Treatment of Costochondritis
Start with NSAIDs at maximum tolerated dosage as first-line therapy, with treatment response evaluated after 2-4 weeks. 1
First-Line Pharmacological Management
NSAIDs are the cornerstone of costochondritis treatment. The American College of Rheumatology recommends initiating NSAIDs or COX-2 inhibitors at maximum tolerated and approved dosages, with reassessment at 2-4 weeks to determine treatment response 1. Use oral NSAIDs at the lowest effective dose for the shortest possible period to minimize adverse effects 1.
For patients with gastrointestinal risk factors, prescribe either:
- Non-selective NSAIDs plus a proton pump inhibitor, OR
- A selective COX-2 inhibitor 1
The evidence shows COX-2 inhibitors reduce serious GI complications with a relative risk of 0.18 (95% CI: 0.14-0.23) compared to non-selective NSAIDs 1.
Topical NSAIDs should be considered to minimize systemic side effects, particularly in elderly patients or those with comorbidities 1.
Alternative and Adjunct Analgesics
Acetaminophen (paracetamol) with regular dosing may be used as an alternative or adjunct when NSAIDs are insufficient, contraindicated, or poorly tolerated 1. This is particularly relevant for patients with cardiovascular or renal disease where NSAIDs pose additional risks 2.
Interventional Options for Refractory Cases
If pain persists after 2-4 weeks of adequate NSAID therapy, consider local corticosteroid injections directed to the specific painful costochondral junction 1. This approach targets focal areas of persistent tenderness that have not responded to systemic therapy 1.
Avoid long-term systemic corticosteroids due to lack of evidence supporting their use and significant adverse effect profile 1. Short courses of oral prednisolone may only be considered as bridging therapy while awaiting the effect of other agents 1.
Non-Pharmacological Interventions
Apply local heat or cold applications to the affected costochondral junctions 1. This simple intervention can provide symptomatic relief without medication-related risks.
Physical therapy with stretching exercises shows significant benefit. A study of 34 patients demonstrated progressive significant improvement in pain (p<0.001) compared to controls when treated with stretching exercises 3. Another case series showed mean pain reduction of 5.1 points on the NPRS with manual therapy and exercise directed at the cervicothoracic spine and ribcage 4.
Advise patients to avoid activities that produce chest muscle overuse during the acute phase 2.
Treatment Algorithm
- Weeks 0-2: Initiate maximum tolerated NSAID dosing + local heat/cold + activity modification 1, 2
- Week 2-4: If inadequate response, switch to different NSAID or add acetaminophen 1
- After 4 weeks: For persistent focal pain, consider local corticosteroid injection to affected costochondral junction 1
- Throughout treatment: Incorporate stretching exercises and physical therapy 3, 4
Critical Safety Monitoring
Monitor for gastrointestinal, hepatic, and cardiorenal toxicity with prolonged NSAID use, particularly in elderly patients and those with comorbidities 1. The risk of serious GI complications with NSAIDs carries a relative risk of 5.36 (95% CI: 1.79-16.10) 1.
For patients over 35 years or those with cardiac risk factors, obtain an electrocardiogram and possibly chest radiograph to rule out coronary artery disease, which is present in 3-6% of adult patients with chest wall tenderness 2.
Patient Education
Provide reassurance that costochondritis is usually self-limited and benign 2. Explain the condition and expected timeline for improvement to reduce psychological burden, particularly in cases lasting beyond several weeks 1, 5.
Common Pitfalls to Avoid
- Do not use long-term systemic corticosteroids - they lack evidence and carry significant adverse effects 1
- Do not assume benign diagnosis without appropriate cardiac workup in patients over 35 or with cardiac risk factors 2
- Do not continue the same NSAID indefinitely without reassessment - evaluate response at 2-4 weeks and adjust accordingly 1