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Physical exam findings were unremarkable, including a normal cardiac exam with RRR, normal S1 & S2, without murmurs, rubs or gallops. Pulses 2+ equal and symmetric. Non-tender over the chest wall or ribs. DIFFERENTIAL DIAGNOSIS: Intercostal muscle strain, rib bone stress injury/fracture, shoulder/scapular injury, cardiac arrhythmia, cardiac structural abnormality (aortic aneurysm, chronic dissection, HOCM). TEST AND RESULTS: Radiographs: left ribs, chest, thoracic spine, scapula normal; MRI: thoracic spine, left shoulder normal; EKG: sinus bradycardia (rate 47), no acute ST-T wave abnormalities; ECHO & Stress ECHO: Excellent exercise tolerance achieving 88% max predicted HR, 2-3mm ST depression in the lat. leads, 1-1.5 mm ST depression in inf. leads (nondiagnostic of ischemia due to baseline abnormalities/LVH) Rare PAC's in recovery; CT coronary angiogram: superficial myocardial bridging of the mid LAD without evidence of narrowing on dynamic imaging; dominant RCA, LVEF 57%; MRI Cardiac w/wo contrast: Mildly dilated LV with mildly depressed biventricular EF. No delayed enhancement to suggest infiltrative process/scar. Mild pectus deformity. FINAL WORKING DIAGNOSIS: Atypical chest pain secondary to myocardial bridge. TREATMENT AND OUTCOMES: After consultation with a cardiologist, the patient was started on metoprolol 25mg PO daily. He was instructed to start a gradual return-to-run protocol, with the recommendation to progressively increase his mileage if pain free, and not exceed more than 5 days per week of activity.

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