DiagnosticTree/BackofArm
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{
"model": "bayesian_lr_scoring",
"version": "1.0",
"description": "Probabilistic scoring model for posterior 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). Bold muscles carry higher priors (0.115385); regular-weight muscles carry lower priors (0.076923). Triceps TrP1 = Long Head (posterior arm, skips elbow); Triceps TrP3 = Lateral Head (posterior arm, 4th/5th digit ache, radial forearm tingling).",
"thresholds": {
"early_exit_posterior": 0.55,
"early_exit_gap": 0.18,
"pairwise_trigger": 0.22
},
"muscles": {
"triceps_long_head": {
"label": "Triceps \u2014 Long Head",
"prior": 0.076923,
"page": "Muscle:Triceps_Brachii",
"key_trp_note": "Latissimus dorsi and serratus posterior superior are key TrP sources that drive long head triceps satellite TrPs. Teres major also commonly activates the long head. Treat these key muscles before the triceps when both are active.",
"subtitle": "Posterior arm and shoulder ache; pain skips the elbow"
},
"triceps_lateral_head": {
"label": "Triceps \u2014 Lateral Head (Radial Nerve Zone)",
"prior": 0.076923,
"page": "Muscle:Triceps_Brachii",
"key_trp_note": "The TrP3 nodule lies just above the point where the radial nerve exits the musculospiral groove. Taut bands here can entrap radial nerve sensory fibres, producing a dual symptom pattern: ulnar-digit aching (TrP itself) plus radial sensory tingling (nerve compression). Injection is usually required \u2014 responds poorly to stretch and spray alone.",
"subtitle": "Posterior arm; 4th/5th digit ache AND radial forearm/hand tingling (dual pattern)"
},
"scalene": {
"label": "Scalene",
"prior": 0.115385,
"page": "Muscle:Scalene",
"key_trp_note": "Scalene TrPs are a key driver of satellite TrPs in triceps long head, serratus posterior superior, upper trapezius, and pectoralis major/minor. Treat scalenes before their satellites. SCM should be treated concurrently.",
"subtitle": "Posterior arm + nocturnal arm aching; must hang arm over bed for relief"
},
"scalenus_minimus": {
"label": "Scalenus Minimus",
"prior": 0.076923,
"page": "Muscle:Scalene",
"key_trp_note": "The scalenus minimus (when present) is a small accessory muscle. Its TrPs can produce a distinct referred pain pattern extending down the posterior and lateral arm to the radial side of the hand and thumb. It is anatomically positioned to compress the lower trunk of the brachial plexus against the first rib, producing a neurogenic thoracic outlet pattern.",
"subtitle": "Posterior arm to radial hand/thumb; may mimic C8-T1 lower plexus entrapment"
},
"teres_major": {
"label": "Teres Major",
"prior": 0.115385,
"page": "Muscle:Teres_Major",
"key_trp_note": "Teres major almost always develops TrPs simultaneously with latissimus dorsi \u2014 treat as a unit. Rhomboid TrPs that are refractory to treatment are often driven by teres major as the key TrP. Posterior deltoid, teres minor, and subscapularis develop secondary TrPs in chronic teres major involvement.",
"subtitle": "Posterior deltoid aching; reaches forward but not back; 3\u20135 cm behind-back restriction"
},
"deltoid_posterior": {
"label": "Posterior Deltoid",
"prior": 0.076923,
"page": "Muscle:Deltoid",
"key_trp_note": "Posterior deltoid TrPs are almost never isolated. Infraspinatus is the most common key TrP source. Check infraspinatus, supraspinatus, teres major, and latissimus dorsi before treating the posterior deltoid directly.",
"subtitle": "Local posterior shoulder and upper arm only; no distant referral; history of direct impact"
},
"subscapularis": {
"label": "Subscapularis",
"prior": 0.076923,
"page": "Muscle:Subscapularis",
"key_trp_note": "Subscapularis is the key TrP initiating the frozen shoulder cascade. Secondary TrPs in pectoralis major, teres major, latissimus dorsi, triceps long head, and anterior deltoid develop sequentially. Until subscapularis TrPs are identified and corrected, these satellites persistently recur.",
