What is the treatment for costochondritis?

Treatment for Costochondritis

Start with NSAIDs at maximum tolerated dosage as first-line treatment, evaluate response after 2-4 weeks, and add physical therapy with manual techniques and stretching exercises for persistent cases. 1

First-Line Pharmacological Management

• Initiate NSAIDs or COX-2 inhibitors at maximum tolerated and approved dosage as the primary treatment. 1
• Use oral NSAIDs at the lowest effective dose for the shortest duration to minimize systemic risks, or consider topical NSAIDs to reduce side effects. 1
• For patients with increased gastrointestinal risk, use either non-selective NSAIDs plus a gastroprotective agent, or a selective COX-2 inhibitor (which reduces serious GI risk by 82%, RR 0.18). 1
• Add acetaminophen as an alternative or adjunct when NSAIDs are insufficient, contraindicated, or poorly tolerated, using regular dosing for adequate pain control. 1

Non-Pharmacological Interventions

• Apply local heat or cold applications to the affected costochondral junction. 1
• Implement stretching exercises targeting the chest wall, which have shown progressive significant improvement compared to controls (p<0.001). 2
• Incorporate manual therapy directed at the cervicothoracic spine and ribcage, including rib manipulation and soft tissue mobilization, which can produce clinically meaningful pain reduction (mean 5.1-point decrease on NPRS). 3, 4
• Prescribe regular exercise and physical therapy as part of comprehensive management. 1

Treatment Algorithm for Inadequate Response

• If no improvement after 2-4 weeks of NSAIDs, switch to a different NSAID or add acetaminophen. 1
• For persistent focal pain at specific costochondral junctions despite adequate NSAID therapy, consider local corticosteroid injections directed to the site of inflammation. 1
• Short courses of oral prednisolone may be used as bridging therapy while awaiting effect of other agents. 1

Critical Safety Monitoring

• Monitor for gastrointestinal, hepatic, and cardiorenal toxicity with prolonged NSAID use, particularly in elderly patients and those with comorbidities (serious GI complications have RR 5.36). 1
• Avoid long-term systemic corticosteroids due to lack of evidence supporting their use for axial pain and significant adverse effect profile. 1

Common Pitfalls to Avoid

• Do not use long-term systemic corticosteroids, which carry substantial risks without proven benefit. 1
• Rule out infectious costochondritis in patients with diabetes, immunosuppression, or postoperative status, as these cases require antibiotics and potentially surgical debridement rather than standard anti-inflammatory treatment. 5
• Ensure proper diagnosis by excluding cardiac, pulmonary, and gastrointestinal causes before treating as costochondritis. 5, 4