Chronic Costochondritis Management
For chronic costochondritis, initiate NSAIDs at maximum tolerated doses combined with structured stretching exercises, as this combination provides superior pain relief compared to NSAIDs alone, with stretching exercises showing progressive significant improvement (p<0.001) over conservative treatment alone.
Initial Diagnostic Confirmation
Before treating as costochondritis, rule out cardiac causes in patients over 35 years or those with cardiac risk factors by obtaining an ECG and potentially chest radiograph 1. The diagnosis is confirmed by reproducible pain on palpation over costal cartilages, typically at the third through seventh costochondral junctions 1, 2.
First-Line Treatment Algorithm
Pharmacological Management
- Start NSAIDs at maximum tolerated and approved dosage as the primary pharmacological intervention 1
- Acetaminophen can be used as an alternative, though NSAIDs are preferred for their anti-inflammatory properties 1
- Evaluate treatment response at 2-4 weeks: if insufficient response, consider NSAID rotation before advancing to other interventions 1
Essential Non-Pharmacological Interventions
- Implement structured stretching exercises immediately - this is critical as stretching exercises demonstrate progressive significant pain reduction (p<0.001) compared to NSAIDs alone 2
- The stretching protocol should target the costochondral junctions and surrounding musculature 2
- Advise patients to avoid activities producing chest muscle overuse during the acute treatment phase 1
Advanced Treatment for Refractory Cases
When symptoms persist beyond 6 months despite first-line treatment:
Impairment-Based Physical Therapy Approach
- Refer to physical therapy for manual therapy and therapeutic exercise targeting the cervicothoracic spine and ribcage 3
- Treatment should include:
- Expected treatment duration: 4-5 sessions with clinically meaningful improvement (mean NPRS decrease of 5.1 points) 3
Multimodal Interventions
- Local heat application for temporary symptom relief 1
- Spinal manipulative therapy when rib dysfunction is identified on examination 5
- Consider clinical acupuncture as an adjunct in competitive athletes or refractory cases 5
Treatment Response Monitoring
- Reassess at 2-4 weeks for initial response to NSAIDs and stretching 1, 2
- Use numerical pain rating scale (NPRS) and patient-specific functional scale (PSFS) to quantify improvement 3
- If no improvement by 6-8 weeks, advance to physical therapy referral rather than continuing ineffective conservative management 3
Critical Clinical Pitfalls
Do not rely solely on NSAIDs - while traditional practice emphasizes NSAIDs, local splinting, and heat, this approach is often disappointing 2. The addition of stretching exercises is essential for optimal outcomes 2.
Do not delay physical therapy referral in cases lasting beyond 2-3 months, as chronic costochondritis (mean duration 6.3 months in one series) significantly limits occupational and fitness activities, and responds well to impairment-based PT 3.
Do not overlook regional interdependence - examination and treatment should include the cervicothoracic spine and ribcage, not just the symptomatic costochondral junction 3, 4.
Avoid local steroid injections as first-line - these have insufficient effectiveness and should be reserved for truly refractory cases after comprehensive conservative management has failed 2.
Expected Outcomes
With appropriate multimodal treatment including stretching exercises and manual therapy when indicated, patients should achieve: