What is the appropriate evaluation and treatment for a patient with costochondria?

Costochondritis: Evaluation and Treatment

Initial Evaluation

Start with a focused cardiovascular examination to exclude life-threatening causes—acute coronary syndrome, aortic dissection, pulmonary embolism, or esophageal rupture—before diagnosing costochondritis. 1

Risk Stratification and Cardiac Workup

• Obtain an ECG for all patients over 35 years old or those with cardiac risk factors to rule out cardiac causes 1
• Coronary artery disease is present in 3-6% of adult patients with chest pain and chest wall tenderness, so cardiac evaluation remains essential despite reproducible chest wall pain 2
• Patients with acute myocardial infarction can still have costochondritis (6% rate in one study), though the rate is lower than in general chest pain populations (28%) 3

Physical Examination Findings

• Systematically palpate the costochondral joints to identify reproducible tenderness—this is the hallmark diagnostic finding 1, 4, 5
• Pain is typically retrosternal (52%) or left-sided (69%), described as stinging (53%) or pressing (35%) 5
• Assess whether pain worsens with deep breathing, coughing, or movement (characteristic of pleuritic pain) 1
• Check for friction rub to exclude pleural or pericardial involvement 1

Imaging Considerations

• Chest radiography is useful as initial imaging to evaluate conditions that may simulate chest wall pain 1
• Consider rib series radiographs for focal chest wall pain to assess for rib fractures or lesions 1
• Ultrasound has higher sensitivity than CT for detecting costochondral abnormalities not visible on radiographs 1
• In younger patients (children, adolescents, young adults) without cardiac risk factors, history and physical examination documenting reproducible palpation pain over costal cartilages is usually sufficient for diagnosis 2

Red Flags for Alternative Diagnoses

• Anginal pain presents as pressure or heaviness rather than sharp or stabbing pain 1
• Anterior chest wall pain may be the first manifestation of axial spondyloarthritis in some patients 1, 4, 5
• Consider fibromyalgia, though only 8% of costochondritis patients meet criteria for this condition 3

Treatment Algorithm

First-Line Pharmacological Management

Initiate NSAIDs for 1-2 weeks as first-line treatment for pleuritic-type pain or when inflammatory component is present 4, 5

Alternative and Adjunctive Therapies

• Use acetaminophen if NSAIDs are contraindicated 4, 5
• Add low-dose colchicine if symptoms persist despite NSAID therapy 4, 5
• Apply topical analgesics like lidocaine patches for localized pain relief with minimal systemic effects 4, 5

Non-Pharmacological Interventions

• Apply local heat or ice as part of initial treatment 4, 5
• Consider osteopathic manipulation techniques and instrument-assisted soft tissue mobilization for atypical costochondritis that does not self-resolve 6
• Advise patients to avoid activities that produce chest muscle overuse 2

Refractory Cases

• For recurrent costochondritis, corticosteroid injections provide symptomatic improvement 7
• Sulfasalazine may provide long-term benefit in recurrent cases that fail other treatments 7
• Reassess patients with persistent symptoms to rule out other potential causes of pain 5

Clinical Course and Follow-Up

• Costochondritis is usually self-limited and benign, with most cases resolving within weeks 6, 2
• Symptoms occur more than once daily in 63% of patients, with 55% experiencing chronic symptoms lasting over 6 months 4, 5
• At 1-year follow-up, 55% of patients still report chest pain, though only one-third have definite costochondritis 3
• Early rheumatological review significantly reduces admission rates (39 pre-review vs 6 post-review) and investigation rates in patients with recurrent presentations 7

Common Pitfalls

• Do not assume reproducible chest wall tenderness completely excludes serious cardiac conditions—maintain appropriate clinical suspicion based on age and risk factors 1, 2
• Atypical costochondritis (non-self-resolving) is associated with high medical expenses and psychological burden, requiring more aggressive multimodal treatment 6
• Women (69%) and Hispanic patients (47%) have higher frequencies of costochondritis in emergency department settings 3