What is the diagnosis and treatment for a patient with costochondritis?

Costochondritis: Diagnosis and Treatment

Diagnosis

Costochondritis is diagnosed clinically by reproducible tenderness to palpation of the affected costochondral joints (typically ribs 3-7), most commonly left-sided or retrosternal, after excluding life-threatening cardiac and thoracic causes. 1

Clinical Presentation

• Pain is characteristically sharp and stabbing, worsening with inspiration or palpation, which markedly reduces the probability of cardiac ischemia 1
• Patients describe pain as stinging (53%) or pressing (35.1%), commonly retrosternal (52%) or left-sided (69.2%) 1
• Symptoms often occur more than once daily (62.9%), with many experiencing chronic symptoms lasting >6 months (55.4%) 1
• Costochondritis accounts for approximately 42% of all nontraumatic musculoskeletal chest wall pain 1, 2

Diagnostic Algorithm

For patients >35 years or with cardiac risk factors:

• Obtain ECG within 10 minutes to exclude acute coronary syndrome, aortic dissection, pulmonary embolism, or esophageal rupture 1, 2
• Consider chest radiography to exclude rib fractures, infection, or neoplasm 2
• Note that coronary artery disease is present in 3-6% of adult patients with chest pain and chest wall tenderness 3

For younger patients without cardiac risk factors:

• History and physical examination documenting reproducible pain by palpation over costal cartilages is usually sufficient 3
• The hallmark finding is tenderness to palpation of costochondral joints, which must be systematically assessed 4

Critical Diagnostic Pitfalls

• Do not use nitroglycerin response as a diagnostic criterion - relief with nitroglycerin does not distinguish cardiac from non-cardiac chest pain 1
• Do not delay cardiac evaluation in high-risk patients - serious cardiac conditions can coexist with musculoskeletal findings 1
• Do not assume all reproducible chest wall tenderness is benign - coronary artery disease remains a potential comorbidity 1

Treatment

First-line treatment consists of NSAIDs for 1-2 weeks, with local application of ice or heat as adjunctive therapy. 1, 4

Pharmacological Management Algorithm

Step 1: Initial therapy (1-2 weeks)

• NSAIDs as first-line pharmacological therapy for pleuritic-type pain or inflammatory component 1, 4
• Acetaminophen as alternative if NSAIDs are contraindicated 1
• Local application of ice or heat as adjunctive therapy 1, 4

Step 2: Persistent symptoms despite NSAIDs

• Add low-dose colchicine if symptoms persist despite NSAID therapy 1, 4
• Consider topical analgesics like lidocaine patches for localized pain relief with minimal systemic effects 1

Step 3: Refractory cases

• Consider local corticosteroid injections directed to the affected costochondral junction 2
• Add analgesics (acetaminophen or tramadol) for residual pain when NSAIDs are insufficient or contraindicated 2

Non-Pharmacological Approaches

• Stretching exercises show progressive significant improvement compared to control groups (p<0.001) 5
• Osteopathic manipulation techniques and instrument-assisted soft tissue mobilization may be useful for rib dysfunction, particularly in atypical costochondritis 6
• Advise patients to avoid activities that produce chest muscle overuse 3

Critical Treatment Pitfalls

• Do not use systemic corticosteroids for isolated costochondritis - there is no evidence supporting their use 2
• Reassess patients with persistent pain to rule out other potential causes 1

Special Populations

Patients with axial spondyloarthritis:

• Costochondritis affects 30-60% of these patients and may be the first disease manifestation 2
• Monitor disease activity with composite measures when using NSAIDs 2

Patients with fibromyalgia:

• Consider multimodal therapy including cognitive behavioral therapy and low-dose amitriptyline 2

Prognosis

• Costochondritis is usually self-limiting and benign, with symptoms typically resolving in a couple of weeks 6, 3
• Atypical costochondritis (not self-resolving) is associated with high medical expenses and psychological burden 6
• Provide reassurance about the benign nature and excellent prognosis 3