"subtitle": "Posterior shoulder + wrist strap band; frozen shoulder; posterior arm to elbow"
},
"supraspinatus": {
"label": "Supraspinatus",
"prior": 0.076923,
"page": "Muscle:Supraspinatus",
"key_trp_note": "Infraspinatus TrPs are often the key TrP source driving supraspinatus satellites. If supraspinatus TrPs recur, examine infraspinatus. The supraspinatus-infraspinatus team is the most common co-active pairing in shoulder pain.",
"subtitle": "Lateral shoulder to lateral arm; lateral epicondyle referral; painful arc 60\u2013120\u00b0"
},
"teres_minor": {
"label": "Teres Minor",
"prior": 0.076923,
"page": "Muscle:Teres_Minor",
"key_trp_note": "Teres minor TrPs are almost always uncovered after infraspinatus treatment. The infraspinatus anterior shoulder pain dominates and masks the teres minor presentation. Treat infraspinatus first; teres minor TrPs emerge as the next layer.",
"subtitle": "Posterior deltoid near humeral attachment; 4th/5th finger dysesthesia on movement"
},
"latissimus": {
"label": "Latissimus Dorsi",
"prior": 0.076923,
"page": "Muscle:Latissimus_Dorsi",
"key_trp_note": "Latissimus dorsi TrPs are a key driver of teres major and iliocostalis thoracis satellite TrPs. Treat latissimus before these satellites. Latissimus is part of the pseudothoracic outlet quadrad (with teres major, subscapularis, pectoralis major).",
"subtitle": "Inferior scapular angle; mid-thoracic back; medial arm to ulnar hand (ring and little fingers)"
},
"serratus_posterior_sup": {
"label": "Serratus Posterior Superior",
"prior": 0.076923,
"page": "Muscle:Serratus_Posterior",
"key_trp_note": "Scalene TrPs are the key TrP source driving serratus posterior superior satellite TrPs. Always examine the neck for scalene TrPs when serratus posterior superior TrPs are found.",
"subtitle": "Deep under scapula (inaccessible); triceps area; elbow; ulnar forearm and little finger"
},
"coracobrachialis": {
"label": "Coracobrachialis",
"prior": 0.076923,
"page": "Muscle:Coracobrachialis",
"key_trp_note": "Coracobrachialis TrPs develop secondarily to key TrPs in anterior deltoid, biceps brachii (short head), supraspinatus, and triceps long head. Treat these muscles first. Coracobrachialis is the residual deep anterior shoulder pain after surrounding muscles have been cleared.",
"subtitle": "Anterior shoulder + posterior arm to dorsal hand skipping elbow and wrist; residual after deltoid/biceps cleared"
}
},
"questions": [
{
"id": "q_skip_pattern",
"text": "Does the arm pain SKIP the elbow \u2014 with aching in the posterior arm and/or dorsal forearm and hand, but the elbow region itself is relatively spared?",
"sublabel": "Back of upper arm hurts, back of forearm or hand may hurt, but the elbow joint area is not the sore spot",
"type": "binary",
"answers": [
{
"id": "yes",
"label": "Yes \u2014 posterior arm pain that skips or jumps over the elbow",
"lr": {
"triceps_long_head": 8.0,
"coracobrachialis": 7.0,
"serratus_posterior_sup": 4.0,
"scalene": 2.0,
"scalenus_minimus": 2.5,
"teres_major": 1.5,
"triceps_lateral_head": 1.5,
"deltoid_posterior": 0.5,
"subscapularis": 0.6,
"supraspinatus": 0.4,
"teres_minor": 0.5,
"latissimus": 0.5
}
},
{
"id": "no",
"label": "No \u2014 the elbow is painful or arm pain does not have a skip pattern",
"lr": {
"triceps_long_head": 0.2,
"coracobrachialis": 0.3,
"serratus_posterior_sup": 0.6,
"scalene": 0.8,
"scalenus_minimus": 0.7,
"teres_major": 0.9,
"triceps_lateral_head": 1.3,
"deltoid_posterior": 1.4,
"subscapularis": 1.3,
"supraspinatus": 1.4,
"teres_minor": 1.3,
"latissimus": 1.2
}
}
]
},
{
"id": "q_anterior_shoulder_component",
"text": "Is there also anterior shoulder pain \u2014 at the front of the shoulder near the proximal humerus \u2014 combined with the posterior arm pain?",
"sublabel": "The front of the shoulder aches alongside the back-of-arm pain",
"type": "binary",
"answers": [
{
"id": "yes",
