Treatment of Costochondritis
First-line treatment consists of NSAIDs for 1-2 weeks, combined with local application of heat or ice, with the addition of low-dose colchicine if symptoms persist despite initial NSAID therapy. 1, 2
Initial Management Approach
Pharmacological Treatment Algorithm
Start with NSAIDs as first-line therapy for 1-2 weeks, particularly effective for pleuritic-type pain or when an underlying inflammatory component is present 1, 2
Acetaminophen serves as an alternative if NSAIDs are contraindicated due to gastrointestinal, renal, or cardiovascular concerns 1, 2
Add low-dose colchicine if symptoms persist despite adequate NSAID therapy after the initial 1-2 week course 1, 2
Consider topical analgesics such as lidocaine patches for localized pain relief with minimal systemic effects, particularly useful in patients who cannot tolerate oral medications 1, 2
Non-Pharmacological Interventions
Apply local heat or ice as part of initial treatment, which can be used in conjunction with pharmacological therapy 1, 2
Advise patients to avoid activities that produce chest muscle overuse or exacerbate symptoms 3
Critical Diagnostic Confirmation Required Before Treatment
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) 1, 2
Essential Cardiac Exclusion in High-Risk Patients
Obtain an ECG within 10 minutes for patients older than 35 years or those with cardiac risk factors to exclude acute coronary syndrome, aortic dissection, pulmonary embolism, or esophageal rupture 1, 4
Sharp, stabbing pain that worsens with inspiration or palpation markedly reduces the probability of cardiac ischemia 1
Do not use nitroglycerin response as a diagnostic criterion, as relief with nitroglycerin does not distinguish cardiac from non-cardiac chest pain 1
Common Pitfalls to Avoid
Never delay cardiac evaluation in high-risk patients, as coronary artery disease can be a comorbidity—coronary artery disease is present in 3-6% of adult patients with chest pain and chest wall tenderness to palpation 3
Do not assume all reproducible chest wall tenderness is benign, as serious cardiac conditions can coexist with musculoskeletal findings 1
Reassess patients with persistent pain to rule out other potential causes, as costochondritis is typically self-limited and should improve within several weeks 1, 3
Expected Clinical Course and Follow-Up
Most cases are self-limited and resolve within several weeks with appropriate treatment 3
Chronic symptoms lasting more than 6 months occur in approximately 55% of patients and may require escalation of therapy or consideration of alternative diagnoses 1, 2
Physical therapy with manual therapy and therapeutic exercise may be considered for cases that do not self-resolve (atypical costochondritis), particularly when symptoms persist beyond the typical timeframe 5, 6