DiagnosticTree/FrontOfArm
{
"model": "bayesian_lr_scoring",
"version": "1.0",
"description": "Probabilistic scoring model for front-of-arm pain using Bayesian likelihood ratio updating with Thurstonian pairwise tiebreakers. Muscles drawn from T&S Vol.1 Ch.18 (Overview: Upper Back, Shoulder, and Arm) and individual chapters. Bold muscles carry higher priors (0.12); regular-weight muscles carry lower priors (0.08). Triceps TrP5 = medial head, referring to medial epicondyle and medial forearm.",
"thresholds": {
"early_exit_posterior": 0.55,
"early_exit_gap": 0.18,
"pairwise_trigger": 0.22
},
"muscles": {
"biceps": {
"label": "Biceps Brachii",
"prior": 0.12,
"page": "Muscle:Biceps_Brachii",
"key_trp_note": "Infraspinatus TrPs are the most important key TrP source driving satellite biceps TrPs. Inactivating infraspinatus is essential for sustained biceps relief and may alone resolve the biceps TrPs. With prolonged biceps TrP activity, expect secondary TrPs in brachialis, supinator, and triceps (in that sequence).",
"subtitle": "Superficial anterior shoulder aching; can lie on affected side; can reach behind waist"
},
"brachialis": {
"label": "Brachialis",
"prior": 0.08,
"page": "Muscle:Brachialis",
"key_trp_note": "Brachialis TrPs are almost always co-active with biceps brachii TrPs. In the tennis elbow pattern, the supinator is the primary TrP; brachialis develops secondarily. The almond-shaped lateral border TrP specifically compresses the sensory radial nerve branch \u2014 causing dorsal thumb dysesthesia alongside the referred aching.",
"subtitle": "Thumb base and dorsal web of thumb; thumb hurts not elbow; passive elbow extension worsens pain"
},
"scalene": {
"label": "Scalene",
"prior": 0.12,
"page": "Muscle:Scalene",
"key_trp_note": "Scalene TrPs drive satellite TrPs in biceps brachii, pectoralis major/minor, serratus posterior superior, and upper trapezius. Treat scalenes before their satellites. SCM should be treated concurrently.",
"subtitle": "Anterior chest and arm symptoms; nocturnal arm aching; must hang arm over bed for relief"
},
"scalenus_minimus": {
"label": "Scalenus Minimus",
"prior": 0.12,
"page": "Muscle:Scalene",
"key_trp_note": "Scalenus minimus (when present) is anatomically positioned to compress the lower trunk of the brachial plexus against the first rib. Its TrPs produce a distinct radial-hand pattern extending to the thumb and index finger. Treat as part of the scalene group in the same session.",
"subtitle": "Posterior arm to radial hand/thumb; lower brachial plexus compression pattern"
},
"subclavius": {
"label": "Subclavius",
"prior": 0.12,
"page": "Muscle:Pectoralis_Major",
"key_trp_note": "Subclavius TrPs almost always coexist with clavicular pectoralis major TrPs. Subclavius shortening draws the clavicle down toward the subclavian neurovascular structures \u2014 vascular thoracic outlet syndrome. Treat clavicular pectoralis major first.",
"subtitle": "Radial forearm and hand SKIPPING the elbow and wrist; thumb, index, and middle fingers"
},
"triceps_trp5": {
"label": "Triceps \u2014 Medial Head (TrP5)",
"prior": 0.12,
"page": "Muscle:Triceps_Brachii",
"key_trp_note": "Triceps TrP5 (medial head) refers to the medial epicondyle and medial forearm \u2014 the front-of-arm pattern that distinguishes it from TrP1 (posterior arm, long head) and TrP3 (lateral head, radial nerve zone). Scalene TrPs drive triceps long head satellite TrPs; the medial head may be activated independently by direct overload or antagonist cramping from biceps/brachialis treatment.",