"label": "Yes \u2014 anterior shoulder pain present alongside the posterior arm pain",
"lr": {
"coracobrachialis": 7.0,
"subscapularis": 3.0,
"supraspinatus": 2.0,
"triceps_long_head": 1.5,
"scalene": 1.5,
"teres_minor": 1.0,
"teres_major": 0.8,
"triceps_lateral_head": 0.7,
"deltoid_posterior": 0.4,
"latissimus": 0.5,
"serratus_posterior_sup": 0.5,
"scalenus_minimus": 1.0
}
},
{
"id": "no",
"label": "No \u2014 posterior arm only; no significant anterior shoulder component",
"lr": {
"coracobrachialis": 0.2,
"subscapularis": 0.6,
"supraspinatus": 0.7,
"triceps_long_head": 1.1,
"scalene": 0.9,
"teres_minor": 1.1,
"teres_major": 1.2,
"triceps_lateral_head": 1.2,
"deltoid_posterior": 1.3,
"latissimus": 1.2,
"serratus_posterior_sup": 1.2,
"scalenus_minimus": 0.9
}
}
]
},
{
"id": "q_dorsal_hand",
"text": "Does the pain extend to the BACK (dorsum) of the hand or fingers?",
"sublabel": "The top of the hand hurts; possibly extending to one or more fingertips on the back of the hand",
"type": "binary",
"answers": [
{
"id": "yes",
"label": "Yes \u2014 dorsal hand or dorsal finger pain present",
"lr": {
"coracobrachialis": 6.0,
"triceps_lateral_head": 4.0,
"scalene": 3.0,
"scalenus_minimus": 4.0,
"serratus_posterior_sup": 3.0,
"triceps_long_head": 2.0,
"teres_minor": 2.0,
"latissimus": 1.5,
"subscapularis": 1.0,
"teres_major": 0.6,
"supraspinatus": 0.5,
"deltoid_posterior": 0.3
}
},
{
"id": "no",
"label": "No \u2014 no dorsal hand or finger pain",
"lr": {
"coracobrachialis": 0.3,
"triceps_lateral_head": 0.5,
"scalene": 0.6,
"scalenus_minimus": 0.4,
"serratus_posterior_sup": 0.5,
"triceps_long_head": 0.7,
"teres_minor": 0.7,
"latissimus": 0.8,
"subscapularis": 1.1,
"teres_major": 1.3,
"supraspinatus": 1.2,
"deltoid_posterior": 1.3
}
}
]
},
{
"id": "q_finger_pattern",
"text": "Which fingers are affected by tingling, numbness, or dysesthesia?",
"sublabel": "Select the finger symptom pattern",
"type": "choice",
"answers": [
{
"id": "ring_little_ache_plus_radial_tingle",
"label": "Ring and little finger ACHING, AND ALSO tingling or numbness over the back of the forearm/wrist/hand",
"sublabel": "Two separate symptom zones: dull ache in 4th/5th digits, PLUS tingling on the back of the forearm and hand \u2014 both present together",
"lr": {
"triceps_lateral_head": 12.0,
"triceps_long_head": 0.4,
"coracobrachialis": 0.5,
"scalene": 1.0,
"scalenus_minimus": 0.8,
"serratus_posterior_sup": 0.8,
"teres_minor": 0.4,
"teres_major": 0.3,
"deltoid_posterior": 0.2,
"subscapularis": 0.3,
"supraspinatus": 0.3,
"latissimus": 0.4
}
},
{
"id": "ring_little_only",
"label": "4th and/or 5th finger only \u2014 ring and little finger tingling or numbness",
"sublabel": "Dysesthesia in the ring and/or little finger; brought on by reaching above or behind the shoulder",
"lr": {
"teres_minor": 8.0,
"serratus_posterior_sup": 4.0,
"scalene": 3.0,
"latissimus": 2.0,
"scalenus_minimus": 1.5,
"triceps_lateral_head": 2.0,
"triceps_long_head": 0.5,
"coracobrachialis": 0.5,
"teres_major": 0.4,
"subscapularis": 0.4,
"supraspinatus": 0.3,
"deltoid_posterior": 0.2
}
},
{
"id": "radial_thumb",
"label": "Thumb, index, or radial forearm tingling",
"sublabel": "Thumb or index finger symptoms; or tingling on the radial (thumb) side of the forearm",
"lr": {
"scalenus_minimus": 6.0,
"scalene": 4.0,
"supraspinatus": 2.0,
"triceps_lateral_head": 0.5,
"teres_minor": 0.4,
"serratus_posterior_sup": 0.4,
"triceps_long_head": 0.4,
"coracobrachialis": 0.4,
"teres_major": 0.3,
"subscapularis": 0.4,
"deltoid_posterior": 0.2,
"latissimus": 0.3
}
},
{
"id": "middle_finger_dorsum",
"label": "Middle finger tip or back of the hand extending to the middle finger",
"sublabel": "Dorsum of hand with middle finger involvement",
"lr": {
"coracobrachialis": 7.0,
"triceps_lateral_head": 2.0,
"scalene": 1.5,
"scalenus_minimus": 1.5,
"triceps_long_head": 1.0,
"teres_minor": 0.5,
"serratus_posterior_sup": 0.5,
"teres_major": 0.4,
"subscapularis": 0.4,
"supraspinatus": 0.4,
