# Costochondritis and Anterior Chest Wall Pain - Category: chronic - Review status: reviewed (every claim checked against a document named on this page) - Sources: MSF Essential Drugs 2024 (ibuprofen oral monograph) · AAFP Guidelines: Evaluation and Management of Musculoskeletal Chest Pain 2021 · Ibuprofen 400 mg film-coated tablets (POM) SmPC section 4.2 (eMC product 7020) · Naproxen 500 mg Tablets SmPC section 4.2 (eMC product 2639) · MSF Essential Drugs 2024 - paracetamol (oral) · Diclofenac topical gel SmPC section 4.2 (eMC) · StatPearls: Ibuprofen (NCBI Bookshelf NBK542299) - Verified date: 2026-08 ## Verified against - MSF Essential Drugs 2024 (ibuprofen oral monograph) - Ibuprofen 400 mg film-coated tablets (POM) SmPC section 4.2 (eMC product 7020) - Naproxen 500 mg Tablets SmPC section 4.2 (eMC product 2639) - MSF Essential Drugs 2024 - paracetamol (oral) - Diclofenac topical gel SmPC section 4.2 (eMC) - Costochondritis - disease-level clinical article (costochondritis-clinical.txt) ## Treatment metadata - Ibuprofen — 400 mg — oral.solid - Naproxen — 250 mg — oral.solid - Referral & safety-netting (no drug therapy) - Diclofenac — 10 mg — topical.gel - Paracetamol — 500 mg — oral.solid ## Complete treatment card ```text COSTOCHONDRITIS AND ANTERIOR CHEST WALL PAIN Sources: MSF Essential Drugs 2024 (ibuprofen oral monograph) · AAFP Guidelines: Evaluation and Management of Musculoskeletal Chest Pain 2021 · Ibuprofen 400 mg film-coated tablets (POM) SmPC section 4.2 (eMC product 7020) · Naproxen 500 mg Tablets SmPC section 4.2 (eMC product 2639) · MSF Essential Drugs 2024 - paracetamol (oral) · Diclofenac topical gel SmPC section 4.2 (eMC) · StatPearls: Ibuprofen (NCBI Bookshelf NBK542299) Review status: REVIEWED against MSF Essential Drugs 2024 (ibuprofen oral monograph), Ibuprofen 400 mg film-coated tablets (POM) SmPC section 4.2 (eMC product 7020), Naproxen 500 mg Tablets SmPC section 4.2 (eMC product 2639), MSF Essential Drugs 2024 - paracetamol (oral), Diclofenac topical gel SmPC section 4.2 (eMC), Costochondritis - disease-level clinical article (costochondritis-clinical.txt) (2026-08) IS IT THIS? - reference only, to read alongside your own examination SYMPTOMS - what the patient reports (2) - Anterior chest wall pain that worsens with movement, deep breathing, coughing, or stretching [cough] - Pain quality varies and may be described as sharp or dull [chest pain] SIGNS - what you find (4) - Point tenderness reproduced by palpating the costochondral junctions where one or two ribs meet the sternum [local tenderness] - No warmth, swelling, or erythema over the sternum or sternoclavicular joints in costochondritis [redness] - Crowing rooster and horizontal arm flexion maneuvers can reproduce costochondritis pain [chest pain] - Vital signs are normal in costochondritis; tachycardia or hypotension points to another cause [hypotension · tachycardia] TESTS (3) - Chest x-ray is recommended in chest pain to rule out pneumonia, pneumothorax, or a lung mass - Chest x-ray and ECG are both normal in costochondritis - Point-of-care ultrasound can detect a rib fracture as an alternative cause IF NOT THIS - what else fits (9) - Acute coronary syndrome is favored by cardiac risk factors such as age, family history, smoking, diabetes, and hypertension - Pericarditis pain is positional, easing when sitting forward and worsening lying supine - Pneumothorax is favored by trauma, a prior pneumothorax, connective tissue disease, or emphysema - Aortic dissection