"subtitle": "Medial epicondyle and medial forearm pain from anterior arm; antagonist cramping after biceps treatment"
},
"infraspinatus": {
"label": "Infraspinatus",
"prior": 0.08,
"page": "Muscle:Infraspinatus",
"key_trp_note": "Infraspinatus is the key TrP source driving satellite biceps brachii TrPs. Inactivating infraspinatus first is essential \u2014 biceps TrPs may resolve without direct treatment once infraspinatus is addressed. Primary infraspinatus presentation is deep anterior joint pain; when it appears in a front-of-arm algorithm it usually reflects the satellite biceps being masked by the primary source.",
"subtitle": "Deep inside anterior shoulder joint; cannot sleep either side; cannot reach behind back"
},
"supraspinatus": {
"label": "Supraspinatus",
"prior": 0.08,
"page": "Muscle:Supraspinatus",
"key_trp_note": "Supraspinatus TrPs refer to the mid-deltoid and lateral upper arm. Infraspinatus TrPs often drive supraspinatus satellites. With prolonged biceps TrP activity, supraspinatus eventually develops secondary TrPs. Inactivating supraspinatus usually resolves middle deltoid satellite TrPs without direct treatment.",
"subtitle": "Lateral shoulder to lateral upper arm; lateral epicondyle referral; painful arc 60\u2013120\u00b0"
},
"deltoid_anterior": {
"label": "Anterior Deltoid",
"prior": 0.08,
"page": "Muscle:Deltoid",
"key_trp_note": "Anterior deltoid TrPs are almost always satellites of infraspinatus, supraspinatus, or pectoralis major key TrPs \u2014 the anterior deltoid lies in the pain reference zone of all three. Treat the key TrP source first; anterior deltoid TrPs usually resolve without direct treatment.",
"subtitle": "Local anterior shoulder surface only; no arm or hand referral; history of direct impact or injection"
},
"sternalis": {
"label": "Sternalis",
"prior": 0.08,
"page": "Muscle:Sternalis",
"key_trp_note": "Sternalis TrPs are almost always co-active with pectoralis major TrPs. SCM sternal division (lower end) may refer pain downward over the sternum and activate sternalis as a satellite. Present in only ~4\u20135% of the population. Treat pectoralis major and SCM before or alongside sternalis.",
"subtitle": "Deep substernal ache; movement-independent; cardiac mimic; may extend to front of shoulder and upper arm"
}
},
"questions": [
{
"id": "q_dominant_pain_zone",
"text": "Where is the front-of-arm pain most concentrated?",
"sublabel": "Choose the single best description of the dominant pain zone",
"type": "choice",
"answers": [
{
"id": "anterior_shoulder_surface",
"label": "Surface of the ANTERIOR SHOULDER \u2014 front of the shoulder bulge; superficial aching",
"sublabel": "Superficial aching over the front of the shoulder and deltoid region; NOT deep inside the joint",
"lr": {
"biceps": 8.0,
"deltoid_anterior": 5.0,
"supraspinatus": 2.0,
"scalene": 1.5,
"infraspinatus": 0.3,
"brachialis": 0.5,
"subclavius": 1.0,
"scalenus_minimus": 0.8,
"triceps_trp5": 0.5,
"sternalis": 0.5
}
},
{
"id": "deep_inside_joint",
"label": "DEEP INSIDE the front of the shoulder joint \u2014 patient places hand over the anterior shoulder",
"sublabel": "The pain is felt inside the joint itself, not on the surface",
"lr": {
"infraspinatus": 10.0,
"biceps": 1.0,
"deltoid_anterior": 0.3,
"supraspinatus": 1.0,
"scalene": 0.7,
"brachialis": 0.3,
"subclavius": 0.4,
"scalenus_minimus": 0.4,
"triceps_trp5": 0.3,
"sternalis": 0.3
}
},
{