"deltoid_posterior": 0.3,
"latissimus": 0.4
}
},
{
"id": "no_finger",
"label": "No finger symptoms",
"lr": {
"teres_major": 2.0,
"deltoid_posterior": 2.0,
"subscapularis": 1.5,
"supraspinatus": 1.5,
"teres_minor": 0.5,
"triceps_long_head": 1.2,
"latissimus": 1.0,
"triceps_lateral_head": 0.4,
"serratus_posterior_sup": 0.5,
"scalene": 0.5,
"scalenus_minimus": 0.4,
"coracobrachialis": 0.5
}
}
]
},
{
"id": "q_nocturnal_arm",
"text": "Is the patient woken at night by arm aching or numbness, requiring the arm to hang over the side of the bed or be shaken for relief?",
"sublabel": "Nocturnal arm symptoms; hanging the arm over the bed edge gives relief",
"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": 6.0,
"serratus_posterior_sup": 1.5,
"triceps_long_head": 0.6,
"triceps_lateral_head": 0.5,
"teres_major": 0.4,
"deltoid_posterior": 0.3,
"subscapularis": 0.5,
"supraspinatus": 0.4,
"teres_minor": 0.5,
"latissimus": 0.5,
"coracobrachialis": 0.4
}
},
{
"id": "no",
"label": "No \u2014 no nocturnal arm hanging symptom",
"lr": {
"scalene": 0.25,
"scalenus_minimus": 0.3,
"serratus_posterior_sup": 1.0,
"triceps_long_head": 1.1,
"triceps_lateral_head": 1.1,
"teres_major": 1.2,
"deltoid_posterior": 1.2,
"subscapularis": 1.1,
"supraspinatus": 1.1,
"teres_minor": 1.1,
"latissimus": 1.1,
"coracobrachialis": 1.1
}
}
]
},
{
"id": "q_back_rub_test",
"text": "Is the Back-rub Test painful \u2014 reaching the arm behind the back at waist level, as when tucking in a shirt or doing up a brassiere?",
"sublabel": "The patient can reach behind the back but pain or limitation occurs at waist level on the affected side",
"type": "choice",
"answers": [
{
"id": "cannot_at_all",
"label": "Cannot reach behind the back at all \u2014 arm will not go behind the body",
"sublabel": "Severely restricted medial rotation; cannot get the hand to the hip pocket",
"lr": {
"subscapularis": 8.0,
"triceps_long_head": 1.5,
"teres_major": 1.0,
"latissimus": 1.0,
"coracobrachialis": 0.8,
"teres_minor": 1.0,
"supraspinatus": 1.0,
"deltoid_posterior": 0.4,
"triceps_lateral_head": 0.5,
"scalene": 0.5,
"scalenus_minimus": 0.4,
"serratus_posterior_sup": 0.5
}
},
{
"id": "restricted_painful",
"label": "Reaches behind but knuckles only reach the midline or less \u2014 painful; cannot reach across the full back",
"sublabel": "Can get the hand behind the back but pain stops full reach across the low back",
"lr": {
"coracobrachialis": 8.0,
"teres_major": 5.0,
"teres_minor": 2.0,
"subscapularis": 2.0,
"triceps_long_head": 1.5,
"latissimus": 1.5,
"supraspinatus": 1.0,
"deltoid_posterior": 0.7,
"triceps_lateral_head": 0.6,
"scalene": 0.7,
"scalenus_minimus": 0.5,
"serratus_posterior_sup": 0.5
}
},
{
"id": "normal",
"label": "Full behind-back reach \u2014 no restriction",
"lr": {
"deltoid_posterior": 1.8,
"triceps_lateral_head": 1.8,
"scalene": 1.5,
"scalenus_minimus": 1.5,
"serratus_posterior_sup": 1.5,
"triceps_long_head": 1.3,
"latissimus": 1.2,
"teres_minor": 0.6,
"teres_major": 0.3,
"coracobrachialis": 0.4,
"subscapularis": 0.3,
"supraspinatus": 0.8
}
}
]
},
{
"id": "q_wrist_band",
"text": "Is there a strap-like band of pain or tenderness around the wrist, particularly on the back of the wrist?",
"sublabel": "The wristwatch band feels uncomfortable; patient may have moved the watch to the other wrist",
"type": "binary",
"answers": [
{
"id": "yes",
"label": "Yes \u2014 strap-like wrist pain or tenderness, predominantly dorsal",
"lr": {
"subscapularis": 12.0,
"triceps_long_head": 0.4,
"teres_major": 0.3,
"coracobrachialis": 0.4,
"deltoid_posterior": 0.2,
"supraspinatus": 0.3,
"teres_minor": 0.3,
"scalene": 0.3,
"scalenus_minimus": 0.3,
"triceps_lateral_head": 0.3,
"latissimus": 0.4,
"serratus_posterior_sup": 0.3
}
},
{
"id": "no",
"label": "No \u2014 no wrist band pain",
"lr": {
"subscapularis": 0.25,
"triceps_long_head": 1.1,
"teres_major": 1.2,
"coracobrachialis": 1.1,
"deltoid_posterior": 1.2,
"supraspinatus": 1.2,
