How should I evaluate and manage an otherwise healthy adult with sharp, localized chest wall pain that worsens with deep inspiration, coughing, or torso movement, suggestive of costochondritis?

Evaluation and Management of Suspected Costochondritis

In an otherwise healthy adult with sharp, localized chest wall pain that worsens with deep inspiration, coughing, or torso movement, first rule out life-threatening cardiac causes with an ECG within 10 minutes if the patient is over 35 years or has any cardiac risk factors, then confirm costochondritis by reproducing the pain with palpation of the costochondral joints (typically ribs 3-7), and treat with a 1-2 week course of NSAIDs plus reassurance. 1, 2

Initial Risk Stratification and Cardiac Exclusion

Critical first step: Age and cardiac risk factors determine your immediate approach. 2

• Patients ≤35 years without cardiac risk factors: History and physical examination documenting reproducible pain by palpation over costal cartilages is usually sufficient for diagnosis. 2

• Patients >35 years OR any cardiac risk factors: Obtain ECG and consider chest radiograph immediately, as coronary artery disease is present in 3-6% of adult patients with chest pain and chest wall tenderness to palpation. 2

• Any cardiopulmonary symptoms present: Perform ECG within 10 minutes and measure cardiac troponin as soon as possible to exclude acute coronary syndrome. 3, 1

Key Pitfall to Avoid

Do not assume reproducible chest wall tenderness excludes cardiac disease: 7% of patients whose pain is fully reproduced with palpation were ultimately recognized to have acute coronary syndrome. 3, 1 Sharp, pleuritic pain reduces but does not eliminate the probability of cardiac ischemia—13% of patients with pleuritic pain had acute ischemia in the Multicenter Chest Pain Study. 3

Diagnostic Confirmation

Physical examination findings that confirm costochondritis: 1, 2

• Tenderness to palpation of the costochondral joints is the hallmark finding—this must be reproducible. 1
• Pain typically affects ribs 3-7, most commonly left-sided or retrosternal. 1
• The affected costochondral junctions should be tender when pressed with your fingertip. 1
• Pain is reproduced with movement or palpation of the chest wall or arms. 3

Features that support the diagnosis: 3

• Sharp or knifelike pain brought on by respiratory movements or cough (pleuritic quality). 3
• Pain localized at the tip of one finger, particularly over a costochondral junction. 3
• Tenderness of costochondral joints on examination. 3

Additional Diagnostic Considerations

Imaging is generally not indicated for typical costochondritis after cardiac causes are excluded. 3

• Chest radiography may be useful initially to evaluate for rib fracture, infection, or neoplasm, but is insensitive for costochondral abnormalities. 3
• Bone scintigraphy can detect costochondritis (positive in 71.4% of cases) but is not useful as first-line imaging. 3
• CT chest has superior sensitivity for chest wall abnormalities but is not useful as first-line evaluation in the absence of trauma, infection, or malignancy risk factors. 3

Treatment Algorithm

First-Line Pharmacological Management

Start with NSAIDs for 1-2 weeks: 1

• NSAIDs are recommended for pleuritic-type pain or when there is an underlying inflammatory component. 1
• Continue for 1-2 weeks as costochondritis is usually self-limited. 2

Alternative if NSAIDs contraindicated: 1

• Use acetaminophen as an alternative analgesic. 1
• Consider topical analgesics like lidocaine patches for localized pain relief with minimal systemic effects. 1

Second-Line Treatment for Persistent Symptoms

If inadequate response to NSAIDs after 1-2 weeks: 1

• Add low-dose colchicine to the treatment regimen. 1
• Consider topical analgesics like lidocaine patches if not already tried. 1

Non-Pharmacological Interventions

Adjunctive measures to combine with medication: 1, 2, 4

• Apply ice packs or local heat to the affected area. 1
• Advise patients to avoid activities that produce chest muscle overuse or repetitive movements. 2
• Stretching exercises showed progressive significant improvement (p<0.001) compared to controls in one study of 51 patients. 4
• Provide reassurance about the benign, self-limited nature of the condition. 2

Monitoring and Follow-Up

Typical course and red flags: 2, 5

• Costochondritis is usually self-limited and resolves within a few weeks. 2
• Atypical costochondritis refers to symptoms that do not self-resolve and may require additional evaluation. 5
• Reassess if symptoms persist beyond 2-3 weeks despite treatment to rule out other potential causes of persistent pain. 1

When to Reconsider the Diagnosis

Persistent or worsening symptoms warrant re-evaluation: 1, 6

• Consider infectious costochondritis if there is fever, purulent drainage, or systemic signs of infection—this requires antibiotics and possible surgical debridement. 6
• Rule out malignancy, infection, or inflammatory conditions (e.g., SAPHO syndrome, spondyloarthritis) if pain persists beyond expected timeframe. 3
• Consider gastrointestinal causes (esophageal reflux, dysmotility) if recurrent pain without cardiac or pulmonary cause. 7

Common Clinical Pitfalls

Critical errors to avoid in diagnosis and management: 3, 1

1. Do not use nitroglycerin response as a diagnostic criterion: Relief with nitroglycerin does not distinguish cardiac from non-cardiac chest pain (35% of patients with active CAD vs. 41% without CAD had relief). 3, 1

2. Do not delay cardiac evaluation in high-risk patients: Coronary artery disease can coexist with musculoskeletal findings. 1

3. Do not assume all reproducible chest wall tenderness is benign: 7% of patients with reproducible pain on palpation have acute coronary syndrome. 3, 1

4. Do not overlook infectious causes: Infectious costochondritis with sternal osteomyelitis requires surgical debridement and prolonged antibiotics. 6