What is the role of trypsin (enzyme) and rutoside (flavonoid) in the treatment of costochondritis?

Treatment of Costochondritis with Trypsin, Bromelain, and Rutoside

Direct Answer

There is no evidence supporting the use of trypsin, bromelain, or rutoside for the treatment of costochondritis. The available guideline evidence addresses rutoside only in the context of post-thrombotic syndrome (a completely different condition involving venous insufficiency), not musculoskeletal chest wall inflammation 1. No guidelines or high-quality studies address enzyme therapy (trypsin, bromelain) for costochondritis.

Evidence-Based Treatment Recommendations for Costochondritis

First-Line Treatment Approach

For acute costochondritis with inflammatory features, a 1-2 week trial of NSAIDs is the recommended initial approach 1. This addresses the inflammatory component directly and has established safety profiles in clinical practice.

• If symptoms persist or worsen with NSAIDs, consider adding low-dose colchicine as needed 1
• If symptoms worsen with NSAIDs, evaluate for esophagitis or esophageal spasm as alternative diagnoses 1

Physical Therapy Interventions

Stretching exercises demonstrate significant pain reduction in costochondritis patients 2. In a study of 51 patients, those treated with stretching exercises showed progressive significant improvement compared to controls (p<0.001) 2.

• Stretching exercises can be implemented as a simple, cost-effective intervention 2
• Osteopathic manipulation techniques (OMT) and instrument-assisted soft tissue mobilization (IASTM) may provide complete symptom resolution in atypical cases 3
• These physical interventions address the mechanical and myofascial components that NSAIDs alone cannot resolve 3, 2

Corticosteroid Injections for Recurrent Cases

Local corticosteroid injections are effective for recurrent costochondritis 4. All 13 patients treated with corticosteroid injections in one study reported symptomatic improvement 4.

• Reserve this approach for cases that fail conservative management with NSAIDs and physical therapy 4
• For patients with recurrent symptoms after injection, sulfasalazine may provide long-term benefit (10 of 11 patients responded in one series) 4

Critical Diagnostic Consideration

Serious cardiac and infectious causes must be excluded before diagnosing costochondritis 5, 3. Costochondritis is a diagnosis of exclusion.

• Infectious costochondritis (though rare) requires surgical debridement and prolonged antibiotic therapy, not anti-inflammatory treatment 5
• Early rheumatological review significantly reduces admission rates (39 pre-review vs 6 post-review, p<0.0001) and investigation burden 4
• The mean time to diagnosis in one series was 9.4 months, during which patients underwent unnecessary cardiac workups 4

Why Enzyme/Rutoside Combinations Are Not Recommended

The evidence base for rutoside relates exclusively to venous disease (post-thrombotic syndrome), where it theoretically reduces capillary filtration and microvascular permeability 1. However:

• Even in post-thrombotic syndrome, the evidence quality is low with high inconsistency and imprecision 1
• Side effects in venous disease studies included headache, hair loss, muscle stiffness, rash, dizziness, and gastric pain 1
• No mechanism of action has been established for costochondritis, which is a musculoskeletal inflammatory condition, not a vascular disorder

There is no published evidence—guideline, drug label, or research—supporting trypsin or bromelain for costochondritis treatment. The absence of evidence, combined with established effective alternatives, makes this combination inappropriate for clinical use.

Treatment Algorithm

1. Confirm diagnosis: Rule out cardiac, infectious, and gastrointestinal causes 5, 3, 4
2. Initial therapy: NSAIDs for 1-2 weeks 1
3. Add physical therapy: Implement stretching exercises concurrently 2
4. Persistent symptoms: Add low-dose colchicine or consider OMT/IASTM 1, 3
5. Recurrent cases: Local corticosteroid injection 4
6. Chronic recurrent disease: Trial of sulfasalazine 4

The combination of trypsin, bromelain, and rutoside has no role in this evidence-based treatment pathway.