DiagnosticTree/MidThoracicBack
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{
"model": "bayesian_lr_scoring",
"version": "1.0",
"description": "Probabilistic scoring model for mid-thoracic back 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 relevant individual chapters. Bold muscles carry higher priors (0.096774); regular-weight muscles carry lower priors (0.064516). Multifidi and Multifidus are treated as one entry (same muscle).",
"thresholds": {
"early_exit_posterior": 0.55,
"early_exit_gap": 0.18,
"pairwise_trigger": 0.22
},
"muscles": {
"rhomboids": {
"label": "Rhomboids",
"prior": 0.096774,
"page": "Muscle:Rhomboids",
"key_trp_note": "Rhomboid TrPs are driven by pectoral muscle shortening — treat pectoralis major and minor first. Upper trapezius TrP1 also drives rhomboid minor as a satellite. Rhomboid TrPs refractory to direct treatment are often maintained by teres major as a key TrP. Check serratus anterior as a contributor to rhomboid overload.",
"subtitle": "Medial scapular border burning at rest; present regardless of posture or arm movement"
},
"multifidi": {
"label": "Multifidi",
"prior": 0.096774,
"page": "Muscle:Multifidi",
"key_trp_note": "Deep paraspinal TrPs are often multiple and bilateral. The depth indicator is key: multifidi lie 1\u20132 cm from midline and refer at single or double vertebral levels. Rotatores refer at a single level only. Semispinalis thoracis refers across 4\u20136 levels. Treat the most symptomatic level first.",
"subtitle": "Deep unilateral paraspinal ache immediately beside the spinous processes"
},
"iliocostalis": {
"label": "Iliocostalis Thoracis",
"prior": 0.096774,
"page": "Muscle:Iliocostalis_Thoracis",
"key_trp_note": "Iliocostalis thoracis at the T6 level mimics cardiac or pleuritic pain (left side) or gallbladder pain (right side) and must not be mistaken for these conditions. Latissimus dorsi is a key TrP source driving iliocostalis satellite TrPs \u2014 treat latissimus first when both are active.",
"subtitle": "Up-and-down referral crossing midline; left T6 mimics cardiac pain; anterior chest component"
},
"scalene": {
"label": "Scalene",
"prior": 0.096774,
"page": "Muscle:Scalene",
"key_trp_note": "Scalene TrPs are a key driver of serratus posterior superior, upper trapezius, and triceps long head satellite TrPs. Treat scalenes before their satellites. SCM should be treated concurrently.",
"subtitle": "Posterior shoulder and mid-back component + arm/hand symptoms; nocturnal arm aching"
},
"latissimus": {
"label": "Latissimus Dorsi",
"prior": 0.096774,
"page": "Muscle:Latissimus_Dorsi",
"key_trp_note": "Latissimus dorsi TrPs drive iliocostalis thoracis satellite TrPs and teres major TrPs \u2014 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"
},
"serratus_posterior_sup": {
"label": "Serratus Posterior Superior",
"prior": 0.096774,
"page": "Muscle:Serratus_Posterior",
"key_trp_note": "Scalene TrPs are the key TrP source driving serratus posterior superior satellite TrPs \u2014 always examine the neck for scalene TrPs. This muscle mimics C8 radiculopathy and thoracic outlet syndrome.",
"subtitle": "Deep under scapula (inaccessible to touch); triceps/elbow/ulnar forearm/little finger"
},
"infraspinatus": {
