Treatment of Costochondritis
Start with NSAIDs at maximum tolerated dosage as first-line therapy, evaluate response after 2-4 weeks, and add stretching exercises and local heat/cold applications for comprehensive pain control. 1
First-Line Pharmacological Management
NSAIDs are the cornerstone of treatment and should be initiated at the following evidence-based dosages 1:
- Naproxen: 375-1100 mg daily in two divided doses 1
- Ibuprofen: 1800 mg daily in divided doses 1
- Diclofenac: Start at 150 mg daily, then maintain at 75-100 mg daily 1
- Celecoxib: 200-400 mg daily for patients with gastrointestinal risk factors 1
Use oral NSAIDs at the lowest effective dose for the shortest possible duration to minimize systemic side effects 1. Topical NSAIDs should be considered as an alternative to reduce systemic exposure 1.
Gastroprotection Strategy
For patients with increased gastrointestinal risk, use either non-selective NSAIDs plus a gastroprotective agent OR a selective COX-2 inhibitor 1. This approach is critical since selective COX-2 inhibitors reduce serious GI events with a relative risk of 0.18 (95% CI: 0.14-0.23) compared to non-selective NSAIDs 1.
Alternative and Adjunctive Analgesics
Acetaminophen (paracetamol) should be used as an alternative or adjunct when NSAIDs are insufficient, contraindicated, or poorly tolerated 1. Regular dosing may be necessary for adequate pain control 1.
Non-Pharmacological Interventions
Stretching exercises provide significant benefit and should be incorporated into the treatment plan 2. A retrospective study of 51 patients demonstrated progressive significant improvement in pain with stretching exercises compared to controls (p<0.001) 2.
Additional non-pharmacological measures include 1:
- Local heat or cold applications to the affected costochondral junction 1
- Regular exercise and physical therapy as part of comprehensive management 1
- Temporary rest of the affected area during the acute phase 1
Treatment Algorithm for Inadequate Response
If pain persists after 2-4 weeks of initial NSAID therapy 1:
- Switch to a different NSAID 1
- Add acetaminophen to the existing NSAID regimen 1
- Consider local corticosteroid injection for focal areas of persistent tenderness at the specific costochondral junction 1
Corticosteroid Use: Critical Caveats
Local corticosteroid injections may be considered for persistent focal pain despite adequate NSAID therapy 1. Short courses of oral prednisolone can serve as bridging therapy while awaiting the effect of other agents 1.
Avoid long-term systemic corticosteroids—they lack evidence for efficacy in costochondritis and carry significant adverse effects 1. This is a common pitfall in management that must be avoided 1.
Critical Safety Monitoring
Patients with active peptic ulcer disease, severe renal impairment, or recent cardiovascular events should avoid NSAID therapy due to increased risk of gastrointestinal, renal, and cardiovascular toxicity 1.
Monitor for the following with prolonged NSAID use, particularly in elderly patients and those with comorbidities 1:
- Gastrointestinal toxicity (RR 5.36 for serious GI complications; 95% CI: 1.79-16.10) 1
- Hepatotoxicity 1
- Cardiorenal toxicity 1
Ruling Out Serious Pathology
Before diagnosing costochondritis, exclude cardiac causes in specific populations 3:
- Patients older than 35 years 3
- Those with history or risk factors for coronary artery disease 3
- Any patient with cardiopulmonary symptoms 3
These patients require electrocardiography and possibly chest radiography 3. Coronary artery disease is present in 3-6% of adult patients with chest pain and chest wall tenderness 3.
For younger patients (children, adolescents, young adults), history and physical examination documenting reproducible pain by palpation over the costal cartilages is usually sufficient for diagnosis 3.
Special Consideration: Infectious Costochondritis
If purulent drainage, fever, or systemic signs of infection are present, consider infectious costochondritis requiring cultures and antibiotic therapy rather than standard anti-inflammatory treatment 4. This represents a distinct entity requiring surgical debridement in severe cases 4.