What is the best treatment approach for a patient with costochondritis?

Treatment of Costochondritis

Start with a 1-2 week course of NSAIDs as first-line therapy, which can be combined with ice application and stretching exercises for optimal pain relief. 1

Initial Pharmacological Management

NSAIDs form the cornerstone of costochondritis treatment. The American College of Cardiology specifically recommends a 1-2 week course of NSAIDs for this inflammatory chest wall condition 1. This recommendation is supported by the World Journal of Emergency Surgery, which emphasizes NSAIDs as primary therapy 1.

• If NSAIDs are contraindicated (e.g., gastrointestinal issues, renal disease, cardiovascular risk), use acetaminophen as an alternative analgesic 1
• For localized pain relief with minimal systemic effects, consider topical lidocaine patches, particularly useful in patients who cannot tolerate oral medications 1

Escalation for Persistent Symptoms

If symptoms persist after 1-2 weeks of NSAID therapy, add low-dose colchicine to the treatment regimen 1. This represents the next step in the treatment algorithm recommended by the American College of Cardiology 1.

Non-Pharmacological Interventions

Ice packs should be applied locally as an adjunct to pharmacological therapy 1. The World Journal of Emergency Surgery supports both heat and ice application as part of initial treatment 1.

Stretching exercises provide significant benefit and should be incorporated into the treatment plan 2. A study demonstrated progressive, statistically significant pain improvement (p<0.001) in patients performing stretching exercises compared to controls, with this simple intervention offering a useful tool when NSAIDs show insufficient effectiveness 2.

Physical Therapy Considerations

For cases lasting beyond several weeks (atypical costochondritis), refer to physical therapy for an impairment-based approach 3. Physical therapy interventions targeting the cervicothoracic spine and ribcage, including manual therapy and therapeutic exercise, have shown clinically meaningful improvements 3:

• Mean pain reduction of 5.1 points on the numerical pain rating scale 3
• Mean functional improvement of 5.3 points on patient-specific functional scales 3
• Average of 4-5 treatment sessions needed 3

Manual therapy techniques including rib manipulation, soft tissue mobilization, and Active Release Techniques may provide complete symptom resolution in refractory cases 4, 5.

Diagnostic Confirmation Before Treatment

Ensure diagnosis by confirming tenderness to palpation of the costochondral joints, which is the hallmark physical finding 1. Pain should be reproducible with palpation of the affected costochondral junctions 1. For pain over ribs 6 and 7, focus examination on these specific junctions 1.

Monitoring and Red Flags

Reassess patients who fail to respond to initial treatment to rule out other causes of chest pain 1. The Journal of the American College of Radiology emphasizes this reassessment for persistent pain 1.

Important caveat: If purulent drainage, fever, or systemic symptoms develop, consider infectious costochondritis, which requires cultures, imaging (CT/MRI), and antibiotic therapy rather than standard treatment 6. This is a rare but serious complication requiring surgical debridement in some cases 6.

Treatment Algorithm Summary

1. Week 1-2: NSAIDs + ice application + stretching exercises 1, 2
2. If inadequate response: Add low-dose colchicine 1
3. If still inadequate: Consider topical lidocaine patches 1
4. If symptoms persist >6-8 weeks: Refer to physical therapy for manual therapy and targeted exercises 3
5. Throughout: Reassess to exclude cardiac, pulmonary, or infectious etiologies 1