"id": "biceps_belly_antecubital",
"label": "BICEPS MUSCLE BELLY or ANTECUBITAL SPACE \u2014 front of the upper arm or elbow crease",
"sublabel": "The arm itself hurts, not just the shoulder; the antecubital fossa may also ache",
"lr": {
"biceps": 5.0,
"brachialis": 6.0,
"scalene": 1.5,
"triceps_trp5": 2.0,
"infraspinatus": 0.5,
"supraspinatus": 0.8,
"deltoid_anterior": 0.4,
"subclavius": 0.8,
"scalenus_minimus": 0.8,
"sternalis": 0.4
}
},
{
"id": "substernal_chest",
"label": "SUBSTERNAL or anterior chest \u2014 behind the breastbone or across the front of the chest",
"sublabel": "The dominant pain is in the chest, not in the arm itself",
"lr": {
"sternalis": 12.0,
"scalene": 2.0,
"subclavius": 1.5,
"scalenus_minimus": 1.0,
"biceps": 0.3,
"brachialis": 0.2,
"infraspinatus": 0.2,
"supraspinatus": 0.2,
"deltoid_anterior": 0.3,
"triceps_trp5": 0.3
}
}
]
},
{
"id": "q_thumb_pain",
"text": "Is the thumb affected \u2014 specifically pain or soreness at the BASE of the thumb or dorsal web space of the thumb?",
"sublabel": "The thumb hurts at its base (carpometacarpal joint area) or on the back of the thumb web; this is the dominant or a prominent complaint",
"type": "binary",
"answers": [
{
"id": "yes",
"label": "Yes \u2014 thumb base or dorsal thumb web is painful or sore",
"lr": {
"brachialis": 12.0,
"subclavius": 3.0,
"scalenus_minimus": 3.0,
"scalene": 1.5,
"biceps": 0.4,
"infraspinatus": 0.4,
"supraspinatus": 0.3,
"deltoid_anterior": 0.2,
"triceps_trp5": 0.3,
"sternalis": 0.2
}
},
{
"id": "no",
"label": "No \u2014 thumb is not specifically affected",
"lr": {
"brachialis": 0.15,
"subclavius": 0.7,
"scalenus_minimus": 0.7,
"scalene": 0.9,
"biceps": 1.2,
"infraspinatus": 1.2,
"supraspinatus": 1.2,
"deltoid_anterior": 1.3,
"triceps_trp5": 1.2,
"sternalis": 1.2
}
}
]
},
{
"id": "q_thumb_vs_elbow",
"text": "Regarding pain when moving the arm or thumb: which hurts more?",
"sublabel": "A key brachialis dissociation test \u2014 the thumb hurts with use; the elbow does not",
"type": "choice",
"condition": {
"q_thumb_pain": "yes"
},
"answers": [
{
"id": "thumb_hurts_elbow_ok",
"label": "Active thumb movement HURTS; active elbow movement does NOT hurt",
"sublabel": "Using the thumb causes pain; bending or straightening the elbow does not",
"lr": {
"brachialis": 14.0,
"subclavius": 1.5,
"scalenus_minimus": 1.5,
"scalene": 0.8,
"biceps": 0.3,
"infraspinatus": 0.3,
"supraspinatus": 0.3,
"deltoid_anterior": 0.3,
"triceps_trp5": 0.3,
"sternalis": 0.2
}
},
{
"id": "elbow_also_hurts",
"label": "Both the thumb AND the elbow hurt with movement",
"sublabel": "Elbow movement is also painful, not just the thumb",
"lr": {
"brachialis": 2.0,
"subclavius": 2.0,
"scalenus_minimus": 2.0,
"scalene": 1.5,
"biceps": 1.5,
"infraspinatus": 0.5,
"supraspinatus": 0.5,
"deltoid_anterior": 0.4,
"triceps_trp5": 1.5,
"sternalis": 0.3
}
}
]
},
{
"id": "q_sleep",
"text": "How does the arm pain affect sleep?",
"sublabel": "Which sleeping position is tolerated?",
"type": "choice",
"answers": [
{
"id": "neither_side",
"label": "Cannot sleep on EITHER side \u2014 may sleep upright or propped in a chair",
"sublabel": "Even the unaffected side causes pain; every lying position wakes the patient",
"lr": {
"infraspinatus": 10.0,
"scalene": 2.0,
"biceps": 1.0,
"brachialis": 0.5,
"supraspinatus": 0.5,
"deltoid_anterior": 0.3,
"subclavius": 0.4,
"scalenus_minimus": 0.4,
"triceps_trp5": 0.4,
"sternalis": 0.5
}
},
{
"id": "not_affected_side",
"label": "Cannot sleep on the AFFECTED side only",
