What is the best treatment for a patient with a costochondritis flare-up, considering their medical history, including any history of gastrointestinal issues or kidney disease?

Treatment for Costochondritis Flare-Up

For a costochondritis flare-up, start with NSAIDs (such as ibuprofen or naproxen) or acetaminophen as first-line therapy, combined with activity modification to avoid movements that reproduce the pain. 1

Initial Pharmacologic Management

• NSAIDs are the preferred first-line treatment when safe and appropriate, as they address the inflammatory component of costochondritis 1
• Acetaminophen is an alternative for patients who cannot tolerate NSAIDs or have contraindications (such as gastrointestinal issues, kidney disease, or cardiovascular risk factors) 1
• In patients with GI issues, add a proton pump inhibitor if NSAIDs are used, similar to the approach for other inflammatory conditions 2
• In patients with chronic kidney disease, avoid NSAIDs entirely and use acetaminophen as the sole analgesic option 2

Activity Modification and Physical Measures

• Advise patients to avoid activities that produce chest muscle overuse or movements that reproduce the pain, as continued mechanical stress perpetuates inflammation 1
• Rest from aggravating activities is essential during the acute flare period 1

When Standard Treatment Fails (Atypical Costochondritis)

If symptoms persist beyond 2-3 weeks despite NSAIDs and activity modification, consider the following:

• Refer to physical therapy for manual therapy techniques, including rib manipulation, soft tissue mobilization, and therapeutic exercise targeting the cervicothoracic spine and ribcage 3, 4
• Physical therapy utilizing an impairment-based examination approach has shown clinically meaningful improvements, with patients reporting pain reduction of approximately 5 points on a 0-10 scale after an average of 5 treatment sessions 4
• Manual therapy addresses potential rib dysfunction and myofascial pain generators that may perpetuate symptoms 3

Critical Diagnostic Considerations Before Treatment

Before diagnosing costochondritis, you must rule out serious cardiac causes:

• In patients over 35 years old, those with cardiac risk factors, or any patient with cardiopulmonary symptoms, obtain an ECG and consider chest radiograph before attributing symptoms to costochondritis 1
• Coronary artery disease is present in 3-6% of adult patients with chest pain and chest wall tenderness to palpation 1
• In younger patients (children, adolescents, young adults) without risk factors, history and physical examination documenting reproducible pain by palpation over costal cartilages is usually sufficient 1

Red Flags Requiring Alternative Diagnosis

• If fever, purulent drainage, or systemic signs of infection are present, consider infectious costochondritis requiring cultures and antibiotic therapy rather than NSAIDs alone 5
• Infectious costochondritis typically requires surgical debridement and prolonged antibiotic therapy (4-6 weeks) 5

Expected Timeline and Reassurance

• Costochondritis is usually self-limited and benign, with symptoms typically resolving within several weeks 1
• Provide reassurance to patients, as the condition does not indicate serious underlying pathology once cardiac causes are excluded 1
• Chronic costochondritis lasting months is associated with high medical expenses and psychological burden, making early aggressive management with physical therapy referral appropriate 3

Common Pitfalls to Avoid

• Do not assume all anterior chest wall pain is benign costochondritis—cardiac evaluation is mandatory in appropriate populations 1
• Do not continue NSAIDs indefinitely without reassessment—if symptoms persist beyond 2-3 weeks, refer to physical therapy rather than continuing passive pharmacologic management 4
• Do not overlook GI protection or renal function when prescribing NSAIDs, particularly in patients with relevant comorbidities 2