Treatment of Costochondritis
NSAIDs at maximum tolerated dosage are the first-line treatment for costochondritis, with treatment response evaluated after 2-4 weeks. 1
First-Line Pharmacological Management
Start with oral NSAIDs or COX-2 inhibitors at the maximum tolerated and approved dosage as initial therapy. 1 Use the lowest effective dose for the shortest possible period to minimize systemic risks, particularly gastrointestinal and cardiovascular toxicity. 1
- For patients with increased GI risk (elderly, history of ulcers, concurrent corticosteroid use), use either non-selective NSAIDs plus a gastroprotective agent (proton pump inhibitor or H2-blocker), or switch to a selective COX-2 inhibitor. 1
- Topical NSAIDs should be considered to minimize systemic side effects, particularly in patients with comorbidities. 1
- Acetaminophen (paracetamol) may be used as an alternative or adjunct when NSAIDs are insufficient, contraindicated, or poorly tolerated, with regular dosing as needed for pain control. 1
Non-Pharmacological Interventions
Apply local heat or cold applications to the affected costochondral junction for symptomatic relief. 1
Stretching exercises targeting the chest wall should be incorporated, as research demonstrates progressive significant improvement in pain compared to controls (p<0.001). 2 Physical therapy utilizing manual therapy techniques directed at the cervicothoracic spine and ribcage has shown clinically meaningful pain reduction (mean decrease of 5.1 points on NPRS) with patients returning to full activities after an average of 4.8 treatment sessions. 3
Patient education about the benign, self-limiting nature of the condition is essential to provide reassurance and reduce anxiety. 1, 4
Treatment Algorithm for Persistent Cases
If inadequate response after 2-4 weeks of initial NSAID therapy:
- Switch to a different NSAID or add acetaminophen. 1
- Consider local corticosteroid injection directed to the specific tender costochondral junction for focal, persistent pain despite adequate NSAID therapy. 1
Short courses of oral prednisolone (typically <8 weeks) may be considered as a bridging option while awaiting the effect of other agents, but avoid long-term systemic corticosteroids due to lack of evidence for axial pain and significant adverse effect profile. 1
Critical Safety Monitoring
Monitor for toxicity with prolonged NSAID use, particularly:
- Gastrointestinal complications (risk ratio 5.36 for serious GI events with non-selective NSAIDs). 1
- Hepatotoxicity through periodic liver function tests. 1
- Cardiorenal toxicity, especially in elderly patients and those with pre-existing cardiovascular disease or renal impairment. 1
Important Diagnostic Caveat
Before diagnosing costochondritis in patients >35 years or those with cardiac risk factors, obtain an electrocardiogram and consider chest radiograph, as coronary artery disease is present in 3-6% of adult patients with chest pain and chest wall tenderness. 4 Costochondritis remains a diagnosis of exclusion after ruling out serious cardiac, pulmonary, and infectious causes. 4
Infectious costochondritis (rare) requires different management with debridement and prolonged antibiotics if purulent drainage, fever, or systemic signs are present. 5