"teres_minor": 1.2,
"scalene": 1.1,
"scalenus_minimus": 1.1,
"triceps_lateral_head": 1.1,
"latissimus": 1.1,
"serratus_posterior_sup": 1.1
}
}
]
},
{
"id": "q_elbow_pain",
"text": "Is there pain at or around the elbow \u2014 lateral epicondyle, olecranon, or medial epicondyle?",
"sublabel": "Elbow pain is part of the presentation",
"type": "choice",
"answers": [
{
"id": "lateral_epicondyle",
"label": "Lateral epicondyle (outer elbow) \u2014 the bony bump on the outside",
"sublabel": "Pain at the outer elbow; may be tender to pressure or worsened by resisted wrist extension",
"lr": {
"triceps_lateral_head": 9.0,
"supraspinatus": 4.0,
"scalene": 2.0,
"serratus_posterior_sup": 2.0,
"triceps_long_head": 0.5,
"coracobrachialis": 0.4,
"teres_major": 0.4,
"teres_minor": 0.4,
"subscapularis": 0.3,
"deltoid_posterior": 0.3,
"latissimus": 0.4,
"scalenus_minimus": 0.5
}
},
{
"id": "olecranon",
"label": "Olecranon (back of elbow tip) \u2014 the pointy bone at the back",
"sublabel": "Pain specifically at the back tip of the elbow",
"lr": {
"triceps_long_head": 5.0,
"serratus_posterior_sup": 3.0,
"triceps_lateral_head": 2.0,
"scalene": 1.5,
"teres_major": 0.8,
"coracobrachialis": 0.5,
"subscapularis": 0.4,
"supraspinatus": 0.4,
"teres_minor": 0.5,
"deltoid_posterior": 0.3,
"latissimus": 0.5,
"scalenus_minimus": 0.8
}
},
{
"id": "medial_epicondyle",
"label": "Medial epicondyle (inner elbow) \u2014 the bony bump on the inside",
"sublabel": "Pain at the inner elbow; may extend to ring and little finger volar surface",
"lr": {
"triceps_long_head": 4.0,
"triceps_lateral_head": 3.0,
"scalene": 2.0,
"serratus_posterior_sup": 1.5,
"teres_minor": 1.0,
"latissimus": 1.0,
"coracobrachialis": 0.5,
"subscapularis": 0.4,
"supraspinatus": 0.3,
"teres_major": 0.5,
"deltoid_posterior": 0.3,
"scalenus_minimus": 1.0
}
},
{
"id": "no_elbow",
"label": "No elbow pain \u2014 the elbow is not involved",
"lr": {
"teres_major": 2.0,
"deltoid_posterior": 2.0,
"coracobrachialis": 1.5,
"subscapularis": 1.5,
"teres_minor": 1.3,
"triceps_long_head": 1.2,
"latissimus": 1.2,
"scalenus_minimus": 0.8,
"scalene": 0.6,
"serratus_posterior_sup": 0.7,
"supraspinatus": 0.8,
"triceps_lateral_head": 0.4
}
}
]
},
{
"id": "q_local_only",
"text": "Is the pain ENTIRELY LOCAL to the posterior shoulder and upper arm \u2014 with no referral to the forearm, hand, or elbow?",
"sublabel": "Pain stays in the back of the shoulder and upper arm; never travels past mid-arm",
"type": "binary",
"answers": [
{
"id": "yes",
"label": "Yes \u2014 entirely local; no distal arm, elbow, or hand referral",
"lr": {
"deltoid_posterior": 9.0,
"teres_major": 3.0,
"teres_minor": 2.5,
"subscapularis": 1.0,
"triceps_long_head": 0.3,
"triceps_lateral_head": 0.2,
"coracobrachialis": 0.2,
"serratus_posterior_sup": 0.2,
"scalene": 0.2,
"scalenus_minimus": 0.2,
"supraspinatus": 0.6,
"latissimus": 0.5
}
},
{
"id": "no",
"label": "No \u2014 there is some distal referral to the forearm, hand, or elbow",
"lr": {
"deltoid_posterior": 0.2,
"teres_major": 0.7,
"teres_minor": 0.7,
"subscapularis": 1.2,
"triceps_long_head": 1.3,
"triceps_lateral_head": 1.4,
"coracobrachialis": 1.4,
"serratus_posterior_sup": 1.4,
"scalene": 1.4,
"scalenus_minimus": 1.4,
"supraspinatus": 1.1,
"latissimus": 1.1
}
}
]
},
{
"id": "q_painful_arc",
"text": "Is there a painful arc during shoulder abduction \u2014 pain appearing between approximately 60\u00b0 and 120\u00b0 of raising the arm sideways, then diminishing above that?",
"sublabel": "Ask the patient to raise the arm sideways \u2014 does pain appear then disappear 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_posterior": 1.5,
"triceps_long_head": 0.5,
"triceps_lateral_head": 0.4,
"coracobrachialis": 0.5,
"serratus_posterior_sup": 0.4,
"scalene": 0.5,
"scalenus_minimus": 0.4,
"teres_major": 0.5,
"teres_minor": 0.5,
"subscapularis": 0.5,
"latissimus": 0.4
}
},
{
"id": "no",
"label": "No \u2014 no arc pattern; abduction is uniformly painful or pain-free throughout",
