What is the appropriate management for costochondritis?

Management of Costochondritis

Start with a 1-2 week course of NSAIDs at maximum tolerated dose as first-line treatment, with pain typically resolving within this timeframe in most cases. 1

Initial Diagnostic Confirmation Required

Before initiating treatment, confirm the diagnosis through:

• Reproducible tenderness on palpation of the affected costochondral joints (typically ribs 3-7, most commonly left-sided or retrosternal) - this is the hallmark physical finding 1
• Rule out life-threatening causes first in 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
• Sharp, stabbing pain that worsens with inspiration or palpation markedly reduces the probability of cardiac ischemia 1

Critical Pitfall to Avoid

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, as coronary artery disease can coexist with musculoskeletal findings 1.

First-Line Pharmacological Treatment

NSAIDs (preferred initial therapy):

• Use maximum tolerated and approved dosage for 1-2 weeks 1, 2
• Particularly effective for pleuritic-type pain or when there is an underlying inflammatory component 1

Alternative if NSAIDs contraindicated:

• Acetaminophen can be substituted 1, 2

Second-Line Treatment (If Inadequate Response After 1-2 Weeks)

Add low-dose colchicine if symptoms persist despite NSAID therapy 1

Consider topical analgesics:

• Lidocaine patches may provide localized pain relief with minimal systemic effects 1

Non-Pharmacological Interventions

Concurrent with pharmacological treatment:

• Apply ice packs or local heat 1
• Stretching exercises show progressive significant improvement compared to NSAIDs alone (p<0.001) and should be incorporated into the treatment plan 3
• Advise patients to avoid activities that produce chest muscle overuse 2

For atypical costochondritis (symptoms >2 weeks):

• Consider osteopathic manipulation techniques (OMT) and instrument-assisted soft tissue mobilization (IASTM) for rib dysfunction 4
• Physical therapy techniques can address myofascial pain generators 4

Treatment Timeline and Monitoring

Week 1-2:

• NSAIDs at maximum tolerated dose + ice/heat application + stretching exercises 1, 3
• Most cases resolve within this timeframe 2

If symptoms persist beyond 2 weeks:

• Add low-dose colchicine to NSAID regimen 1
• Consider topical lidocaine patches 1
• Refer for physical therapy/OMT evaluation 4

If symptoms persist beyond 6 months (chronic/atypical costochondritis):

• Reassess to rule out other potential causes of persistent pain 1
• Consider multimodal approach with manipulation therapy and soft tissue mobilization 4

Special Considerations

Infectious costochondritis (rare):

• Suspect if purulent drainage, fever, or systemic signs present 5
• Requires blood cultures, imaging (CT/MRI), and antibiotic therapy with possible surgical debridement 5
• This is a completely different entity from typical costochondritis and requires urgent infectious disease consultation 5