What is the primary treatment for a patient with costochondritis (inflammation of the cartilage that connects the ribs to the breastbone) or Tietze's syndrome?

Treatment of Costochondritis and Tietze Syndrome

First-line treatment consists of NSAIDs at maximum tolerated dosage for 1-2 weeks, with the option to add low-dose colchicine if symptoms persist, and local corticosteroid injection reserved for refractory cases. 1, 2

Initial Management Approach

Pharmacological First-Line Treatment

• Start NSAIDs/COXIBs at maximum tolerated and approved adult dosage as the cornerstone of initial therapy for both costochondritis and Tietze syndrome 3, 1, 2
• Continue NSAIDs for 1-2 weeks when there is pleuritic-type pain or underlying inflammatory component 1, 2
• Evaluate treatment response at 2-4 weeks: if sufficient response occurs, continue and re-evaluate at 12 weeks; consider tapering or on-demand treatment with sustained improvement 3
• If NSAIDs are contraindicated, use acetaminophen as an alternative analgesic 1, 2

Adjunctive Non-Pharmacological Measures

• Apply local heat or ice packs in conjunction with pharmacological therapy 1, 2
• Consider topical analgesics like lidocaine patches for localized pain relief with minimal systemic effects 1, 2
• Implement stretching exercises, which have shown progressive significant improvement in pain compared to controls (p<0.001) 4

Second-Line Treatment for Persistent Symptoms

Oral Corticosteroids

• Add low-dose colchicine if symptoms persist despite adequate NSAID therapy 1, 2
• For Tietze syndrome specifically, short-term oral corticosteroids (prednisolone 40 mg daily for 1 week, then 20 mg for 1 week, then 10 mg for 1 week) demonstrate significant superiority over NSAIDs alone, with 46.8% vs 17.7% pain reduction at week 1 (p<0.001) and sustained benefit at 6.5 months follow-up 5
• Short courses of oral prednisolone may be considered as bridging options throughout treatment steps, but avoid long-term glucocorticoid use 3

Local Corticosteroid Injection

• Ultrasound-guided corticosteroid injection into the affected costochondral joint provides prompt, complete, and prolonged relief in 87.5% of cases 6, 7
• This approach is particularly effective for Tietze syndrome with documented joint swelling on ultrasound 7
• Intra-articular glucocorticoid injections can be considered as bridging options while awaiting effect of other agents 3

Critical Diagnostic Confirmation Required First

Before initiating treatment, confirm the diagnosis through reproducible tenderness on palpation of affected costochondral joints (typically ribs 3-7) and rule out life-threatening causes in patients >35 years or with cardiac risk factors 1, 2

Essential Exclusions

• Obtain ECG within 10 minutes to exclude acute coronary syndrome, aortic dissection, pulmonary embolism, or esophageal rupture in appropriate clinical contexts 1
• Sharp, stabbing pain that worsens with inspiration or palpation markedly reduces probability of cardiac ischemia 1
• Do not use nitroglycerin response as a diagnostic criterion, as relief does not distinguish cardiac from non-cardiac chest pain 1

Treatment Algorithm Summary

1. Week 0-2: Maximum-dose NSAIDs + local heat/ice + stretching exercises 3, 1, 4
2. Week 2-4: If insufficient response, consider NSAID rotation OR add low-dose colchicine 3, 1
3. Refractory cases: Either short-term oral corticosteroids (3-week taper) OR ultrasound-guided local corticosteroid injection 5, 6, 7
4. Week 12: Re-evaluate; if sustained response, consider tapering to on-demand treatment 3

Important Caveats

• For Tietze syndrome with visible joint swelling, improvement in pain and quality of life does not necessarily correlate with resolution of swelling (only 10% showed swelling improvement despite significant pain relief) 5
• Consider physiotherapy consultation as part of comprehensive management 3
• Reassess patients with persistent pain to rule out other potential causes, including chronic non-bacterial osteitis, SAPHO syndrome, or axial spondyloarthritis 3
• The condition is self-limited and benign, but symptoms can be chronic (>6 months in 55.4% of patients) 1, 2