The use of corticosteroids in the management of costochondritis
Report By: Vanita Gandhi - FY2 in Emergency Medicine
Search checked by Jonathan Costello - Consultant in Emergency Medicine
Institution: Royal Free Hospital
Date Submitted: 2nd February 2012
Date Completed: 14th August 2012
Last Modified: 14th August 2012
Status: Green (complete)
Three Part Question
In [adults diagnosed with costochondritis] is [corticosteroid therapy of clinical benefit] in [reducing presenting symptomatology]?
A 42-year-old man presented to the emergency department with unilateral parasternal chest pain of recent onset. Examination revealed reproducible tenderness overlying the 2nd to 4th right sided costochondral junctions. Significant differentials were excluded subsequent to clinical examination and normal investigations, and a diagnosis of costochondritis was made. You prescribe ibuprofen, however he states he is intolerant to all non-steroidal anti-inflammatory drugs and asks whether there are any alternative treatments. Your registrar suggests giving either a local corticosteroid injection or oral soluble format prednisolone. You wonder what evidence exists to support this.
Ovid MEDLINE (from 1946 to February 2012)
EMBASE (from 1980 to 2012 Week 05)
[exp steroids/ or "steroid".mp. or exp adrenal cortex hormones/ or "adrenal cortex hormones".mp. or "corticosteroids".mp. or exp methylprednisolone/ or "methylprednisolone".mp. or exp hydrocortisone/ or "hydrocortisone".mp. or exp dexamethasone/ or "dexamethasone".mp. or exp prednisolone/ or "prednisolone".mp] AND [ Tietze$.mp. or exp costochondritis/] AND [exp pain/ or exp symptom$/] LIMIT to human
36 papers were found.
No clinical studies, including RCTs, were identified that were relevant to the three part question.
Chest pain is one of the commonest presenting complaints to hospital. In patients with non-cardiac chest pain, up to 49% of adults are diagnosed with musculoskeletal pain, of which a common cause is costochondritis, also known as costosternal syndrome or anterior chest wall syndrome. Due to the variable course of this condition, patients frequently present to the emergency department, resulting in multiple admissions and unnecessary investigations. The diagnosis is based on clinical signs and symptoms, comprising chest wall pain at multiple levels, exacerbated by local palpation and/or movement. Costochondritis, as a diagnosis, is commonly used interchangeably with Tietze syndrome (the latter being a rare disorder and is distinguishable by a localised swelling of a single costal cartilage, typically the second or third rib). Although separate, their treatment is usually the same. The traditional treatment for costochondritis, where safe and appropriate, is oral non-steroidal anti-inflammatory drugs; however, local corticosteroid injections/oral corticosteroids have empirically been purported to have benefit in refractory presentations. At present, there are no published trials assessing the use of corticosteroids in costochondritis.
Clinical Bottom Line
There are no clinical studies assessing the use of corticosteroids in the management of costochondritis. This area needs to be researched and explored further by way of conducting randomised control trials before incorporating into clinical practice.