features pain radiating to the back with asymmetric limb blood pressures - Pulmonary embolism is suggested by malignancy, recent travel or surgery, or a prior clot history - GERD-related chest pain worsens after eating or lying down - Herpes zoster shows a dermatomal vesicular rash with severe neuropathic pain - Tietze syndrome causes visible costal joint swelling at the 2nd or 3rd rib, unlike costochondritis - Panic disorder adds dizziness, a feeling of impending doom, palpitations, plus breathlessness to the chest pain Source StatPearls "Costochondritis" - disease-level clinical article Status traced to the source above 1. IBUPROFEN [1st line] Adult 400 mg orally three times daily with food Peds 5-10 mg/kg/dose [child max 400 mg] (Children 20-29 kg (6-9 years): 200 mg 1-3 times a day; maximum daily dose 600 mg. Contraindicated below 20 kg body weight or younger than 6 years.) 6 to 9 years: At 20 to 29 kg: 200 mg one to three times a day, maximum 600 mg daily. Contraindicated below 20 kg or younger than 6 years. 3kg -> 15-30 mg/dose 4kg -> 20-40 mg/dose 5kg -> 25-50 mg/dose 6kg -> 30-60 mg/dose 7kg -> 35-70 mg/dose 8kg -> 40-80 mg/dose 9kg -> 45-90 mg/dose 10kg -> 50-100 mg/dose 11kg -> 55-110 mg/dose 12kg -> 60-120 mg/dose 13kg -> 65-130 mg/dose 14kg -> 70-140 mg/dose 15kg -> 75-150 mg/dose 16kg -> 80-160 mg/dose 17kg -> 85-170 mg/dose 18kg -> 90-180 mg/dose 19kg -> 95-190 mg/dose 20kg -> 100-200 mg/dose 21kg -> 105-210 mg/dose 22kg -> 110-220 mg/dose 23kg -> 115-230 mg/dose 24kg -> 120-240 mg/dose 25kg -> 125-250 mg/dose 26kg -> 130-260 mg/dose 27kg -> 135-270 mg/dose 28kg -> 140-280 mg/dose 29kg -> 145-290 mg/dose 30kg -> 150-300 mg/dose 31kg -> 155-310 mg/dose 32kg -> 160-320 mg/dose 33kg -> 165-330 mg/dose 34kg -> 170-340 mg/dose 35kg -> 175-350 mg/dose 36kg -> 180-360 mg/dose 37kg -> 185-370 mg/dose 38kg -> 190-380 mg/dose 39kg -> 195-390 mg/dose 40kg -> 200-400 mg/dose 41kg -> 205-400 mg/dose (upper capped) 42kg -> 210-400 mg/dose (upper capped) 43kg -> 215-400 mg/dose (upper capped) 44kg -> 220-400 mg/dose (upper capped) 45kg -> 225-400 mg/dose (upper capped) 46kg -> 230-400 mg/dose (upper capped) 47kg -> 235-400 mg/dose (upper capped) 48kg -> 240-400 mg/dose (upper capped) 49kg -> 245-400 mg/dose (upper capped) 50kg -> 250-400 mg/dose (upper capped) Choice Alternatives, both non-selective NSAIDs. Ibuprofen is the cheaper and the more widely stocked. Source Ibuprofen 400 mg film-coated tablets (POM) SmPC section 4.2 (eMC product 7020) for the adult dose: "200-400 mg given as a single dose or 3-4 times a day with an interval of 6 hours as required" and, in rheumatic disease, "a maximum of 2400 mg in 3 or 4 divided doses". That label is contraindicated below 20 kg or 6 years and its only mg/kg line is for adolescents 15 to 17 years, so the paediatric 5 to 10 mg/kg per dose is from MSF Essential Drugs 2024 (ibuprofen oral monograph): "Child over 3 months: 5 to 10 mg/kg 3 to 4 times daily (max. 30 mg/kg daily)". Why Non-selective NSAID used to control the musculoskeletal inflammatory pain of costochondritis once dangerous cardiac, pulmonary, and vascular causes of chest pain have been excluded. Caution CRITICAL: Thoroughly exclude life-threatening cardiac (acute coronary syndrome), pulmonary (pulmonary embolism, pneumothorax), and vascular (aortic dissection) chest pain before diagnosing costochondritis. Take with food or milk to minimize gastrointestinal adverse effects. Avoid in active gastrointestinal ulceration, severe renal impairment, severe