Treatment of Costochondritis
First-line treatment consists of NSAIDs for 1-2 weeks, combined with reassurance and activity modification. 1, 2
Initial Diagnostic Confirmation Required
Before initiating treatment, confirm the diagnosis through:
- Reproducible tenderness on palpation of the affected costochondral joints (typically ribs 3-7, most commonly left-sided or retrosternal) 3, 1
- Rule out life-threatening causes first: In patients >35 years or with cardiac risk factors, obtain an ECG within 10 minutes to exclude acute coronary syndrome, aortic dissection, pulmonary embolism, or esophageal rupture 3, 4, 5
- Key distinguishing features: Sharp, stabbing pain that worsens with inspiration or palpation markedly reduces the probability of cardiac ischemia 3
Pharmacological Treatment Algorithm
Step 1: First-Line Therapy
- NSAIDs for 1-2 weeks for pleuritic-type pain or underlying inflammatory component 1, 2
- Acetaminophen as an alternative if NSAIDs are contraindicated (gastrointestinal issues, renal disease, anticoagulation) 1, 2, 5
Step 2: Persistent Symptoms
- Add low-dose colchicine if symptoms persist despite adequate NSAID trial 1, 2
- Topical lidocaine patches for localized pain relief with minimal systemic effects 1, 2
Step 3: Refractory Cases
- Reassess to rule out other causes of persistent pain, including axial spondyloarthritis (costochondritis may be the first manifestation) 1, 2
- Consider infectious costochondritis if fever, purulent drainage, or systemic symptoms develop—requires cultures and possible surgical debridement 6
Non-Pharmacological Interventions
- Local application of ice or heat as adjunctive therapy 1, 2
- Stretching exercises targeting the chest wall musculature show progressive significant improvement compared to controls (p<0.001) 7
- Activity modification: Advise patients to avoid movements that produce chest muscle overuse or repetitive strain 5
- Osteopathic manipulation techniques and instrument-assisted soft tissue mobilization may provide complete resolution in atypical or chronic cases (>6 months duration) 8
Critical Pitfalls to Avoid
- Do not use nitroglycerin response as a diagnostic criterion—relief with nitroglycerin does not distinguish cardiac from non-cardiac chest pain 3
- Do not delay cardiac evaluation in high-risk patients: Coronary artery disease is present in 3-6% of adult patients with chest pain and chest wall tenderness 5
- Do not assume all reproducible chest wall tenderness is benign—serious cardiac conditions can coexist with musculoskeletal findings 3, 5
- Recognize chronic presentations: 55.4% of patients experience symptoms >6 months, requiring more aggressive multimodal treatment 1
Expected Clinical Course
- Most cases are self-limited, resolving within 2-3 weeks with conservative treatment 5, 8
- Symptoms occurring >once daily are common (62.9% of patients) and do not indicate treatment failure 1
- Atypical costochondritis (non-resolving beyond several weeks) warrants consideration of physical therapy techniques and reassessment for alternative diagnoses 8