What is the best treatment approach for a patient with chronic costochondritis (inflammation of the cartilage that connects the ribs to the breastbone)?

Treatment of Chronic Costochondritis

For chronic costochondritis, the optimal treatment approach combines NSAIDs (with gastroprotection if indicated) as first-line pharmacological therapy, alongside physical therapy interventions including manual therapy, stretching exercises, and therapeutic exercise targeting the cervicothoracic spine and ribcage. 1, 2

Initial Management Strategy

First-Line Pharmacological Treatment

• Start NSAIDs at maximum tolerated doses for 2-4 weeks, evaluating treatment response at this timeframe 3, 4
• If using diclofenac specifically: initiate at 150 mg/day in divided doses, with maintenance of 75-100 mg/day 4
• Add gastroprotection (PPI or misoprostol) if any GI risk factors are present 4
• Consider NSAID rotation if insufficient response occurs at 2-4 weeks 3

Critical Safety Considerations for NSAIDs

• Contraindicated in patients with recent myocardial infarction, coronary artery bypass graft surgery, or uncontrolled hypertension 4
• Diclofenac carries increased cardiovascular risk (relative risk 1.63 for vascular events) compared to other NSAIDs, with highest risk in first 6 months 4
• Use lowest effective dose and shortest duration necessary 4
• Patients over 35 years or those with cardiac risk factors require electrocardiogram before treatment to exclude coronary artery disease 5

Physical Therapy Interventions

Evidence-Based Manual Therapy Approach

• Implement impairment-based examination targeting the cervicothoracic spine and ribcage 2
• Manual therapy techniques including rib manipulation and soft tissue mobilization show complete symptom resolution in atypical cases 6
• Stretching exercises demonstrate progressive significant improvement (p<0.001) compared to control groups 1
• Treatment typically requires 4-5 sessions over several weeks 2

Expected Outcomes with Physical Therapy

• Mean pain reduction of 5.1 points on numerical pain rating scale 2
• Mean functional improvement of 5.3 points on patient-specific functional scale 2
• Return to previous activities without restrictions achievable at discharge 2

Alternative Pharmacological Options

When NSAIDs Are Contraindicated or Ineffective

• Low-dose oral colchicine (0.5-1.0 mg daily) as an alternative anti-inflammatory agent 3
• Short tapering course of oral glucocorticosteroids for patients unable to tolerate NSAIDs 3
• Acetaminophen for mild cases, though less effective than NSAIDs 5

Non-Pharmacological Adjuncts

Conservative Measures

• Application of ice or cool packs to affected area 3
• Temporary rest and activity modification to avoid chest muscle overuse 5
• Patient education regarding the benign, self-limiting nature of the condition 5

Treatment Algorithm

1. Rule out cardiac causes in patients >35 years or with cardiac risk factors via ECG 5
2. Initiate NSAIDs at maximum tolerated dose with gastroprotection if indicated 3, 4
3. Simultaneously begin physical therapy with manual therapy and stretching exercises 1, 2
4. Evaluate response at 2-4 weeks: 3
   • If sufficient response: continue treatment and re-evaluate at 12 weeks
   • If insufficient response: consider NSAID rotation or advance to alternative agents
5. For refractory cases: add low-dose colchicine or short-course glucocorticosteroids 3

Common Pitfalls to Avoid

• Do not dismiss chest pain without cardiac evaluation in appropriate populations - coronary artery disease is present in 3-6% of adult patients with chest wall tenderness 5
• Avoid long-term glucocorticoid use - only short courses should be considered as bridging therapy 3
• Do not rely solely on NSAIDs - physical therapy interventions are essential for chronic cases lasting >6 months 2
• Do not overlook cardiovascular contraindications before prescribing NSAIDs, particularly diclofenac 4

Duration and Follow-Up

• Costochondritis typically resolves within several weeks to months 5
• Atypical costochondritis (not self-resolving beyond several weeks) requires multimodal treatment including both pharmacological and physical therapy approaches 6
• Cases lasting >6 months benefit significantly from structured physical therapy programs 2