heart failure, or late pregnancy. The 400 mg per-dose ceiling comes from the reference literature, not from the suspension label - that label's largest paediatric single dose is 200 mg. Below about 40 kg the weight calculation binds first and the ceiling never comes into it. Egypt DAJUANOFEN 400 MG 20 F.C. TABS. COPAD PHARMA 5.00 EGP (0.25/unit) FLABU 400MG 10 F.C.TAB. DELTA PHARMA 3.75 EGP (0.38/unit) NOVA-PROFEN 400MG 30 F.C. TABLETS SANOFI 12.75 EGP (0.42/unit) IBUPROFEN 400 MG 10 TAB. SEDICO 6.00 EGP (0.60/unit) MAFO 400 MG 30 F.C.TABS EIPICO 42.00 EGP (1.40/unit) BRUFEN 400 MG 30 TABS. KAHIRA > ABBO... 78.00 EGP (2.60/unit) PROFUSOL 400MG 20 S.G CAPS. EUROPEAN EGYP... 31.00 EGP ANALGIPROF 400 MG 25 SACHETS EVA PHARMA 37.50 EGP NOVA-PROFEN 100MG/5ML ORAL SUSP. 100ML SANOFI 2.25 EGP -> ? strength differs, ? different route - not oral solid BRUFEMOL-N SUSP. 60 ML ARAB DRUG COM... 4.50 EGP -> ? strength differs, ? different route - not oral solid 2. NAPROXEN [1st line] Adult 500 mg initially followed by 250 mg at 6-8 hour intervals up to a maximum daily dose after the first day of 1250 mg Peds Not recommended under 16 years for this indication - the product label restricts paediatric naproxen to juvenile idiopathic arthritis (10 mg/kg/day in two divided doses, child over 5 years). Use paracetamol or ibuprofen instead. Source Naproxen 500 mg Tablets SmPC section 4.2 (eMC product 2639) Why Alternative non-selective NSAID for costochondritis pain, giving longer-acting anti- inflammatory relief once serious cardiac and pulmonary causes of chest pain have been ruled out. Caution Rule out cardiac and pulmonary causes of chest pain prior to initiating therapy. Co-prescribe proton pump inhibitor in patients at increased risk for upper gastrointestinal bleeding. Egypt NAPROFEN 250MG 10 TAB. EL NILE. 3.65 EGP (0.36/unit) NAPROSYN 250 MG 20 TAB. MISR > F.HOFF... 9.30 EGP (0.47/unit) MYOPROX 250MG 20 F.C.TAB. EL-OBOUR 11.00 EGP (0.55/unit) 3. REFERRAL & SAFETY-NETTING (NO DRUG THERAPY) [1st line] Adult Source Costochondritis - disease-level clinical article (costochondritis-clinical.txt) Why Carries the referral criteria and warning signs for this condition, which apply whichever treatment is chosen. Caution RED FLAG - Advise the patient to return for evaluation if worsening chest pain, shortness of breath, dizziness, syncope, or visible chest lesions develop during treatment. 4. DICLOFENAC [2nd line] Adult Apply 2-4 g of 1% gel topically to tender costosternal joints three to four times daily and rub gently - Up to 7 days unless recommended by a doctor Peds Not for children under 14. The 1% gel is licensed for adults and adolescents from 14 years; below that there is not enough data. Source Diclofenac topical gel SmPC section 4.2 (eMC) Why Topical NSAID gel provides effective localized pain relief for anterior chest wall tenderness with minimal systemic absorption and lower GI adverse risk. Caution Apply only to intact skin; do not apply to broken, rash-affected, or infected skin. Wash hands thoroughly after application and avoid contact with eyes or mucous membranes. Contraindicated in patients with renal impairment. Concomitant use of oral NSAIDs and other products containing diclofenac is contraindicated. Concomitant use of oral NSAIDs and other diclofenac products is contraindicated. Egypt RHEUMAFEN ACTI-GEL 1% GEL 15 GM GLAXO SMITHKLINE 5.00 EGP [? strength differs] OLFEN 1% TOPICAL GEL 15 GM MUP > ACINO 9.00 EGP [? strength differs] DECLOFENAC 1% GEL 20 GM EL NASR 13.00 EGP [? strength differs] DECLOPHEN GEL 1% 30 GM PHARCO 29.00 EGP [? strength differs] ANTIFLAM 1% EMULGEL 20 GM UP PHARMA 7.50 EGP [? strength differs] DOLPHIN 3% TOPICAL GEL 30 GM DELTA PHARMA 34.00 EGP [? strength differs] DOLPHIN 3% TOPICAL GEL 60 GM DELTA PHARMA 58.00 EGP [? strength differs] DICLAC-N 4% GEL 50 GM MINA PHARM > ... 