What is the best treatment approach for a patient with costochondritis, considering their potential history of inflammatory conditions such as arthritis or fibromyalgia?

Treatment of Costochondritis

The first-line treatment for costochondritis is NSAIDs for 1-2 weeks, with local ice or heat application as adjunctive therapy, and low-dose colchicine added if symptoms persist despite NSAID therapy. 1, 2

Initial Assessment and Risk Stratification

Before initiating treatment, cardiac causes must be excluded in specific populations:

• Obtain an ECG for patients older than 35 years or those with cardiac risk factors to rule out coronary artery disease, which is present in 3-6% of adult patients with chest pain and chest wall tenderness 3, 4
• In younger patients without risk factors, diagnosis can be made clinically based on reproducible tenderness to palpation over the costochondral junctions 1, 3

Pharmacological Treatment Algorithm

Step 1: First-Line Therapy

NSAIDs for 1-2 weeks represent the standard initial pharmacological approach 1, 2, 4:

• This addresses the inflammatory component directly
• Use the lowest effective dose to control symptoms 5
• For patients with cardiovascular disease or risk factors, follow a stepped-care approach: start with acetaminophen, aspirin, or tramadol before progressing to NSAIDs 5

Step 2: Alternative Analgesics (if NSAIDs contraindicated)

Acetaminophen can be used as an alternative when NSAIDs are not appropriate 5, 2:

• Particularly relevant for patients with GI bleeding history 5
• Consider adding proton-pump inhibitors if NSAIDs are necessary in patients with GI risk 5

Step 3: Refractory Cases

Add low-dose colchicine if symptoms persist despite adequate NSAID trial 1, 2

Local anesthetic-steroid injection may be reserved for cases refractory to oral medications 2

Non-Pharmacological Interventions

Adjunctive Physical Modalities

• Apply ice packs or heat to the affected area as complementary treatment 1, 2
• Topical analgesics such as lidocaine patches provide localized pain relief with minimal systemic effects 2

Physical Therapy Approaches

Stretching exercises have demonstrated progressive significant improvement compared to control groups (p<0.001) 6:

• This provides a useful non-pharmacological tool when NSAIDs have insufficient effectiveness
• Can be particularly valuable for chronic or atypical costochondritis 7, 6

Osteopathic manipulation techniques may be beneficial for rib dysfunction, especially in atypical costochondritis that does not self-resolve 7

Special Considerations for Inflammatory Conditions

Patients with Arthritis or Fibromyalgia History

For fibromyalgia patients, the treatment approach aligns with general recommendations 5:

• Tramadol is specifically recommended for pain management in fibromyalgia 5
• Simple analgesics like paracetamol can be considered, but corticosteroids and strong opioids are not recommended 5
• Antidepressants (amitriptyline, fluoxetine, duloxetine) reduce pain and improve function in fibromyalgia, which may help if costochondritis coexists 5

For patients with inflammatory arthropathies (such as those with inflammatory bowel disease or ankylosing spondylitis):

• Short-term NSAIDs are generally supported, though long-term use should be avoided if possible due to safety concerns 5
• The risk of NSAIDs aggravating underlying inflammatory conditions appears low, particularly at low doses and short durations 5
• Local steroid injections are effective for localized musculoskeletal inflammation 5
• Short-term systemic glucocorticoids can be considered for rapid symptom relief as a bridge to other therapies, but long-term use should be avoided 5

Important Caveats

Avoid long-term NSAID therapy in patients with cardiovascular disease or risk factors 5:

• Prescribe the lowest dose required to control symptoms
• Consider adding low-dose aspirin (81 mg) and PPI in patients at increased thrombotic risk, though this may not provide sufficient protection 5

Distinguish costochondritis from infectious causes: If there is purulent drainage, fever, or systemic signs of infection, consider infectious costochondritis requiring antibiotics and possible surgical debridement 8

Differentiate from Tietze syndrome (which involves visible swelling) and other conditions like slipping rib syndrome or SAPHO syndrome, as these may require different management approaches 3