"label": "Infraspinatus",
"prior": 0.096774,
"page": "Muscle:Infraspinatus",
"key_trp_note": "Infraspinatus TrPs drive satellite TrPs in the anterior deltoid, biceps brachii, and supraspinatus. The vertebral border trigger area of infraspinatus refers into the adjacent interscapular rhomboid region \u2014 a pattern difficult to distinguish from trapezius TrP4. Treat infraspinatus before its satellites.",
"subtitle": "Vertebral border trigger area \u2014 interscapular referral; primary pain is deep anterior shoulder"
},
"trapezius_trp5": {
"label": "Trapezius (TrP5 \u2014 Mid-Trapezius)",
"prior": 0.096774,
"page": "Muscle:Trapezius",
"key_trp_note": "Lower trapezius TrP3 is the most clinically important and most overlooked of the trapezius TrPs \u2014 it is the key TrP maintaining upper trapezius and levator scapulae satellites. TrP5 refers interscapularly. Treat lower trapezius TrP3 before addressing TrP5 if both are active.",
"subtitle": "Superficial burning between the shoulder blades; postural aggravation; desk work"
},
"serratus_anterior": {
"label": "Serratus Anterior",
"prior": 0.096774,
"page": "Muscle:Serratus_Anterior",
"key_trp_note": "Serratus anterior is the key unidentified TrP in many persistent unilateral interscapular pain syndromes \u2014 analogous to subscapularis in frozen shoulder. The TrP is on the anterolateral chest wall (midaxillary line, 5th\u20136th rib) but the pain is posterior. The interscapular syndrome will not resolve until serratus anterior TrPs are identified and inactivated.",
"subtitle": "Interscapular pain with TrP on anterior chest wall (midaxillary line); air hunger; cannot finish a sentence"
},
"trapezius_trp4": {
"label": "Trapezius (TrP4 \u2014 Mid-Fibres)",
"prior": 0.064516,
"page": "Muscle:Trapezius",
"key_trp_note": "Trapezius TrP4 burning along the medial scapular border can be difficult to distinguish from infraspinatus vertebral border trigger area referral. The infraspinatus vertebral border pattern is an enthesopathy secondary to primary infraspinatus TrPs \u2014 the primary infraspinatus pain (deep anterior shoulder) will be present if infraspinatus is the source.",
"subtitle": "Burning along medial scapular border extending to cervical region; suprascapular spillover"
},
"levator": {
"label": "Levator Scapulae",
"prior": 0.064516,
"page": "Muscle:Levator_Scapulae",
"key_trp_note": "Lower trapezius TrP3 is the key TrP most commonly driving levator scapulae satellites. If levator TrPs recur or respond poorly, lower trapezius TrP3 has not been addressed. Upper trapezius TrP1 also drives levator as a satellite.",
"subtitle": "Neck angle stiffness; cannot look over sore shoulder; vertebral border of scapula extension"
}
},
"questions": [
{
"id": "q_rest_burning",
"text": "Is the mid-thoracic pain a BURNING or gnawing quality along the medial border of the scapula \u2014 present AT REST and NOT clearly worse with posture or movement?",
"sublabel": "The pain burns along the inner edge of the shoulder blade regardless of sitting, standing, or lying down",
"type": "binary",
"answers": [
{
"id": "yes",
"label": "Yes \u2014 burning along the medial scapular border, present at rest",
"lr": {
"rhomboids": 8.0,
"trapezius_trp4": 2.0,
"trapezius_trp5": 1.5,