72.00 EGP [? strength differs] 5. PARACETAMOL [add-on - not a substitute] Adult 1 g 3 or 4 times daily (max. 4 g daily) Peds 10-15 mg/kg/dose [child max 500 mg] (Child 1 month and over: 15 mg/kg 3 or 4 times daily (max. 60 mg/kg daily). Child under 1 month: 10 mg/kg 3 or 4 times daily (max. 40 mg/kg daily).) 3kg -> 30-45 mg/dose 4kg -> 40-60 mg/dose 5kg -> 50-75 mg/dose 6kg -> 60-90 mg/dose 7kg -> 70-105 mg/dose 8kg -> 80-120 mg/dose 9kg -> 90-135 mg/dose 10kg -> 100-150 mg/dose 11kg -> 110-165 mg/dose 12kg -> 120-180 mg/dose 13kg -> 130-195 mg/dose 14kg -> 140-210 mg/dose 15kg -> 150-225 mg/dose 16kg -> 160-240 mg/dose 17kg -> 170-255 mg/dose 18kg -> 180-270 mg/dose 19kg -> 190-285 mg/dose 20kg -> 200-300 mg/dose 21kg -> 210-315 mg/dose 22kg -> 220-330 mg/dose 23kg -> 230-345 mg/dose 24kg -> 240-360 mg/dose 25kg -> 250-375 mg/dose 26kg -> 260-390 mg/dose 27kg -> 270-405 mg/dose 28kg -> 280-420 mg/dose 29kg -> 290-435 mg/dose 30kg -> 300-450 mg/dose 31kg -> 310-465 mg/dose 32kg -> 320-480 mg/dose 33kg -> 330-495 mg/dose 34kg -> 340-500 mg/dose (upper capped) 35kg -> 350-500 mg/dose (upper capped) 36kg -> 360-500 mg/dose (upper capped) 37kg -> 370-500 mg/dose (upper capped) 38kg -> 380-500 mg/dose (upper capped) 39kg -> 390-500 mg/dose (upper capped) 40kg -> 400-500 mg/dose (upper capped) 41kg -> 410-500 mg/dose (upper capped) 42kg -> 420-500 mg/dose (upper capped) 43kg -> 430-500 mg/dose (upper capped) 44kg -> 440-500 mg/dose (upper capped) 45kg -> 450-500 mg/dose (upper capped) 46kg -> 460-500 mg/dose (upper capped) 47kg -> 470-500 mg/dose (upper capped) 48kg -> 480-500 mg/dose (upper capped) 49kg -> 490-500 mg/dose (upper capped) 50kg -> 500 mg/dose (capped) Source MSF Essential Drugs 2024 - paracetamol (oral) Why Adjunct analgesic added to an NSAID for extra pain control in costochondritis; works centrally rather than through an anti-inflammatory action and does not replace the NSAID. Caution Ensure dangerous non-musculoskeletal causes of chest pain have been ruled out. Do not exceed total paracetamol dose of 4000 mg/day from all prescription and over-the- counter products. 500 mg is the per-dose ceiling used here for a child. 1000 mg is the adult dose and does not belong in a weight calculation - the daily 60 mg/kg limit is the one that binds first in any case. Egypt FEBRIMOL 500 MG 20 TAB. PHARCO 3.50 EGP (0.17/unit) CETAMOL 500 MG 20 TABS. MEMPHIS 8.00 EGP (0.40/unit) PARACETAMOL-MUP 500MG B.P. 20 TABS. MUP 13.00 EGP (0.65/unit) CETAL 500 MG 20 TABS. EIPICO 24.00 EGP (1.20/unit) ARKADOLOW 500 MG 30 F.C. TABS. UTOPIA 42.00 EGP (1.40/unit) PARAMOL 500MG 20 TAB. MISR 38.00 EGP (1.90/unit) ADOL 500MG 24 CAPLETS JULPHAR 32.00 EGP AUGICETAMIDE 500 MG 20 SACHETS AUG PHARMA 50.00 EGP FEBRIMOL ORAL DROPS 20 ML PHARCO 4.00 EGP -> ? strength differs, ? different route - not oral solid THERA-LO 3.2G/100ML ORAL SUSP. 100 ML PHAROPHARMA 5.00 EGP -> ? strength differs, ? different route - not oral solid Prices are indicative (dataset snapshot 2026-06); verify with the pharmacy. ``` --- Dawaa Reference is a reference for prescribers, not a medical device, and does not replace clinical judgement. [Privacy policy](/privacy)