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Musculoskeletal and Sports Medicine

(Kiosk 2) Median Arcuate Ligament Syndrome in an Athletic Female with Abdominal Pain: A Case Report

Thursday, November 16, 2023
5:00 PM – 7:00 PM CT

    Primary Author(s)

  • Aarthi Manjunathan, DO

    Resident
    University of Michigan Health System PM&R Program
    Rochester, Michigan

    • Co-Author(s)

  • Alex Donaghy, MD

    Physician, Assistant Clinical Professor
    University of Michigan
    Ann Arbot, Michigan

Case Diagnosis: 17-year-old female with postural orthostatic tachycardia syndrome (POTS) and diffuse abdominal pain.

Case Description or Program Description: The patient reported a longstanding history of abdominal bloating and pain which was both post-prandial and associated with sporting activities. The discomfort presented while playing lacrosse and would resolve gradually over the next 12 hours. She was evaluated by her gynecologist which included an unremarkable ultrasound. She was referred to gastroenterology and workup included esophagogastroduodenoscopy, gastric emptying study, and a right upper quadrant ultrasound, all of which were unremarkable. Given the association with physical activity, she was referred to PM&R.

Setting: Outpatient clinic at university hospital

Assessment/Results: She underwent a duplex ultrasonography of the celiac trunk, which revealed over 70% diameter stenosis along with narrowing of the celiac artery. The superior mesenteric origin was also suggestive of over 70% diameter stenosis. Confirmatory diagnostics were recommended so she underwent a computed tomography angiography of the abdomen and pelvis, which demonstrated marked focal narrowing of the celiac trunk consistent with the diagnosis of median arcuate ligament syndrome (MALS).

Discussion (relevance): Exercise-related transient abdominal pain is common in athletes, includes a broad differential diagnosis, and is often diagnosed following extensive gastroenterological workup. MALS can manifest with vague symptoms including exercised-induced epigastric pain, post-prandial pain, nausea, vomiting, or weight loss. It may be a presenting symptom in athletes with abdominal pain. Current treatment options are primarily surgical, with little physiatrist literature to describe rehabilitation options either pre- or post-operatively.

Conclusions: Though rare, MALS should be on the differential diagnosis for physiatrists evaluating patients with exercise-induced abdominal pain. Rehabilitative treatment approaches may be an avenue for future research.