What is the treatment for chronic costochondritis (inflammation of the costochondral junctions)?

Treatment of Chronic Costochondritis

Start with NSAIDs/COXIBs at maximum tolerated and approved dosage as first-line treatment, evaluate response at 2-4 weeks, and consider physiotherapy as an essential adjunct. 1

First-Line Pharmacological Management

• NSAIDs are the cornerstone of treatment for chronic costochondritis, prescribed at the lowest effective dose for the shortest duration to minimize gastrointestinal, hepatic, and cardiorenal toxicity 1
• Evaluate treatment response at 2-4 weeks: if insufficient response occurs, consider rotating to a different NSAID before advancing to other therapies 1
• For patients with increased gastrointestinal risk (elderly, history of ulcers, concurrent corticosteroid use), use either non-selective NSAIDs plus a gastroprotective agent OR a selective COX-2 inhibitor 1
• Topical NSAIDs should be considered to minimize systemic side effects, particularly in patients with comorbidities 1

Common pitfall: Long-term NSAID use carries significant risks including ulcers, bleeding, cardiovascular events, and renal dysfunction—monitor closely and use the shortest effective course 2

Adjunctive Pain Management

• Regular dosing of acetaminophen (paracetamol) may be needed as an alternative or adjunct when NSAIDs are insufficient, contraindicated, or poorly tolerated 1
• If inadequate response after 2-4 weeks of NSAIDs, consider adding acetaminophen before escalating to other interventions 1

Bridging Therapy and Corticosteroids

• Short courses of oral prednisolone may be considered as bridging options while awaiting the effect of NSAIDs, but avoid long-term glucocorticoid use due to lack of evidence and significant adverse effects 1
• For persistent focal pain at specific costochondral junctions despite adequate NSAID therapy, local corticosteroid injections directed to the site may be considered 1
• Intra-articular glucocorticoid injections can serve as bridging therapy but should not be used chronically 1

Critical caveat: Long-term systemic corticosteroids lack evidence for costochondritis and carry substantial adverse effects including osteoporosis, hyperglycemia, and immunosuppression—avoid this approach 1

Non-Pharmacological Interventions

• Patient education about the benign, self-limiting nature of costochondritis is essential to reduce psychological burden and unnecessary healthcare utilization 1, 3
• Apply local heat or cold applications to the affected area for symptomatic relief 1
• Regular exercise and physical therapy should be incorporated as part of comprehensive treatment, with evidence suggesting manual therapy techniques and therapeutic exercise facilitate resolution 1, 4
• Advise temporary rest and avoidance of activities that produce chest muscle overuse during acute flares 3

Physical Therapy Approach

• Physical therapy utilizing impairment-based examination and treatment, including manual therapy directed at the cervicothoracic spine and ribcage, shows clinically meaningful improvements 4
• Instrument-assisted soft tissue mobilization (IASTM) and stretching may address myofascial pain generators contributing to chronic symptoms 5
• Osteopathic manipulation techniques for rib dysfunction can be useful, particularly in atypical costochondritis that fails to self-resolve 5

Treatment Algorithm for Chronic Cases

Week 0-4:

• Initiate maximum tolerated dose of NSAIDs with gastroprotection if indicated 1
• Begin local heat/cold applications and activity modification 1
• Provide patient education and reassurance 1

Week 4-12 (if insufficient response):

• Rotate to different NSAID or add acetaminophen 1
• Initiate physical therapy with manual therapy and therapeutic exercise 4
• Consider local corticosteroid injection for focal persistent pain 1

Beyond 12 weeks (atypical costochondritis):

• Continue physical therapy with focus on cervicothoracic spine and rib mobilization 4
• Short course oral prednisolone may be considered as bridging therapy 1
• Re-evaluate for alternative diagnoses if no improvement 3

Safety Monitoring

• Monitor for NSAID-related gastrointestinal toxicity (nausea, abdominal pain, black stools, vomiting blood), particularly in elderly patients and those with comorbidities 2
• Watch for cardiovascular symptoms (chest pain, shortness of breath, weakness) and renal dysfunction (unusual weight gain, swelling) with prolonged NSAID use 2
• The risk of serious GI complications increases with longer use, smoking, alcohol consumption, older age, and concurrent corticosteroid or anticoagulant use 2

Differential Diagnosis Considerations

• In patients older than 35 years or those with cardiac risk factors, obtain electrocardiogram and possibly chest radiograph to rule out coronary artery disease, which is present in 3-6% of adults with chest pain and chest wall tenderness 3
• Rule out infectious costochondritis if there is fever, purulent drainage, or systemic signs of infection—this requires antibiotics and potentially surgical debridement 6