What is the recommended treatment for costochondritis?

Treatment of Costochondritis

First-Line Pharmacological Management

Start with a 1-2 week course of NSAIDs at maximum tolerated dosing as the primary treatment for costochondritis. 1, 2

Specific NSAID Dosing Regimens:

• Naproxen: 375-1100 mg daily in two divided doses 2
• Ibuprofen: 1800 mg daily in divided doses 2
• Diclofenac: Start at 150 mg daily, then maintain at 75-100 mg daily 2
• Celecoxib (for patients with GI risk factors): 200-400 mg daily 2

The American College of Cardiology and American College of Rheumatology both recommend NSAIDs as first-line therapy, with evaluation of treatment response after 2-4 weeks. 1, 2 Use the lowest effective dose for the shortest duration to minimize systemic risks. 2

Alternative Analgesics:

• Acetaminophen (paracetamol) at regular dosing intervals if NSAIDs are contraindicated or insufficient 1, 2
• Topical NSAIDs may be considered to minimize systemic side effects, particularly in elderly patients or those with comorbidities 1, 2

Adjunctive Non-Pharmacological Interventions

Apply local heat or cold applications to the affected costochondral joints for symptomatic relief. 1, 2

• Modify activities to avoid movements that exacerbate pain while maintaining general physical activity 1
• Rest during acute painful episodes, then gradually return to normal activities 1
• Stretching exercises targeting the chest wall may provide significant pain reduction beyond standard conservative treatment 3

Treatment Algorithm for Persistent Symptoms

If inadequate response after 2-4 weeks of NSAID therapy:

1. Switch to a different NSAID or add acetaminophen 2
2. Add low-dose colchicine for persistent inflammatory symptoms 1
3. Consider local corticosteroid injection directed to the specific tender costochondral junction for focal persistent pain 2
4. Short course of oral prednisolone may be used as a bridging option while awaiting effect of other agents 2

Avoid long-term systemic corticosteroids due to lack of evidence supporting their use and significant adverse effect profile. 2

Critical Safety Considerations and Monitoring

NSAID Contraindications:

Patients with active peptic ulcer disease, severe renal impairment, or recent cardiovascular events should avoid NSAID therapy. 2

Risk Mitigation Strategies:

• For patients with increased GI risk: use non-selective NSAIDs plus a gastroprotective agent (PPI or H2-blocker), OR use a selective COX-2 inhibitor 2
• COX-2 inhibitors reduce serious GI complications by 82% compared to non-selective NSAIDs (RR 0.18,95% CI: 0.14-0.23) 2
• Monitor for gastrointestinal, renal, and cardiovascular toxicity with prolonged use, especially in elderly patients 1, 2

Physical Therapy and Manual Techniques

For atypical costochondritis (symptoms persisting beyond typical 2-week self-limited course):

• Rib manipulation and soft tissue mobilization may provide complete symptom resolution when standard treatment fails 4
• Instrument-assisted soft tissue mobilization (IASTM) combined with stretching addresses myofascial pain generators 4
• Regular exercise and physical therapy should be incorporated into comprehensive treatment 2

Common Pitfalls to Avoid

• Never delay cardiac workup in appropriate patients: Although costochondritis is diagnosed by tenderness to palpation of costochondral joints 5, coronary artery disease is present in 3-6% of adult patients with chest pain and chest wall tenderness 6
• Patients over 35 years, those with cardiac risk factors, or any cardiopulmonary symptoms require ECG within 10 minutes and possibly chest radiograph before attributing pain to costochondritis 5, 6
• Do not use personal automobile for transport if cardiac etiology cannot be excluded; use EMS 5
• Avoid prolonged NSAID courses without reassessment at 2-4 weeks 2