"sublabel": "Lying on the painful arm wakes the patient; other positions are tolerated",
"lr": {
"biceps": 5.0,
"deltoid_anterior": 3.0,
"supraspinatus": 2.5,
"brachialis": 2.0,
"triceps_trp5": 2.0,
"scalene": 1.0,
"subclavius": 1.0,
"scalenus_minimus": 0.8,
"infraspinatus": 0.4,
"sternalis": 1.0
}
},
{
"id": "sleep_ok",
"label": "Sleep is largely unaffected or only mildly disturbed",
"sublabel": "The patient finds a comfortable position without significant waking",
"lr": {
"sternalis": 3.0,
"subclavius": 2.0,
"scalenus_minimus": 1.5,
"scalene": 1.5,
"deltoid_anterior": 1.5,
"supraspinatus": 1.0,
"brachialis": 1.0,
"biceps": 0.5,
"infraspinatus": 0.2,
"triceps_trp5": 1.2
}
}
]
},
{
"id": "q_behind_back",
"text": "Can the patient reach comfortably behind the back?",
"sublabel": "Test: reaching the arm behind the back to the hip pocket or brassiere hooks",
"type": "binary",
"answers": [
{
"id": "restricted",
"label": "Painful or restricted \u2014 cannot reach behind the back fully",
"lr": {
"infraspinatus": 8.0,
"biceps": 3.0,
"supraspinatus": 2.0,
"brachialis": 1.5,
"scalene": 1.0,
"deltoid_anterior": 0.6,
"subclavius": 0.5,
"scalenus_minimus": 0.4,
"triceps_trp5": 0.5,
"sternalis": 0.4
}
},
{
"id": "normal",
"label": "Full behind-back reach \u2014 no restriction",
"lr": {
"infraspinatus": 0.2,
"biceps": 0.5,
"supraspinatus": 0.7,
"brachialis": 0.9,
"scalene": 1.0,
"deltoid_anterior": 1.4,
"subclavius": 1.4,
"scalenus_minimus": 1.4,
"triceps_trp5": 1.3,
"sternalis": 1.4
}
}
]
},
{
"id": "q_elbow_extension_test",
"text": "Does PASSIVELY straightening (extending) the elbow increase pain in the arm, antecubital space, or thumb?",
"sublabel": "With the arm relaxed, the examiner gently straightens the elbow fully \u2014 does this increase pain?",
"type": "binary",
"answers": [
{
"id": "yes",
"label": "Yes \u2014 passively extending the elbow worsens pain",
"lr": {
"brachialis": 10.0,
"biceps": 4.0,
"triceps_trp5": 1.5,
"scalene": 0.8,
"infraspinatus": 0.5,
"supraspinatus": 0.5,
"deltoid_anterior": 0.4,
"subclavius": 0.5,
"scalenus_minimus": 0.5,
"sternalis": 0.3
}
},
{
"id": "no",
"label": "No \u2014 elbow extension does not worsen pain",
"lr": {
"brachialis": 0.2,
"biceps": 0.6,
"triceps_trp5": 1.0,
"scalene": 1.1,
"infraspinatus": 1.2,
"supraspinatus": 1.2,
"deltoid_anterior": 1.3,
"subclavius": 1.2,
"scalenus_minimus": 1.2,
"sternalis": 1.2
}
}
]
},
{
"id": "q_supination_vs_pronation",
"text": "Is arm pain or weakness worse when the forearm is SUPINATED (palm up) compared to PRONATED (palm down) during elbow flexion?",
"sublabel": "Test: flex the elbow with palm facing up, then repeat with palm facing down \u2014 which position is more painful or weak?",
"type": "choice",
"answers": [
{
"id": "supination_worse",
"label": "Supination (palm up) is more painful or weak than pronation (palm down)",
"sublabel": "Lifting with palm up hurts more than lifting with palm down",
"lr": {
"biceps": 8.0,
"scalene": 1.5,
"infraspinatus": 1.0,
"brachialis": 0.4,
"supraspinatus": 0.8,
"deltoid_anterior": 0.7,
"subclavius": 0.8,
"scalenus_minimus": 0.8,
"triceps_trp5": 0.5,
"sternalis": 0.5
}
},
{
"id": "equal_both",
"label": "Both positions are equally painful or weak",
"sublabel": "No difference between palm up and palm down during elbow flexion",
"lr": {
"brachialis": 6.0,
"triceps_trp5": 2.0,
"scalene": 1.5,
"scalenus_minimus": 1.5,
"subclavius": 1.5,
"sternalis": 1.5,
"infraspinatus": 1.0,
"supraspinatus": 1.0,
"biceps": 0.4,
