What is the recommended treatment for costochondritis?

Treatment of Costochondritis

Start with NSAIDs at maximum tolerated dose as first-line therapy, evaluate response after 2-4 weeks, and add stretching exercises for persistent symptoms. 1

First-Line Pharmacological Management

• NSAIDs/COXIBs at maximum tolerated and approved dosage should be initiated as first-line treatment 1
• Use oral NSAIDs at the lowest effective dose for the shortest possible period to minimize systemic risks 1
• Consider topical NSAIDs to reduce systemic side effects, particularly in elderly patients or those with comorbidities 1
• Regular acetaminophen (paracetamol) may be used as an alternative or adjunct when NSAIDs are insufficient, contraindicated, or poorly tolerated 1

NSAID Selection Based on GI Risk

• For patients with increased gastrointestinal risk, use either:
  • Non-selective NSAIDs plus a gastroprotective agent, OR
  • A selective COX-2 inhibitor 1
• Selective COX-2 inhibitors reduce serious GI events with RR 0.18 (95% CI: 0.14-0.23) compared to non-selective NSAIDs 1

Non-Pharmacological Interventions

• Stretching exercises demonstrate progressive significant improvement compared to controls (p<0.001) and should be prescribed for all patients 2
• Apply local heat or cold applications to the affected costochondral junction 1
• Patient education about the benign, self-limiting nature of the condition is essential to reduce anxiety 1
• Consider physical therapy techniques including soft tissue mobilization and manipulation for persistent cases 3

Treatment Algorithm for Inadequate Response

After 2-4 Weeks of Initial Therapy:

• Switch to a different NSAID if inadequate response to first agent 1
• Add acetaminophen if NSAIDs alone are insufficient 1
• For focal areas of persistent tenderness, consider local corticosteroid injection directed to the specific costochondral junction 1

Bridging Therapy:

• Short courses of oral prednisolone may be considered as bridging options while awaiting effect of other agents 1
• Avoid long-term systemic corticosteroids due to lack of evidence and significant adverse effect profile 1

Critical Safety Monitoring

• Monitor for gastrointestinal, hepatic, and cardiorenal toxicity with prolonged NSAID use, especially in elderly patients and those with comorbidities 1
• The risk of serious GI complications with NSAIDs has RR of 5.36 (95% CI: 1.79-16.10) 1

Important Clinical Pitfalls

• Rule out cardiac causes first in patients older than 35 years, those with cardiac risk factors, or any cardiopulmonary symptoms—coronary artery disease is present in 3-6% of adult patients with chest pain and chest wall tenderness 4
• Costochondritis is typically self-limited and resolves within weeks; persistent symptoms beyond this timeframe warrant re-evaluation 4, 3
• Infectious costochondritis is rare but must be excluded if there is fever, purulent drainage, or systemic signs—this requires antibiotics and potentially surgical debridement 5
• Do not use long-term glucocorticoids as they lack evidence for efficacy in costochondritis and carry significant adverse effects 1