"serratus_anterior": 1.5,
"multifidi": 0.4,
"iliocostalis": 0.4,
"scalene": 0.7,
"latissimus": 0.5,
"serratus_posterior_sup": 0.5,
"infraspinatus": 0.5,
"levator": 0.4
}
},
{
"id": "no",
"label": "No \u2014 pain varies with posture, activity, or movement",
"lr": {
"rhomboids": 0.25,
"trapezius_trp4": 0.8,
"trapezius_trp5": 0.9,
"serratus_anterior": 0.9,
"multifidi": 1.3,
"iliocostalis": 1.3,
"scalene": 1.1,
"latissimus": 1.2,
"serratus_posterior_sup": 1.2,
"infraspinatus": 1.2,
"levator": 1.2
}
}
]
},
{
"id": "q_pain_location",
"text": "Where is the mid-thoracic pain most concentrated?",
"sublabel": "Choose the single best description of the dominant pain zone",
"type": "choice",
"answers": [
{
"id": "medial_border",
"label": "Along the medial border of the scapula \u2014 the inner edge of the shoulder blade",
"sublabel": "Burning or aching specifically along the vertebral border, between the scapula and the spine",
"lr": {
"rhomboids": 5.0,
"trapezius_trp4": 4.0,
"serratus_anterior": 2.0,
"trapezius_trp5": 1.5,
"infraspinatus": 1.5,
"levator": 1.5,
"scalene": 1.5,
"serratus_posterior_sup": 1.0,
"multifidi": 0.3,
"iliocostalis": 0.4,
"latissimus": 0.5
}
},
{
"id": "interscapular_diffuse",
"label": "Between the shoulder blades \u2014 diffuse interscapular or mid-thoracic",
"sublabel": "Aching or burning between or below the scapulae, not specifically the inner edge",
"lr": {
"trapezius_trp5": 5.0,
"serratus_anterior": 4.0,
"iliocostalis": 2.0,
"scalene": 2.0,
"trapezius_trp4": 1.5,
"rhomboids": 1.0,
"latissimus": 1.0,
"serratus_posterior_sup": 1.0,
"multifidi": 0.6,
"infraspinatus": 0.6,
"levator": 0.5
}
},
{
"id": "deep_paraspinal",
"label": "Deep unilateral paraspinal ache \u2014 immediately beside the spine only",
"sublabel": "Strictly within 2\u20133 cm of the spinous processes, not spreading to the scapula",
"lr": {
"multifidi": 9.0,
"iliocostalis": 2.0,
"trapezius_trp5": 0.5,
"trapezius_trp4": 0.5,
"rhomboids": 0.3,
"scalene": 0.4,
"serratus_anterior": 0.3,
"latissimus": 0.4,
"serratus_posterior_sup": 0.5,
"infraspinatus": 0.3,
"levator": 0.4
}
},
{
"id": "inferior_scapular_angle",
"label": "Inferior angle of the scapula \u2014 the bottom tip of the shoulder blade",
"sublabel": "Pain centred at or just below the inferior scapular angle; may extend into the mid-back",
"lr": {
"latissimus": 8.0,
"serratus_anterior": 2.0,
"iliocostalis": 2.0,
"serratus_posterior_sup": 1.5,
"rhomboids": 0.5,
"trapezius_trp5": 0.6,
"trapezius_trp4": 0.4,
"multifidi": 0.3,
"scalene": 0.5,
"infraspinatus": 0.4,
"levator": 0.3
}
},
{
"id": "deep_under_scapula",
"label": "Deep under the scapula \u2014 inaccessible; feels like it cannot be reached or rubbed",
"sublabel": "Pain seems to be under the shoulder blade itself; patient cannot touch it with the opposite hand",
"lr": {
"serratus_posterior_sup": 10.0,
"serratus_anterior": 2.0,
"infraspinatus": 1.5,
"scalene": 1.0,
"rhomboids": 0.3,
"trapezius_trp5": 0.3,
"trapezius_trp4": 0.4,
"multifidi": 0.3,
"iliocostalis": 0.3,
"latissimus": 0.4,
"levator": 0.4
}
}
]
},
{
"id": "q_arm_symptoms",
"text": "Are there arm or hand symptoms alongside the mid-thoracic back pain?",
"sublabel": "Arm numbness, tingling, hand swelling, arm heaviness, or nocturnal arm aching",
