PSFS increase of 5+ points, and GROC scores of 6+ 3
- Complete resolution allows return to full occupational and fitness activities without restrictions 3
Critical Pitfalls to Avoid
- Never assume costochondritis without excluding cardiac causes, particularly in patients with risk factors for coronary disease 1
- Do not miss infectious costochondritis, which presents with purulent drainage, systemic symptoms, or occurs in immunocompromised/diabetic patients and requires surgical debridement plus prolonged antibiotics (not NSAIDs) 4
- Avoid local steroid injections as first-line therapy, as they have insufficient effectiveness compared to stretching exercises 2
- Do not delay physical therapy referral beyond 2-3 months, as prolonged symptoms (mean 6+ months) create unnecessary psychological burden and medical expenses 1, 3
Special Considerations for Infectious Costochondritis
- Surgical debridement is the single most important factor for eradicating infectious costochondritis, guided by preoperative MRI, intraoperative bone cortex hardness, and bone bleeding 4, 5
- Antibiotic coverage should not extend beyond 3 weeks post-debridement in uncomplicated cases 5
- Well-vascularized tissue coverage (pectoralis major, latissimus dorsi, or rectus abdominis muscle flaps) promotes healing and resists secondary infection 5