What is the initial treatment approach for a patient with costochondritis, particularly one with a history of trauma, physical activity, or pre-existing conditions like arthritis or fibromyalgia?

Treatment of Costochondritis

Begin with NSAIDs as first-line pharmacological treatment combined with patient education and stretching exercises, as costochondritis is a self-limiting musculoskeletal condition that typically resolves within weeks to months with conservative management. 1, 2

Initial Clinical Assessment

Before initiating treatment, confirm the diagnosis through physical examination:

• Reproduce pain with palpation of the costochondral junctions (typically 2nd-7th ribs), which is the hallmark diagnostic finding 1
• Rule out cardiac causes with ECG in patients >35 years or with cardiac risk factors 1
• Obtain chest radiography as initial imaging to exclude rib fractures, infection, or neoplasm, though radiographs may miss costochondral abnormalities 3
• Consider differential diagnoses including Tietze syndrome (visible swelling at costochondral junction), slipping rib syndrome, or SAPHO syndrome in atypical presentations 1

First-Line Treatment Algorithm

Pharmacological Management

NSAIDs are the cornerstone of initial treatment:

• Naproxen 500 mg twice daily is an appropriate starting regimen, with onset of pain relief within 1 hour 4
• Alternative dosing: 250 mg every 6-8 hours as needed, not exceeding 1000 mg daily after the first day 4
• Continue NSAIDs for 2-4 weeks as costochondritis typically self-resolves during this timeframe 1, 5
• Monitor for NSAID complications including gastrointestinal bleeding, fluid retention, and renal dysfunction, particularly in elderly patients 4

Non-Pharmacological Interventions (Equally Important)

Stretching exercises provide significant pain reduction:

• Implement daily stretching exercises targeting the pectoral muscles and anterior chest wall, which demonstrate progressive significant improvement compared to NSAIDs alone (p<0.001) 2
• Apply local heat before stretching to enhance effectiveness 2
• Educate patients that this is a benign, self-limiting condition to reduce psychological burden 5, 6
• Modify activities that exacerbate pain, particularly repetitive movements and heavy lifting 7

Second-Line Options for Refractory Cases

If symptoms persist beyond 2-4 weeks despite NSAIDs and stretching:

• Local corticosteroid injections directed to the affected costochondral junction may be considered 3
• Analgesics (acetaminophen or tramadol) can be added for residual pain when NSAIDs are insufficient or contraindicated 3
• Physical therapy with manual techniques including rib manipulation and instrument-assisted soft tissue mobilization (IASTM) may provide complete resolution in atypical costochondritis 5

Special Populations and Comorbidities

Patients with Arthritis or Fibromyalgia

• Recognize that costochondritis affects 30-60% of patients with axial spondyloarthritis and may be the first disease manifestation 3
• Only 8% of costochondritis patients meet fibromyalgia criteria, though widespread pain is more common (42% vs 5% in controls) 6
• For fibromyalgia patients, consider multimodal therapy including cognitive behavioral therapy and low-dose amitriptyline as per EULAR recommendations 3
• For inflammatory arthritis patients, NSAIDs remain first-line but monitor disease activity with composite measures 3

Post-Trauma or Physical Activity-Related Cases

• Obtain chest radiography to exclude occult rib fractures, particularly in trauma or severe coughing 3
• Consider CT chest if clinical suspicion for fracture remains high despite negative radiographs, as CT has superior sensitivity 3
• Implement activity modification and gradual return to physical training once pain resolves 8

Critical Pitfalls to Avoid

• Do not dismiss cardiac causes prematurely - obtain ECG in appropriate patients before attributing chest pain to costochondritis 1
• Do not use systemic corticosteroids for isolated costochondritis, as there is no evidence supporting their use 3
• Do not overlook infectious costochondritis in patients with diabetes, immunosuppression, or recent surgery who present with persistent pain and systemic symptoms 7
• Do not rely solely on NSAIDs - the combination of NSAIDs plus stretching exercises is superior to either alone 2

Expected Outcomes and Follow-Up

• Most patients experience resolution within 2-4 weeks with conservative treatment 1, 5
• At 1-year follow-up, 55% of patients may still report chest pain, but only one-third have persistent costochondritis on examination 6
• Atypical costochondritis (symptoms >2 months) requires reassessment for alternative diagnoses and consideration of manual therapy techniques 5
• Recurrence is uncommon when treated appropriately with combined pharmacological and non-pharmacological approaches 2, 8