"type": "binary",
"answers": [
{
"id": "yes",
"label": "Yes \u2014 arm, forearm, or hand symptoms present",
"lr": {
"scalene": 5.0,
"serratus_posterior_sup": 4.0,
"latissimus": 2.0,
"infraspinatus": 1.5,
"trapezius_trp4": 1.0,
"rhomboids": 0.3,
"multifidi": 0.3,
"trapezius_trp5": 0.4,
"iliocostalis": 0.4,
"serratus_anterior": 0.5,
"levator": 0.5
}
},
{
"id": "no",
"label": "No \u2014 pain confined to the mid-thoracic back",
"lr": {
"scalene": 0.25,
"serratus_posterior_sup": 0.5,
"latissimus": 0.7,
"infraspinatus": 0.8,
"trapezius_trp4": 1.0,
"rhomboids": 1.4,
"multifidi": 1.4,
"trapezius_trp5": 1.3,
"iliocostalis": 1.2,
"serratus_anterior": 1.2,
"levator": 1.1
}
}
]
},
{
"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",
"condition": {
"q_arm_symptoms": "yes"
},
"answers": [
{
"id": "yes",
"label": "Yes \u2014 woken at night; arm must hang over bed side for relief",
"lr": {
"scalene": 9.0,
"serratus_posterior_sup": 1.5,
"latissimus": 0.5,
"infraspinatus": 0.4,
"trapezius_trp4": 0.5,
"rhomboids": 0.3,
"multifidi": 0.3,
"trapezius_trp5": 0.3,
"iliocostalis": 0.3,
"serratus_anterior": 0.4,
"levator": 0.4
}
},
{
"id": "no",
"label": "No \u2014 arm symptoms are daytime or positional only",
"lr": {
"scalene": 0.4,
"serratus_posterior_sup": 1.2,
"latissimus": 1.2,
"infraspinatus": 1.2,
"trapezius_trp4": 1.0,
"rhomboids": 1.0,
"multifidi": 1.0,
"trapezius_trp5": 1.0,
"iliocostalis": 1.0,
"serratus_anterior": 1.0,
"levator": 1.0
}
}
]
},
{
"id": "q_postural",
"text": "Is the pain clearly worse during or after sustained sitting, desk work, or forward-head posture?",
"sublabel": "Pain builds during a sitting work session and is relieved by moving or lying down",
"type": "binary",
"answers": [
{
"id": "yes",
"label": "Yes \u2014 clearly postural; builds with sustained sitting or forward posture",
"lr": {
"trapezius_trp5": 5.0,
"trapezius_trp4": 3.0,
"levator": 3.0,
"scalene": 2.0,
"iliocostalis": 2.0,
"multifidi": 2.0,
"serratus_anterior": 1.5,
"rhomboids": 1.0,
"latissimus": 1.0,
"serratus_posterior_sup": 0.8,
"infraspinatus": 0.8
}
},
{
"id": "no",
"label": "No \u2014 not clearly worse with posture or sitting",
"lr": {
"trapezius_trp5": 0.3,
"trapezius_trp4": 0.5,
"levator": 0.5,
"scalene": 0.7,
"iliocostalis": 0.7,
"multifidi": 0.7,
"serratus_anterior": 0.8,
"rhomboids": 1.5,
"latissimus": 1.3,
"serratus_posterior_sup": 1.3,
"infraspinatus": 1.2
}
}
]
},
{
"id": "q_breathing_symptoms",
"text": "Does the patient report RESPIRATORY symptoms alongside the back pain \u2014 specifically air hunger, inability to take a full breath, or inability to finish sentences without pausing to breathe?",
"sublabel": "Not dyspnoea from exertion \u2014 specifically a sense of air hunger or restricted chest expansion at rest or during conversation",
"type": "binary",
"answers": [
{
"id": "yes",
"label": "Yes \u2014 air hunger, restricted chest expansion, or cannot finish sentences present",
"lr": {
"serratus_anterior": 12.0,
"scalene": 2.0,
"iliocostalis": 1.5,
"rhomboids": 0.5,
"trapezius_trp5": 0.4,
"trapezius_trp4": 0.4,
"multifidi": 0.3,
"latissimus": 0.4,
"serratus_posterior_sup": 0.5,
"infraspinatus": 0.3,
"levator": 0.4
}
},
{
"id": "no",
"label": "No \u2014 no respiratory symptoms",
"lr": {
"serratus_anterior": 0.2,