"deltoid_anterior": 1.0
}
},
{
"id": "no_difference_painless",
"label": "No pain with either position \u2014 elbow flexion is not a trigger",
"sublabel": "Bending the elbow does not provoke the arm pain",
"lr": {
"infraspinatus": 2.0,
"deltoid_anterior": 2.0,
"sternalis": 2.0,
"subclavius": 1.5,
"scalenus_minimus": 1.5,
"scalene": 1.5,
"supraspinatus": 1.5,
"biceps": 0.4,
"brachialis": 0.3,
"triceps_trp5": 1.0
}
}
]
},
{
"id": "q_arm_referral",
"text": "Does the arm pain extend to the forearm or hand?",
"sublabel": "Choose the best description of the distal referral",
"type": "choice",
"answers": [
{
"id": "radial_skip",
"label": "Radial forearm and/or thumb/index/middle fingers \u2014 SKIPPING the elbow and wrist",
"sublabel": "The radial side of the forearm and/or the thumb, index, or middle finger hurt; the elbow joint area is pain-free",
"lr": {
"subclavius": 10.0,
"scalenus_minimus": 6.0,
"brachialis": 3.0,
"scalene": 2.0,
"biceps": 0.5,
"infraspinatus": 0.8,
"supraspinatus": 0.5,
"deltoid_anterior": 0.2,
"triceps_trp5": 0.4,
"sternalis": 0.3
}
},
{
"id": "medial_epicondyle",
"label": "Medial epicondyle (inner elbow) and/or medial forearm",
"sublabel": "The inner bump of the elbow and/or the medial forearm is part of the pain",
"lr": {
"triceps_trp5": 9.0,
"scalene": 2.0,
"brachialis": 1.5,
"biceps": 1.0,
"scalenus_minimus": 1.0,
"infraspinatus": 0.5,
"supraspinatus": 0.4,
"subclavius": 0.4,
"deltoid_anterior": 0.3,
"sternalis": 0.3
}
},
{
"id": "ulnar_forearm_hand",
"label": "Ulnar forearm and/or ring and little fingers",
"sublabel": "The inner forearm and/or the two ulnar digits hurt",
"lr": {
"scalene": 4.0,
"scalenus_minimus": 2.0,
"sternalis": 2.0,
"brachialis": 1.0,
"biceps": 0.5,
"triceps_trp5": 1.5,
"subclavius": 0.5,
"infraspinatus": 0.5,
"supraspinatus": 0.4,
"deltoid_anterior": 0.3
}
},
{
"id": "suprascapular_spillover",
"label": "Pain skips upward to the suprascapular region \u2014 above the scapular spine",
"sublabel": "The area above the shoulder blade also aches, almost as if the pain jumps over the shoulder",
"lr": {
"biceps": 7.0,
"scalene": 2.0,
"infraspinatus": 1.5,
"supraspinatus": 1.5,
"scalenus_minimus": 1.0,
"brachialis": 0.5,
"deltoid_anterior": 0.4,
"subclavius": 0.5,
"triceps_trp5": 0.4,
"sternalis": 0.4
}
},
{
"id": "lateral_arm_epicondyle",
"label": "Lateral upper arm or lateral epicondyle \u2014 outer elbow region",
"sublabel": "The outer side of the upper arm or the outer elbow bump is included in the pain",
"lr": {
"supraspinatus": 7.0,
"biceps": 1.0,
"scalene": 1.5,
"infraspinatus": 1.5,
"brachialis": 0.5,
"deltoid_anterior": 0.8,
"subclavius": 0.5,
"scalenus_minimus": 0.5,
"triceps_trp5": 0.5,
"sternalis": 0.3
}
},
{
"id": "no_distal_referral",
"label": "No forearm or hand referral \u2014 pain stays in the shoulder and upper arm",
"sublabel": "Pain does not travel below the elbow",
"lr": {
"deltoid_anterior": 3.0,
"sternalis": 3.0,
"infraspinatus": 1.5,
"biceps": 1.0,
"supraspinatus": 1.0,
"brachialis": 0.5,
"scalene": 0.5,
"subclavius": 0.4,
"scalenus_minimus": 0.4,
"triceps_trp5": 0.5
}
}
]
},
{
"id": "q_nocturnal_arm",
"text": "Is the patient woken at night by arm aching or numbness \u2014 requiring the arm to hang over the side of the bed or be shaken for relief?",
"sublabel": "Nocturnal arm symptoms specifically relieved by hanging the arm over the bed edge",
"type": "binary",
"answers": [
{
"id": "yes",
"label": "Yes \u2014 woken at night; arm must hang over bed side for relief",
