What is the recommended management approach for an 18-year-old male patient presenting with symptoms of costochondritis?

Management of Costochondritis in an 18-Year-Old Male

Start with maximum-dose NSAIDs for 1-2 weeks combined with local ice or heat application and stretching exercises, after first confirming the diagnosis through reproducible tenderness on palpation of the costochondral joints (typically ribs 3-7). 1, 2

Initial Diagnostic Confirmation (Essential First Step)

Before initiating treatment, you must confirm costochondritis through:

• Reproducible tenderness on palpation of the affected costochondral joints—this is the hallmark physical finding 1
• Pain typically involves ribs 3-7, most commonly left-sided or retrosternal 1, 2
• Sharp, stabbing pain that worsens with inspiration or palpation (this finding markedly reduces the probability of cardiac ischemia) 2

Critical pitfall to avoid: In an 18-year-old healthy male, cardiac causes are unlikely, but do not assume all reproducible chest wall tenderness is benign if any cardiac risk factors are present 2

First-Line Treatment (Weeks 0-2)

Pharmacological:

• NSAIDs at maximum tolerated adult dosage for 1-2 weeks as the cornerstone of therapy 1, 2
• If NSAIDs are contraindicated, substitute with acetaminophen 1, 2
• Consider topical analgesics like lidocaine patches for localized pain relief with minimal systemic effects 1, 2

Non-pharmacological (equally important):

• Apply local heat or ice packs in conjunction with drug therapy 1, 2
• Stretching exercises should be initiated immediately—research demonstrates progressive significant improvement with stretching compared to controls (p<0.001) 3

Second-Line Treatment (Weeks 2-4)

Evaluate treatment response at 2-4 weeks 2:

If insufficient response:

• Add low-dose colchicine to the NSAID regimen 1, 2
• Consider rotating to a different NSAID 2
• Continue stretching exercises 3

If sufficient response:

• Continue current regimen and re-evaluate at 12 weeks 2

Long-Term Management (Week 12 and Beyond)

• Re-evaluate at 12 weeks: If sustained improvement occurs, consider tapering to on-demand treatment 2
• Reassess if symptoms persist beyond expected timeframe to rule out other causes (chronic non-bacterial osteitis, SAPHO syndrome, or axial spondyloarthritis) 2
• Note that symptoms can be chronic (>6 months in 55.4% of patients), though the condition remains benign and self-limited 2

Additional Therapeutic Considerations

Physiotherapy consultation may be beneficial as part of comprehensive management 2:

• Manual therapy techniques including rib manipulation have shown complete symptom resolution in atypical cases 4, 5
• Instrument-assisted soft tissue mobilization (IASTM) can address myofascial pain generators 4

Key Clinical Pearls

• Do not use nitroglycerin response as a diagnostic criterion—relief does not distinguish cardiac from non-cardiac chest pain 2
• The condition is self-limited and benign, but requires proper initial management to prevent chronicity 2
• Stretching exercises are not optional—they provide a simple, effective intervention that significantly improves outcomes 3
• Most nontraumatic musculoskeletal chest wall pain (42%) is attributed to costochondritis 1