"scalene": 0.9,
"iliocostalis": 0.9,
"rhomboids": 1.1,
"trapezius_trp5": 1.1,
"trapezius_trp4": 1.1,
"multifidi": 1.2,
"latissimus": 1.1,
"serratus_posterior_sup": 1.0,
"infraspinatus": 1.1,
"levator": 1.1
}
}
]
},
{
"id": "q_anterior_chest",
"text": "Is there ANTERIOR chest pain alongside the mid-thoracic back pain?",
"sublabel": "The front of the chest aches or burns; may be described as a pressure, squeezing, or sharp quality",
"type": "binary",
"answers": [
{
"id": "yes",
"label": "Yes \u2014 anterior chest pain is part of the presentation",
"lr": {
"iliocostalis": 7.0,
"serratus_anterior": 4.0,
"scalene": 2.0,
"serratus_posterior_sup": 1.5,
"rhomboids": 0.4,
"trapezius_trp5": 0.4,
"trapezius_trp4": 0.4,
"multifidi": 0.3,
"latissimus": 0.4,
"infraspinatus": 0.4,
"levator": 0.3
}
},
{
"id": "no",
"label": "No \u2014 pain is confined to the posterior thorax",
"lr": {
"iliocostalis": 0.3,
"serratus_anterior": 0.5,
"scalene": 0.8,
"serratus_posterior_sup": 0.9,
"rhomboids": 1.2,
"trapezius_trp5": 1.2,
"trapezius_trp4": 1.2,
"multifidi": 1.3,
"latissimus": 1.2,
"infraspinatus": 1.2,
"levator": 1.2
}
}
]
},
{
"id": "q_neck_rotation",
"text": "Is cervical rotation restricted or painful toward the PAINFUL side \u2014 cannot fully look over the sore shoulder?",
"sublabel": "The patient finds it difficult or painful to turn the head toward the side with the back pain",
"type": "binary",
"answers": [
{
"id": "yes",
"label": "Yes \u2014 cannot look fully over the sore shoulder; neck rotation restricted toward that side",
"lr": {
"levator": 8.0,
"scalene": 2.0,
"trapezius_trp4": 2.0,
"trapezius_trp5": 1.0,
"rhomboids": 0.3,
"multifidi": 0.5,
"iliocostalis": 0.5,
"serratus_anterior": 0.4,
"latissimus": 0.4,
"serratus_posterior_sup": 0.5,
"infraspinatus": 0.5
}
},
{
"id": "no",
"label": "No \u2014 cervical rotation is not restricted toward the sore side",
"lr": {
"levator": 0.15,
"scalene": 0.8,
"trapezius_trp4": 0.8,
"trapezius_trp5": 1.0,
"rhomboids": 1.3,
"multifidi": 1.1,
"iliocostalis": 1.1,
"serratus_anterior": 1.2,
"latissimus": 1.2,
"serratus_posterior_sup": 1.1,
"infraspinatus": 1.1
}
}
]
},
{
"id": "q_round_shoulder",
"text": "Does the patient have a visibly round-shouldered or slumped posture \u2014 with the shoulders rolling forward?",
"sublabel": "Forward head posture, dropped shoulders, flat chest appearance \u2014 the patient cannot stand fully upright without effort",
"type": "binary",
"answers": [
{
"id": "yes",
"label": "Yes \u2014 clearly round-shouldered or forward-slumped posture",
"lr": {
"rhomboids": 6.0,
"trapezius_trp5": 3.0,
"serratus_anterior": 2.5,
"trapezius_trp4": 2.0,
"levator": 1.5,
"scalene": 1.5,
"iliocostalis": 1.0,
"multifidi": 0.6,
"latissimus": 0.8,
"serratus_posterior_sup": 0.6,
"infraspinatus": 0.7
}
},
{
"id": "no",
"label": "No \u2014 posture is not particularly round-shouldered",
"lr": {
"rhomboids": 0.3,
"trapezius_trp5": 0.7,
"serratus_anterior": 0.7,
"trapezius_trp4": 0.7,
"levator": 0.8,
"scalene": 0.9,
"iliocostalis": 1.1,
"multifidi": 1.2,
"latissimus": 1.1,
"serratus_posterior_sup": 1.2,
"infraspinatus": 1.1
}
}
]
},
{
"id": "q_deep_anterior_shoulder",
"text": "Is there deep ANTERIOR shoulder pain \u2014 inside the front of the shoulder joint \u2014 alongside the mid-thoracic back pain?",