"lr": {
"scalene": 9.0,
"scalenus_minimus": 5.0,
"subclavius": 2.0,
"brachialis": 0.5,
"biceps": 0.5,
"infraspinatus": 0.5,
"supraspinatus": 0.4,
"deltoid_anterior": 0.3,
"triceps_trp5": 0.4,
"sternalis": 0.3
}
},
{
"id": "no",
"label": "No \u2014 no nocturnal arm hanging symptom",
"lr": {
"scalene": 0.25,
"scalenus_minimus": 0.35,
"subclavius": 0.8,
"brachialis": 1.1,
"biceps": 1.1,
"infraspinatus": 1.1,
"supraspinatus": 1.1,
"deltoid_anterior": 1.2,
"triceps_trp5": 1.1,
"sternalis": 1.1
}
}
]
},
{
"id": "q_movement_independence",
"text": "Is the arm or chest pain MOVEMENT-INDEPENDENT \u2014 present at rest and NOT worsened by any specific shoulder or arm movement?",
"sublabel": "No position, movement, or activity clearly makes the pain better or worse",
"type": "binary",
"answers": [
{
"id": "yes",
"label": "Yes \u2014 pain present at rest, unchanged by movement",
"lr": {
"sternalis": 10.0,
"scalene": 2.0,
"scalenus_minimus": 1.5,
"biceps": 0.5,
"brachialis": 0.4,
"infraspinatus": 0.5,
"supraspinatus": 0.4,
"deltoid_anterior": 0.5,
"subclavius": 0.5,
"triceps_trp5": 0.5
}
},
{
"id": "no",
"label": "No \u2014 pain varies with position, activity, or movement",
"lr": {
"sternalis": 0.2,
"scalene": 0.9,
"scalenus_minimus": 0.9,
"biceps": 1.2,
"brachialis": 1.2,
"infraspinatus": 1.2,
"supraspinatus": 1.2,
"deltoid_anterior": 1.2,
"subclavius": 1.1,
"triceps_trp5": 1.1
}
}
]
},
{
"id": "q_painful_arc",
"text": "Is there a painful arc during shoulder abduction \u2014 pain appearing between 60\u00b0 and 120\u00b0 of raising the arm sideways, then diminishing above that?",
"sublabel": "Pain appears then disappears as the arm reaches overhead",
"type": "binary",
"answers": [
{
"id": "yes",
"label": "Yes \u2014 painful arc between 60\u00b0 and 120\u00b0 of abduction",
"lr": {
"supraspinatus": 8.0,
"deltoid_anterior": 2.0,
"biceps": 0.8,
"infraspinatus": 0.7,
"brachialis": 0.4,
"scalene": 0.5,
"scalenus_minimus": 0.4,
"subclavius": 0.4,
"triceps_trp5": 0.4,
"sternalis": 0.3
}
},
{
"id": "no",
"label": "No \u2014 no arc pattern; abduction is uniformly painful or pain-free",
"lr": {
"supraspinatus": 0.2,
"deltoid_anterior": 0.9,
"biceps": 1.1,
"infraspinatus": 1.1,
"brachialis": 1.2,
"scalene": 1.1,
"scalenus_minimus": 1.1,
"subclavius": 1.1,
"triceps_trp5": 1.2,
"sternalis": 1.2
}
}
]
},
{
"id": "q_onset",
"text": "How did the front-of-arm pain begin?",
"sublabel": "Choose the onset pattern that best describes this episode",
"type": "choice",
"answers": [
{
"id": "sustained_flexion_load",
"label": "Sustained elbow flexion under load \u2014 carrying groceries, using power tools at elbow height, ironing, violin playing",
"sublabel": "Pain crept in over repeated sessions of forearm flexion activity",
"lr": {
"brachialis": 8.0,
"biceps": 5.0,
"triceps_trp5": 2.0,
"scalene": 1.0,
"infraspinatus": 0.5,
"supraspinatus": 0.5,
"deltoid_anterior": 0.5,
"subclavius": 0.7,
"scalenus_minimus": 0.7,
"sternalis": 0.4
}
},
{
"id": "acute_overstretch",
"label": "Acute overstretch \u2014 catching a fall, reaching backward suddenly, lifting at arm\u2019s length",
"sublabel": "A specific sudden event the patient can recall",
"lr": {
"biceps": 6.0,
"infraspinatus": 5.0,
"brachialis": 2.0,
"deltoid_anterior": 3.0,
"supraspinatus": 2.0,
"scalene": 1.0,
"subclavius": 0.7,
"scalenus_minimus": 0.7,
"triceps_trp5": 1.0,
"sternalis": 0.5
}
},
{
"id": "gradual_postural",
"label": "Gradual onset without clear incident \u2014 prolonged desk work, sustained sitting, poor posture",
