Costochondritis: Evaluation and Treatment
Diagnostic Confirmation
Costochondritis is diagnosed clinically by reproducible tenderness on palpation of the costochondral joints (typically ribs 3-7), most commonly left-sided or retrosternal, without need for imaging in most cases. 1, 2
Essential Clinical Features
- Pain characteristics: Sharp, stabbing, or pressing quality that worsens with deep breathing, coughing, or chest wall movement 1
- Location: Most commonly affects ribs 3-7, frequently left-sided (69.2%) or retrosternal (52%) 1
- Hallmark finding: Direct palpation of affected costochondral junctions reproduces the pain 2, 3
- Duration: Symptoms often occur more than once daily (62.9%), with over half of patients experiencing chronic symptoms lasting >6 months 1
Critical Exclusions Before Diagnosis
In patients >35 years or with cardiac risk factors, obtain an ECG within 10 minutes and measure cardiac troponin to exclude acute coronary syndrome before attributing symptoms to costochondritis. 1, 2, 3
High-Risk Features Requiring Cardiac Workup:
- Age >35 years 3
- Known coronary artery disease or cardiac risk factors 1, 3
- Dyspnea, diaphoresis, or radiation to jaw/arm 1
- Critical caveat: 7% of patients with reproducible chest wall tenderness still have acute coronary syndrome 1, 2
Features That Lower (But Don't Eliminate) Cardiac Probability:
- Sharp, pleuritic pain worsened by respiration 1
- Pain localized to one finger-tip area over costochondral junction 1
- Pain fully reproduced by palpation 1
- Important: Even with these features, 13-22% may still have acute ischemia 1
When Imaging Is NOT Indicated
Diagnostic imaging is not useful for typical costochondritis in low-risk patients with characteristic examination findings. 1, 3
- Costochondritis accounts for 42% of nontraumatic musculoskeletal chest wall pain and is readily diagnosed by physical examination alone 1
- In children, adolescents, and young adults without cardiac risk factors, history and physical examination documenting reproducible palpation tenderness are sufficient 3
When to Consider Imaging
Order chest radiograph and consider advanced imaging if: 1, 3
- Fever, weight loss, or night sweats (concern for infection or malignancy) 1
- History of malignancy (evaluate for metastases) 1
- Immunosuppression or diabetes (risk for infectious costochondritis) 1, 4
- Symptoms persist >3 months despite appropriate treatment 5
- Recent thoracic surgery (evaluate for postoperative infection) 1
Treatment Algorithm
First-Line Pharmacologic Management
Initiate a 1-2 week course of NSAIDs as first-line therapy for costochondritis. 2, 3
- NSAIDs reduce inflammation and pain in the costochondral joints 2, 3
- Alternative: Acetaminophen if NSAIDs are contraindicated (renal disease, GI bleeding risk, anticoagulation) 2, 3
- Topical analgesics (lidocaine patches) provide localized relief with minimal systemic effects 2
Second-Line: Add Colchicine for Persistent Symptoms
If symptoms persist after 1-2 weeks of NSAIDs, add low-dose colchicine (0.5-0.6 mg once or twice daily). 2
- Colchicine reduces inflammation and lowers recurrence risk 2
- Continue for approximately 3 months 2
- Reduce dose for patients <70 kg 2
Non-Pharmacologic Interventions
Advise patients to avoid activities that produce chest muscle overuse and apply ice or heat to the affected area. 2, 3
- Ice packs can be used in conjunction with drug therapy 2
- Stretching exercises show progressive significant improvement compared to controls (p<0.001) 6
- Consider osteopathic manipulation or physical therapy for atypical costochondritis (symptoms >2 years) 5
Follow-Up and Red Flags
Reassessment Timing
Reassess at 2-3 weeks to confirm symptom improvement and rule out alternative diagnoses if pain persists. 1, 2
Warning Signs Requiring Urgent Re-Evaluation:
- Development of fever, purulent drainage, or skin changes (infectious costochondritis) 4
- Progressive swelling or erythema over affected area 4
- New onset dyspnea, syncope, or hemodynamic instability 1
- Worsening pain despite appropriate therapy 1
Common Pitfalls to Avoid
Do not use nitroglycerin response as a diagnostic test: Relief with nitroglycerin does not distinguish cardiac from non-cardiac chest pain 1, 2
Do not assume all reproducible tenderness is benign: 7% of patients with palpable chest wall tenderness have acute coronary syndrome 1, 2
Do not delay cardiac evaluation in high-risk patients: Coronary artery disease is present in 3-6% of adult patients with chest pain and chest wall tenderness 3
Do not over-image low-risk patients: Most costochondritis is diagnosed clinically without imaging 1, 3
Do not miss infectious costochondritis: Patients with diabetes, immunosuppression, or recent surgery require higher suspicion for infection 1, 4