"sublabel": "The patient places their hand over the front of the shoulder to indicate where it hurts most",
"type": "binary",
"answers": [
{
"id": "yes",
"label": "Yes \u2014 deep inside the front of the shoulder joint",
"lr": {
"infraspinatus": 8.0,
"scalene": 1.5,
"serratus_posterior_sup": 1.0,
"trapezius_trp4": 0.7,
"rhomboids": 0.3,
"trapezius_trp5": 0.4,
"multifidi": 0.3,
"iliocostalis": 0.3,
"serratus_anterior": 0.4,
"latissimus": 0.4,
"levator": 0.4
}
},
{
"id": "no",
"label": "No \u2014 no significant anterior shoulder component",
"lr": {
"infraspinatus": 0.2,
"scalene": 0.9,
"serratus_posterior_sup": 1.1,
"trapezius_trp4": 1.1,
"rhomboids": 1.2,
"trapezius_trp5": 1.2,
"multifidi": 1.2,
"iliocostalis": 1.2,
"serratus_anterior": 1.1,
"latissimus": 1.1,
"levator": 1.1
}
}
]
},
{
"id": "q_up_down_pattern",
"text": "Does the back pain refer UPWARD toward the shoulder or neck, AND also DOWNWARD toward the lower back or buttock \u2014 a crossing or up-and-down spread pattern?",
"sublabel": "The pain seems to travel both up and down from the mid-thoracic area, not just laterally",
"type": "binary",
"answers": [
{
"id": "yes",
"label": "Yes \u2014 pain spreads both upward and downward from the mid-back",
"lr": {
"iliocostalis": 8.0,
"multifidi": 3.0,
"scalene": 1.0,
"latissimus": 1.0,
"rhomboids": 0.4,
"trapezius_trp5": 0.5,
"trapezius_trp4": 0.4,
"serratus_anterior": 0.4,
"serratus_posterior_sup": 0.5,
"infraspinatus": 0.4,
"levator": 0.4
}
},
{
"id": "no",
"label": "No \u2014 pain is localised to the mid-thoracic region without this vertical spread",
"lr": {
"iliocostalis": 0.25,
"multifidi": 0.7,
"scalene": 1.0,
"latissimus": 1.1,
"rhomboids": 1.2,
"trapezius_trp5": 1.2,
"trapezius_trp4": 1.2,
"serratus_anterior": 1.2,
"serratus_posterior_sup": 1.1,
"infraspinatus": 1.2,
"levator": 1.2
}
}
]
},
{
"id": "q_trp_location",
"text": "Can the patient point to a specific accessible tender spot on the chest wall or axilla that reproduces the back pain \u2014 pressing it makes the interscapular pain flare?",
"sublabel": "A localised anterior or lateral chest wall tender point that when pressed reproduces the posterior pain",
"type": "binary",
"answers": [
{
"id": "yes",
"label": "Yes \u2014 pressing an anterior or lateral chest wall point reproduces the posterior back pain",
"lr": {
"serratus_anterior": 10.0,
"iliocostalis": 2.0,
"scalene": 1.5,
"serratus_posterior_sup": 1.0,
"rhomboids": 0.5,
"trapezius_trp5": 0.5,
"trapezius_trp4": 0.4,
"multifidi": 0.3,
"latissimus": 0.5,
"infraspinatus": 0.4,
"levator": 0.3
}
},
{
"id": "no",
"label": "No \u2014 no anterior chest wall point reproduces the back pain",
"lr": {
"serratus_anterior": 0.15,
"iliocostalis": 0.9,
"scalene": 0.9,
"serratus_posterior_sup": 1.1,
"rhomboids": 1.2,
"trapezius_trp5": 1.2,
"trapezius_trp4": 1.2,
"multifidi": 1.3,
"latissimus": 1.1,
"infraspinatus": 1.2,
"levator": 1.2
}
}
]
}
],
"pairwise": [
{
"id": "pw_rhomboids_trapezius_trp4",
"pair": ["rhomboids", "trapezius_trp4"],
"text": "Tiebreaker \u2014 Rhomboids vs Trapezius TrP4",
"question": "Is the pain clearly worse with sustained sitting or forward posture, OR is it present equally at rest regardless of posture?",
"answers": [
