Is myofascial bridging clinically significant?

Is Myofascial Bridging Clinically Significant?

The clinical significance of myofascial bridging depends entirely on the anatomical context: coronary artery myocardial bridging has limited clinical significance in most cases, while myofascial pain syndrome (trigger points in skeletal muscle) is highly clinically significant and requires treatment.

Coronary Artery Myocardial Bridging

Clinical Significance Assessment

• Myocardial bridges occur in 30-50% of patients with hypertrophic cardiomyopathy and have been suggested as a possible cause of sudden cardiac death (SCD), though long-term prognosis of isolated myocardial bridges appears to be excellent 1

• The European Society of Cardiology notes that while myocardial bridges may in some cases cause myocardial ischemia, myocardial infarction, malignant ventricular arrhythmias, and SCD, most are thought to be innocent 1

• Short-tunneled (bridged) intramyocardial segments of left anterior descending coronary artery may independently convey increased risk for cardiac arrest, probably mediated by myocardial ischemia, though potential biases in patient selection and the frequency of coronary arterial bridging in surviving adults mitigate the power of coronary bridging as a risk factor for SCD 1

Management Approach for Competitive Athletes

• Asymptomatic competitive athletes with incidental diagnosis of myocardial bridging can participate in competitive sports without restriction 1

• Symptomatic competitive athletes with myocardial bridging should undergo assessment for inducible myocardial ischemia using maximum-effort stress electrocardiography, cardiopulmonary exercise testing, stress echocardiography, stress nuclear perfusion imaging, or stress magnetic resonance perfusion imaging 1

• For athletes with myocardial bridging who have inducible myocardial ischemia or symptoms suggestive of myocardial ischemia (exertional syncope, exertional angina, dizziness with diagnostic abnormalities), treatment options—either medical or surgical—should be considered before participation in competitive sports, as the risks likely outweigh the benefits of competitive sports participation for those with evidence of persistent or residual myocardial ischemia 1

Treatment Options

• Patients usually improve with beta-blockers, which are first-line medical therapy 1

• Nitrates increase the angiographic systolic narrowing and can lead to worsening of symptoms, so they should be avoided 1

• In refractory patients, surgery (myotomy and/or coronary bypass), angioplasty, or stenting can be considered 1

Myofascial Pain Syndrome (Skeletal Muscle)

Clinical Significance

• Myofascial pain syndrome affects up to 95% of people with chronic pain disorders and is a highly clinically significant condition that impairs mobility, causes pain, and reduces overall sense of well-being 2

• A myofascial trigger point is a hyperirritable spot, usually within a taut band of skeletal muscle, which is painful on compression and can give rise to characteristic referred pain, motor dysfunction, and autonomic phenomena 3

First-Line Treatment Approach

• Manual physical therapy techniques should be offered as first-line treatment for patients with myofascial pain syndrome who present with pelvic floor tenderness or muscle trigger points, as they provide the largest reduction in pain severity with minimal risk of harm 4, 5

• Treatment protocols should include 10 sessions of 60 minutes over 12 weeks, which has been shown to result in 59% of patients reporting moderate or marked improvement 5

• Manual physical therapy techniques include maneuvers that resolve muscular trigger points, techniques that lengthen muscle contractures, and release of painful scars and connective tissue restrictions 4

Pharmacological Management

• NSAIDs should be used for symptomatic relief of myofascial pain as first-line pharmacological therapy 4

• Topical treatments, including lidocaine patches, capsaicin, and diclofenac patches, are preferred for safety and may provide symptomatic relief 4, 5

• Tricyclic antidepressants and serotonin-norepinephrine reuptake inhibitors (SNRIs) may be beneficial for myofascial pain 4

• Anticonvulsants (gabapentin, pregabalin) can be considered for persistent pain 4

Interventional Procedures

• Trigger point injections should only be considered as part of multimodal treatment after conservative measures (NSAIDs, muscle relaxants, physical therapy, topical treatments) have failed for 3+ months, and patients must continue concurrent physical therapy 6

• Limit to 4 sets of injections maximum to assess therapeutic response 6

• Repeated trigger point injections should be avoided, and corticosteroids should not be injected into trigger points 2

• Peripheral somatic nerve blocks should NOT be used for long-term treatment of chronic pain in myofascial pain syndrome 5, 6

Common Pitfalls

• Do not confuse myofascial pain syndrome with bursitis, tendonitis, hypermobility syndromes, fibromyalgia, or fasciitis—it must be distinguished from these conditions though it often coexists with them 7

• Avoid using trigger point injections as monotherapy; they must be part of a comprehensive rehabilitation program 6

• Do not prescribe nitrates for coronary myocardial bridging as they worsen symptoms 1