"lr": {
"supraspinatus": 0.2,
"deltoid_posterior": 1.0,
"triceps_long_head": 1.2,
"triceps_lateral_head": 1.2,
"coracobrachialis": 1.1,
"serratus_posterior_sup": 1.2,
"scalene": 1.1,
"scalenus_minimus": 1.1,
"teres_major": 1.2,
"teres_minor": 1.2,
"subscapularis": 1.1,
"latissimus": 1.2
}
}
]
},
{
"id": "q_onset",
"text": "How did the arm pain begin?",
"sublabel": "Choose the onset pattern that best describes this episode",
"type": "choice",
"answers": [
{
"id": "driving_steering",
"label": "Gradual onset from prolonged driving \u2014 especially heavy or non-power-assisted steering",
"sublabel": "Weeks or months of driving requiring sustained steering effort",
"lr": {
"teres_major": 8.0,
"latissimus": 3.0,
"scalene": 1.5,
"subscapularis": 1.0,
"triceps_long_head": 0.8,
"teres_minor": 0.5,
"triceps_lateral_head": 0.6,
"deltoid_posterior": 0.7,
"coracobrachialis": 0.5,
"supraspinatus": 0.5,
"serratus_posterior_sup": 0.5,
"scalenus_minimus": 0.6
}
},
{
"id": "elbow_forward_sustained",
"label": "Gradual onset from sustained elbow-forward posture \u2014 driving, handwork, writing without armrest",
"sublabel": "Elbow held in front of the chest for extended periods without arm support",
"lr": {
"triceps_long_head": 7.0,
"coracobrachialis": 3.0,
"scalene": 2.0,
"scalenus_minimus": 1.5,
"teres_major": 0.7,
"triceps_lateral_head": 1.5,
"deltoid_posterior": 0.6,
"subscapularis": 0.5,
"supraspinatus": 0.5,
"teres_minor": 0.5,
"latissimus": 0.6,
"serratus_posterior_sup": 0.7
}
},
{
"id": "acute_incident",
"label": "Sudden onset from a specific remembered incident \u2014 MVA, fall, catching a fall, reaching jerk",
"sublabel": "Patient can name the exact moment pain started",
"lr": {
"teres_minor": 4.0,
"teres_major": 3.0,
"triceps_lateral_head": 3.0,
"subscapularis": 3.0,
"deltoid_posterior": 3.0,
"triceps_long_head": 1.5,
"scalene": 1.0,
"scalenus_minimus": 1.0,
"supraspinatus": 1.0,
"coracobrachialis": 0.8,
"serratus_posterior_sup": 0.7,
"latissimus": 0.8
}
},
{
"id": "coughing_respiratory",
"label": "Onset during or after prolonged coughing, pneumonia, or severe respiratory illness",
"sublabel": "Shoulder and arm pain developed during or after a period of heavy coughing",
"lr": {
"serratus_posterior_sup": 8.0,
"scalene": 3.0,
"scalenus_minimus": 2.0,
"triceps_long_head": 0.6,
"teres_major": 0.4,
"triceps_lateral_head": 0.4,
"deltoid_posterior": 0.3,
"subscapularis": 0.4,
"supraspinatus": 0.3,
"teres_minor": 0.3,
"latissimus": 0.4,
"coracobrachialis": 0.3
}
}
]
},
{
"id": "q_residual_after_other_treatment",
"text": "Has the patient already been treated for shoulder muscles (anterior deltoid, biceps brachii) and anterior shoulder pain resolved \u2014 but deep arm or shoulder pain persists?",
"sublabel": "Previous treatment cleared other muscles, but this arm pain remains unexplained",
"type": "binary",
"answers": [
{
"id": "yes",
"label": "Yes \u2014 anterior shoulder muscles already treated; this is the residual pain",
"lr": {
"coracobrachialis": 10.0,
"teres_minor": 4.0,
"serratus_posterior_sup": 2.0,
"scalene": 1.5,
"triceps_long_head": 1.5,
"triceps_lateral_head": 1.5,
"teres_major": 1.0,
"subscapularis": 0.7,
"deltoid_posterior": 0.7,
"supraspinatus": 0.6,
"latissimus": 0.8,
"scalenus_minimus": 1.0
}
},
{
"id": "no",
"label": "No \u2014 first presentation; no prior treatment of surrounding muscles",
"lr": {
"coracobrachialis": 0.25,
"teres_minor": 0.8,
"serratus_posterior_sup": 1.0,
"scalene": 1.0,
"triceps_long_head": 1.0,
"triceps_lateral_head": 1.0,
"teres_major": 1.1,
"subscapularis": 1.2,
"deltoid_posterior": 1.2,
"supraspinatus": 1.2,
"latissimus": 1.0,
"scalenus_minimus": 1.0
}
}
]
},
{
"id": "q_scapula_inaccessible",
"text": "Is the pain felt UNDER the upper portion of the scapula \u2014 deep to the shoulder blade, seemingly unreachable?",
"sublabel": "The patient reaches back with the opposite arm but cannot touch the sore spot because the shoulder blade covers it",