{
"id": "postural",
"label": "Clearly worse with sustained sitting or forward posture",
"lr": {
"trapezius_trp4": 3.5,
"rhomboids": 0.3
}
},
{
"id": "rest",
"label": "Present at rest \u2014 not clearly worse with posture",
"lr": {
"trapezius_trp4": 0.3,
"rhomboids": 3.5
}
}
]
},
{
"id": "pw_trapezius5_serratus_anterior",
"pair": ["trapezius_trp5", "serratus_anterior"],
"text": "Tiebreaker \u2014 Trapezius TrP5 vs Serratus Anterior",
"question": "Is there a tender point on the anterior or lateral chest wall (midaxillary line, rib 5\u20136) that reproduces the interscapular pain when pressed?",
"answers": [
{
"id": "anterior_trp_present",
"label": "Yes \u2014 pressing the anterolateral chest wall reproduces the posterior pain",
"lr": {
"trapezius_trp5": 0.2,
"serratus_anterior": 5.0
}
},
{
"id": "no_anterior_trp",
"label": "No \u2014 no anterior chest wall point reproduces the back pain",
"lr": {
"trapezius_trp5": 4.0,
"serratus_anterior": 0.25
}
}
]
},
{
"id": "pw_scalene_serratus_posterior",
"pair": ["scalene", "serratus_posterior_sup"],
"text": "Tiebreaker \u2014 Scalene vs Serratus Posterior Superior",
"question": "Is nocturnal arm aching (requiring the arm to hang over the bed) the dominant feature, OR is deep inaccessible scapular pain the dominant feature?",
"answers": [
{
"id": "nocturnal_arm",
"label": "Nocturnal arm aching \u2014 must hang arm over bed for relief",
"lr": {
"scalene": 5.0,
"serratus_posterior_sup": 0.3
}
},
{
"id": "deep_inaccessible",
"label": "Deep under the scapula, inaccessible \u2014 cannot touch it",
"lr": {
"scalene": 0.3,
"serratus_posterior_sup": 5.0
}
}
]
},
{
"id": "pw_iliocostalis_multifidi",
"pair": ["iliocostalis", "multifidi"],
"text": "Tiebreaker \u2014 Iliocostalis Thoracis vs Multifidi",
"question": "Does the pain spread both upward and downward from the mid-back, OR is it a strictly localised deep ache immediately beside the spine?",
"answers": [
{
"id": "up_down_spread",
"label": "Spreads upward and downward \u2014 a vertical referral pattern",
"lr": {
"iliocostalis": 5.0,
"multifidi": 0.3
}
},
{
"id": "localised_paraspinal",
"label": "Localised deep ache immediately beside the spine \u2014 within 2\u20133 cm of midline",
"lr": {
"iliocostalis": 0.3,
"multifidi": 5.0
}
}
]
},
{
"id": "pw_infraspinatus_trapezius_trp4",
"pair": ["infraspinatus", "trapezius_trp4"],
"text": "Tiebreaker \u2014 Infraspinatus vs Trapezius TrP4",
"question": "Is there deep anterior shoulder joint pain as the primary complaint, OR is the burning along the medial scapular border the primary complaint without anterior shoulder pain?",
"answers": [
{
"id": "anterior_shoulder_primary",
"label": "Deep inside the front of the shoulder \u2014 the primary pain",
"lr": {
"infraspinatus": 5.0,
"trapezius_trp4": 0.2
}
},
{
"id": "medial_border_primary",
"label": "Burning along the medial scapular border \u2014 no significant anterior shoulder pain",
"lr": {
"infraspinatus": 0.2,
"trapezius_trp4": 5.0
}
}
]
},
{
"id": "pw_latissimus_iliocostalis",
"pair": ["latissimus", "iliocostalis"],
"text": "Tiebreaker \u2014 Latissimus Dorsi vs Iliocostalis Thoracis",
"question": "Is the pain centred at the inferior scapular angle or mid-back with ulnar hand referral, OR does it include an anterior chest component?",