"sublabel": "Pain developed insidiously over weeks without a specific event",
"lr": {
"scalene": 4.0,
"scalenus_minimus": 3.0,
"subclavius": 3.0,
"sternalis": 2.5,
"biceps": 1.5,
"brachialis": 1.0,
"infraspinatus": 0.5,
"supraspinatus": 0.8,
"deltoid_anterior": 1.0,
"triceps_trp5": 1.5
}
},
{
"id": "post_cardiac",
"label": "During or after a cardiac event \u2014 myocardial infarction or sustained angina",
"sublabel": "Chest and arm pain began or intensified around the time of a cardiac event",
"lr": {
"sternalis": 9.0,
"scalene": 1.5,
"scalenus_minimus": 1.0,
"subclavius": 0.8,
"biceps": 0.3,
"brachialis": 0.3,
"infraspinatus": 0.3,
"supraspinatus": 0.3,
"deltoid_anterior": 0.3,
"triceps_trp5": 0.3
}
}
]
}
],
"pairwise": [
{
"id": "pw_brachialis_biceps",
"pair": ["brachialis", "biceps"],
"text": "Tiebreaker \u2014 Brachialis vs Biceps Brachii",
"question": "Does elbow flexion pain differ between palm-up and palm-down positions?",
"answers": [
{
"id": "equal_both_positions",
"label": "Equally painful or weak in both palm-up and palm-down flexion",
"lr": {
"brachialis": 5.0,
"biceps": 0.25
}
},
{
"id": "worse_palm_up",
"label": "Worse with palm-up (supinated) flexion than palm-down",
"lr": {
"brachialis": 0.25,
"biceps": 5.0
}
}
]
},
{
"id": "pw_scalene_scalenus_minimus",
"pair": ["scalene", "scalenus_minimus"],
"text": "Tiebreaker \u2014 Scalene vs Scalenus Minimus",
"question": "Which arm symptom pattern dominates?",
"answers": [
{
"id": "nocturnal_ulnar",
"label": "Nocturnal arm aching (hanging over bed) OR posterior arm and ulnar hand symptoms dominate",
"lr": {
"scalene": 4.0,
"scalenus_minimus": 0.3
}
},
{
"id": "radial_thumb_plexus",
"label": "Radial forearm, thumb, or lower brachial plexus compression symptoms dominate",
"lr": {
"scalene": 0.3,
"scalenus_minimus": 4.0
}
}
]
},
{
"id": "pw_subclavius_scalenus_minimus",
"pair": ["subclavius", "scalenus_minimus"],
"text": "Tiebreaker \u2014 Subclavius vs Scalenus Minimus",
"question": "Does arm abduction worsen the radial forearm and hand symptoms (Wright position), OR is the nocturnal arm pattern more prominent?",
"answers": [
{
"id": "wright_worsens",
"label": "Arm raised and rotated outward (Wright position) worsens symptoms",
"lr": {
"subclavius": 4.0,
"scalenus_minimus": 0.3
}
},
{
"id": "nocturnal_lower_plexus",
"label": "Nocturnal arm symptoms OR lower plexus compression features dominate \u2014 Wright position not specifically positive",
"lr": {
"subclavius": 0.3,
"scalenus_minimus": 4.0
}
}
]
},
{
"id": "pw_infraspinatus_biceps",
"pair": ["infraspinatus", "biceps"],
"text": "Tiebreaker \u2014 Infraspinatus vs Biceps Brachii",
"question": "Is the primary pain DEEP INSIDE the shoulder joint, OR is it a superficial surface ache over the anterior shoulder?",
"answers": [
{
"id": "deep_joint",
"label": "Deep inside the joint \u2014 the patient covers the anterior joint",
"lr": {
"infraspinatus": 5.0,
"biceps": 0.2
}
},
{
"id": "surface_ache",
"label": "Superficial surface ache \u2014 can lie comfortably on the affected side",
"lr": {
"infraspinatus": 0.2,
"biceps": 5.0
}
}
]
},
{
"id": "pw_supraspinatus_biceps",
"pair": ["supraspinatus", "biceps"],
"text": "Tiebreaker \u2014 Supraspinatus vs Biceps Brachii",
"question": "Is there a painful arc between 60\u00b0 and 120\u00b0 of shoulder abduction, OR is the arm pain primarily at the anterior shoulder without an arc pattern?",
"answers": [
{
"id": "painful_arc",