"type": "binary",
"answers": [
{
"id": "yes",
"label": "Yes \u2014 deep under the scapula; inaccessible to touch",
"lr": {
"serratus_posterior_sup": 10.0,
"scalene": 2.0,
"scalenus_minimus": 1.5,
"triceps_long_head": 1.5,
"subscapularis": 1.0,
"latissimus": 0.6,
"teres_major": 0.4,
"teres_minor": 0.4,
"triceps_lateral_head": 0.4,
"coracobrachialis": 0.3,
"deltoid_posterior": 0.3,
"supraspinatus": 0.4
}
},
{
"id": "no",
"label": "No \u2014 pain is accessible on the surface",
"lr": {
"serratus_posterior_sup": 0.2,
"scalene": 0.9,
"scalenus_minimus": 0.9,
"triceps_long_head": 1.0,
"subscapularis": 1.1,
"latissimus": 1.1,
"teres_major": 1.2,
"teres_minor": 1.2,
"triceps_lateral_head": 1.2,
"coracobrachialis": 1.2,
"deltoid_posterior": 1.2,
"supraspinatus": 1.1
}
}
]
}
],
"pairwise": [
{
"id": "pw_triceps_long_coraco",
"pair": ["triceps_long_head", "coracobrachialis"],
"text": "Tiebreaker \u2014 Triceps Long Head vs Coracobrachialis",
"question": "Is there also ANTERIOR shoulder pain alongside the posterior arm pain \u2014 and has this pain persisted after treating nearby shoulder muscles?",
"answers": [
{
"id": "posterior_only_first_presentation",
"label": "Posterior arm and shoulder only; first presentation \u2014 no anterior shoulder component",
"lr": {
"triceps_long_head": 4.0,
"coracobrachialis": 0.25
}
},
{
"id": "anterior_residual",
"label": "Anterior shoulder pain present; or this is residual pain after other shoulder muscles were treated",
"lr": {
"triceps_long_head": 0.25,
"coracobrachialis": 4.0
}
}
]
},
{
"id": "pw_triceps_lateral_teres_minor",
"pair": ["triceps_lateral_head", "teres_minor"],
"text": "Tiebreaker \u2014 Triceps Lateral Head vs Teres Minor",
"question": "Which finger symptom pattern is present?",
"answers": [
{
"id": "dual_ache_plus_tingle",
"label": "Ring/little finger ACHING plus back-of-forearm/hand TINGLING \u2014 two distinct zones simultaneously",
"lr": {
"triceps_lateral_head": 6.0,
"teres_minor": 0.2
}
},
{
"id": "movement_provoked_ring_little",
"label": "4th/5th finger dysesthesia only, provoked by reaching above or behind the shoulder",
"lr": {
"triceps_lateral_head": 0.2,
"teres_minor": 5.0
}
}
]
},
{
"id": "pw_scalene_scalenus_minimus",
"pair": ["scalene", "scalenus_minimus"],
"text": "Tiebreaker \u2014 Scalene vs Scalenus Minimus",
"question": "Which symptom pattern best describes the arm involvement?",
"answers": [
{
"id": "nocturnal_posterior_arm",
"label": "Nocturnal arm aching requiring hanging the arm over the bed; OR posterior arm and ulnar hand symptoms",
"lr": {
"scalene": 4.0,
"scalenus_minimus": 0.3
}
},
{
"id": "radial_thumb_plexus",
"label": "Radial forearm or thumb tingling; OR symptoms suggesting lower brachial plexus compression",
"lr": {
"scalene": 0.3,
"scalenus_minimus": 4.0
}
}
]
},
{
"id": "pw_teres_major_latissimus",
"pair": ["teres_major", "latissimus"],
"text": "Tiebreaker \u2014 Teres Major vs Latissimus Dorsi",
"question": "Where is the pain centred \u2014 posterior deltoid region, OR inferior scapular angle and mid-back?",
"answers": [
{
"id": "posterior_deltoid",
"label": "Posterior deltoid region \u2014 back of the shoulder",
"lr": {
"teres_major": 4.0,
"latissimus": 0.25
}
},
{
"id": "inferior_scapula_midback",
"label": "Inferior scapular angle or mid-thoracic back \u2014 lower or more central than the shoulder",
"lr": {
"teres_major": 0.25,
"latissimus": 4.0
}
}
]
},
{
"id": "pw_subscapularis_triceps_long",
"pair": ["subscapularis", "triceps_long_head"],
"text": "Tiebreaker \u2014 Subscapularis vs Triceps Long Head",
"question": "Is there a strap-like wrist band pain, OR is the pain primarily in the posterior arm and shoulder without wrist involvement?",
"answers": [
{
"id": "wrist_band",
"label": "Strap-like wrist band pain is present (dorsal predominantly)",
"lr": {
"subscapularis": 6.0,
"triceps_long_head": 0.2
}
},
{
"id": "posterior_arm_no_wrist",