"answers": [
{
"id": "inferior_scapula_ulnar",
"label": "Inferior scapular angle or mid-back; possibly ulnar hand \u2014 no anterior chest component",
"lr": {
"latissimus": 4.0,
"iliocostalis": 0.3
}
},
{
"id": "anterior_chest_component",
"label": "Anterior chest pain is part of the presentation",
"lr": {
"latissimus": 0.3,
"iliocostalis": 4.0
}
}
]
},
{
"id": "pw_levator_scalene",
"pair": ["levator", "scalene"],
"text": "Tiebreaker \u2014 Levator Scapulae vs Scalene",
"question": "Is cervical rotation toward the painful side the dominant restriction, OR are arm or hand symptoms the dominant associated feature?",
"answers": [
{
"id": "neck_rotation_dominant",
"label": "Cervical rotation is the dominant restriction \u2014 cannot look over the sore shoulder",
"lr": {
"levator": 4.0,
"scalene": 0.3
}
},
{
"id": "arm_hand_dominant",
"label": "Arm or hand symptoms dominate \u2014 numbness, tingling, or nocturnal aching",
"lr": {
"levator": 0.3,
"scalene": 4.0
}
}
]
}
],
"treatment_dag": {
"edges": [
{
"from": "latissimus",
"to": "iliocostalis",
"type": "key_satellite",
"label": "Latissimus dorsi TrPs drive iliocostalis thoracis satellite TrPs \u2014 treat latissimus before iliocostalis"
},
{
"from": "scalene",
"to": "serratus_posterior_sup",
"type": "key_satellite",
"label": "Scalene TrPs are the key driver of serratus posterior superior satellite TrPs \u2014 always examine the neck"
},
{
"from": "scalene",
"to": "trapezius_trp5",
"type": "key_satellite",
"label": "Scalene TrPs drive mid-trapezius satellite TrPs"
},
{
"from": "scalene",
"to": "levator",
"type": "secondary_load",
"label": "Levator scapulae overloaded secondarily when scaleni are in protective splinting"
},
{
"from": "rhomboids",
"to": "trapezius_trp4",
"type": "functional_unit",
"label": "Rhomboids and mid-trapezius share scapular retraction and mid-thoracic stabilisation \u2014 treat in the same session"
},
{
"from": "rhomboids",
"to": "trapezius_trp5",
"type": "functional_unit",
"label": "Rhomboids and mid-trapezius share scapular retraction function \u2014 treat concurrently"
},
{
"from": "serratus_anterior",
"to": "rhomboids",
"type": "secondary_load",
"label": "Serratus anterior TrPs abduct the scapula, overloading the rhomboids under sustained stretch \u2014 treat serratus anterior first"
},
{
"from": "serratus_anterior",
"to": "scalene",
"type": "secondary_load",
"label": "Scalene muscles become overloaded secondarily to serratus anterior TrPs (shared accessory inspiratory role)"
},
{
"from": "infraspinatus",
"to": "trapezius_trp4",
"type": "key_satellite",
"label": "Infraspinatus vertebral border trigger area refers into the interscapular rhomboid zone \u2014 treat infraspinatus before attributing persistent medial border pain to trapezius TrP4 alone"
},
{
"from": "multifidi",
"to": "trapezius_trp5",
"type": "functional_unit",
"label": "Multifidi and mid-trapezius share thoracic stabilisation function \u2014 treat concurrently"
},
{
"from": "latissimus",
"to": "rhomboids",
"type": "secondary_load",
"label": "Latissimus dorsi shortening pulls the inferior scapular angle downward, overloading rhomboids \u2014 treat latissimus first"
}
],
"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"
}
}
}