Median Arcuate Ligament Syndrome: Navigating Diagnostic Uncertainty and Multidisciplinary Management - A Narrative Revie

Median Arcuate Ligament Syndrome (MALS) is characterised as an intra‑abdominal vascular compression syndrome in which the caudad migration of the Median Arcuate Ligament (MAL) impinges the coeliac artery and/or coeliac plexus, causing foregut ischaemia, neuropathic pain and dysautonomia. Clinically, MALS can present with postprandial epigastric pain, weight loss, nausea, vomiting, upper abdominal bloating and dysautonomia. Its common comorbidities are Postural Orthostatic Tachycardia Syndrome (POTS), Ehlers-Danlos syndrome (EDS), Mast Cell Activation Syndrome (MCAS), other abdominal vascular compression syndromes such as nutcracker and Superior Mesenteric Artery Syndrome (SMA), along with anxiety, and functional gastrointestinal disorders. Surgical decompression of the median arcuate ligament, with or without coeliac plexus intervention or endovascular stenting, can provide meaningful pain reduction and functional improvement; however, postoperative symptom recurrence, persistent dysautonomia and variable long‑term outcomes are common.This narrative review synthesises current evidence on MALS pathophysiology, symptom presentation, diagnostic imaging and management, with a particular focus on autonomic dysfunction and the emerging role of osteopathic and manual therapies. It highlights the current knowledge gap regarding autonomic pathophysiology and conservative non-surgical care in MALS, as only a limited number of case reports and series systematically assess dysautonomia or evaluate osteopathic and manual therapy. This paper aims to critically assess vascular, neurogenic, connective‑tissue, and autonomic mechanisms, evaluate current diagnostic and surgical pathways with an autonomic nervous system focus, and examine the theoretical rationale and preliminary clinical data for osteopathic and manual therapies as adjunctive or non-invasive options, thereby outlining priorities for future multimodality, phenotype‑based management and research.