"label": "Painful arc between 60\u00b0 and 120\u00b0 of abduction",
"lr": {
"supraspinatus": 5.0,
"biceps": 0.2
}
},
{
"id": "anterior_shoulder_no_arc",
"label": "Anterior shoulder aching without a painful arc pattern",
"lr": {
"supraspinatus": 0.2,
"biceps": 4.0
}
}
]
},
{
"id": "pw_sternalis_scalene",
"pair": ["sternalis", "scalene"],
"text": "Tiebreaker \u2014 Sternalis vs Scalene",
"question": "Is the chest pain completely unaffected by any shoulder or arm movement, OR do arm or hand symptoms accompany it?",
"answers": [
{
"id": "movement_independent",
"label": "Completely movement-independent \u2014 no position or activity changes the pain",
"lr": {
"sternalis": 5.0,
"scalene": 0.3
}
},
{
"id": "arm_symptoms_present",
"label": "Arm or hand symptoms accompany the chest pain",
"lr": {
"sternalis": 0.3,
"scalene": 4.0
}
}
]
},
{
"id": "pw_triceps_trp5_brachialis",
"pair": ["triceps_trp5", "brachialis"],
"text": "Tiebreaker \u2014 Triceps Medial Head vs Brachialis",
"question": "Is the medial epicondyle the dominant distal referral, OR is the thumb base the dominant distal referral?",
"answers": [
{
"id": "medial_epicondyle_dominant",
"label": "Medial epicondyle (inner elbow) or medial forearm is the dominant distal referral",
"lr": {
"triceps_trp5": 5.0,
"brachialis": 0.25
}
},
{
"id": "thumb_base_dominant",
"label": "Thumb base or dorsal web of the thumb is the dominant distal referral",
"lr": {
"triceps_trp5": 0.25,
"brachialis": 5.0
}
}
]
}
],
"treatment_dag": {
"edges": [
{
"from": "infraspinatus",
"to": "biceps",
"type": "key_satellite",
"label": "Infraspinatus is the most important key TrP driving satellite biceps TrPs \u2014 treat infraspinatus first; biceps may resolve without direct treatment"
},
{
"from": "biceps",
"to": "brachialis",
"type": "functional_unit",
"label": "Biceps and brachialis are the primary elbow flexor pair \u2014 examine and treat together in the same session"
},
{
"from": "scalene",
"to": "biceps",
"type": "key_satellite",
"label": "Scalene TrPs drive biceps brachii satellite TrPs"
},
{
"from": "scalene",
"to": "scalenus_minimus",
"type": "functional_unit",
"label": "Scalenus minimus (when present) is part of the scalene group \u2014 treat in the same session"
},
{
"from": "biceps",
"to": "triceps_trp5",
"type": "antagonist_risk",
"label": "\u26a0 Triceps (medial head) may reactively cramp when biceps is released \u2014 spray triceps after biceps release; treat in alternating partial cycles if both are active"
},
{
"from": "infraspinatus",
"to": "supraspinatus",
"type": "functional_unit",
"label": "Infraspinatus-supraspinatus team \u2014 almost always active together; treat in the same session"
},
{
"from": "infraspinatus",
"to": "deltoid_anterior",
"type": "key_satellite",
"label": "Infraspinatus is the most important key TrP driving anterior deltoid satellite TrPs"
},
{
"from": "supraspinatus",
"to": "deltoid_anterior",
"type": "key_satellite",
"label": "Supraspinatus TrPs drive anterior and middle deltoid satellite TrPs"
},
{
"from": "subclavius",
"to": "scalene",
"type": "secondary_load",
"label": "Subclavius shortening draws the clavicle down, increasing load on the scalene group \u2014 treat together"
}
],
"edge_type_labels": {
"key_satellite": "Treat first \u2014 key TrP driving satellites",
"functional_unit": "Treat concurrently in same session",
"secondary_load": "Treat after primary resolves",
"antagonist_risk": "\u26a0 Treat in alternating cycles \u2014 reactive activation risk"
}
}
}