"label": "Posterior arm and shoulder ache; no wrist band",
"lr": {
"subscapularis": 0.2,
"triceps_long_head": 4.0
}
}
]
},
{
"id": "pw_serratus_posterior_triceps_long",
"pair": ["serratus_posterior_sup", "triceps_long_head"],
"text": "Tiebreaker \u2014 Serratus Posterior Superior vs Triceps Long Head",
"question": "Is the pain UNDER the scapula and inaccessible to touch, OR in the posterior arm where it can be palpated?",
"answers": [
{
"id": "under_scapula",
"label": "Deep under the scapula \u2014 inaccessible; scapula seems to cover the sore area",
"lr": {
"serratus_posterior_sup": 5.0,
"triceps_long_head": 0.3
}
},
{
"id": "posterior_arm_palpable",
"label": "Posterior arm \u2014 accessible on the back of the arm",
"lr": {
"serratus_posterior_sup": 0.3,
"triceps_long_head": 4.0
}
}
]
},
{
"id": "pw_deltoid_teres_minor",
"pair": ["deltoid_posterior", "teres_minor"],
"text": "Tiebreaker \u2014 Posterior Deltoid vs Teres Minor",
"question": "Is the pain entirely local (no finger symptoms, no arm referral below elbow), or are there 4th/5th finger symptoms?",
"answers": [
{
"id": "local_only",
"label": "Entirely local \u2014 no finger symptoms; no referral below the elbow",
"lr": {
"deltoid_posterior": 5.0,
"teres_minor": 0.2
}
},
{
"id": "ring_little_finger",
"label": "4th/5th finger tingling or numbness accompanies the shoulder and arm pain",
"lr": {
"deltoid_posterior": 0.2,
"teres_minor": 5.0
}
}
]
}
],
"treatment_dag": {
"edges": [
{
"from": "scalene",
"to": "triceps_long_head",
"type": "key_satellite",
"label": "Scalene TrPs are a key driver of triceps long head satellite TrPs \u2014 treat scalenes first"
},
{
"from": "scalene",
"to": "serratus_posterior_sup",
"type": "key_satellite",
"label": "Scalene TrPs drive serratus posterior superior satellite TrPs \u2014 always examine the neck"
},
{
"from": "latissimus",
"to": "triceps_long_head",
"type": "key_satellite",
"label": "Latissimus dorsi TrPs are a key driver of triceps long head satellite TrPs"
},
{
"from": "latissimus",
"to": "teres_major",
"type": "functional_unit",
"label": "Latissimus dorsi and teres major share the posterior axillary fold \u2014 treat as a unit in the same session"
},
{
"from": "teres_major",
"to": "triceps_long_head",
"type": "key_satellite",
"label": "Teres major TrPs commonly activate triceps long head satellite TrPs"
},
{
"from": "teres_major",
"to": "deltoid_posterior",
"type": "secondary_load",
"label": "Posterior deltoid develops secondary TrPs in chronic teres major involvement \u2014 treat teres major first"
},
{
"from": "subscapularis",
"to": "triceps_long_head",
"type": "key_satellite",
"label": "Triceps long head develops secondary TrPs in the frozen shoulder cascade driven by subscapularis"
},
{
"from": "subscapularis",
"to": "teres_major",
"type": "key_satellite",
"label": "Subscapularis initiates the frozen shoulder cascade; teres major develops early as a secondary TrP"
},
{
"from": "triceps_long_head",
"to": "coracobrachialis",
"type": "key_satellite",
"label": "Triceps long head TrPs are a key driver of coracobrachialis satellite TrPs \u2014 treat triceps before coracobrachialis"
},
{
"from": "triceps_long_head",
"to": "teres_minor",
"type": "functional_unit",
"label": "Triceps long head and teres minor share the posterior shoulder functional unit \u2014 treat concurrently"
},
{
"from": "teres_major",
"to": "teres_minor",
"type": "functional_unit",
"label": "Teres major and teres minor share the scapular lateral border \u2014 treat concurrently"
},
{
"from": "subscapularis",
"to": "latissimus",
"type": "key_satellite",
"label": "Latissimus develops secondary TrPs as part of the frozen shoulder cascade driven by subscapularis"
},
{
"from": "scalene",
"to": "scalenus_minimus",
"type": "functional_unit",
"label": "Scalenus minimus (when present) is functionally part of the scalene group \u2014 treat in the same session"
}
],
"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"
}
}
}