DiagnosticTree/BackofNeck
{
"tree_id": "back-of-neck-pain", "region": "Back-of-Neck Pain", "start": "agg-1",
"redflags": {
"emergency": [
{
"id": "rf-e1",
"label": "Cervical myelopathy",
"question": "Is there neck pain with bilateral arm or leg weakness, gait disturbance, loss of hand dexterity, or bowel/bladder dysfunction?",
"rationale": "Cervical cord compression from stenosis, disc prolapse, or instability can present as posterior neck pain with upper or lower motor neuron signs. Urgent imaging is required.",
"action": "Emergency medical referral. MRI cervical spine urgently."
},
{
"id": "rf-e2",
"label": "Acute cervical disc prolapse with radiculopathy",
"question": "Is there neck pain radiating into the arm in a dermatomal pattern, with associated arm weakness, reflex loss, or paraesthesia?",
"rationale": "Acute disc prolapse with nerve root compression requires urgent assessment. Significant neurological deficit (weakness, reflex loss) warrants urgent imaging.",
"action": "Urgent neurology or spinal surgery referral. MRI cervical spine."
},
{
"id": "rf-e3",
"label": "Meningism or posterior fossa pathology",
"question": "Is there neck pain and stiffness with fever, photophobia, or cerebellar signs (ataxia, dysarthria, nystagmus)?",
"rationale": "True meningism and posterior fossa pathology can present with posterior neck pain and stiffness. Distinguish from myofascial restricted range by the presence of systemic or neurological signs.",
"action": "Call emergency services immediately."
}
],
"urgent": [
{
"id": "rf-u1",
"label": "Cervical instability",
"question": "Is there a history of significant trauma to the head or neck combined with upper limb symptoms, gait disturbance, or neck pain dramatically worsened by specific positions?",
"rationale": "Odontoid fracture or atlantoaxial instability can present as posterior neck pain. Manual therapy is contraindicated until cleared.",
"action": "Urgent spinal assessment — no manual therapy until cleared. Flexion/extension radiographs or MRI."
},
{
"id": "rf-u2",
"label": "Inflammatory arthropathy",
"question": "Is there bilateral posterior neck stiffness that is WORSE in the morning and improves with movement, with associated peripheral joint swelling or systemic symptoms?",
"rationale": "Rheumatoid arthritis, ankylosing spondylitis, and other inflammatory arthropathies affect the cervical spine and present as morning stiffness. C1/C2 instability in RA is a specific risk.",
"action": "Urgent rheumatology referral. Imaging of the cervical spine including the upper cervical region."
},
{
"id": "rf-u3",
"label": "Vertebral artery dissection",
"question": "Is there sudden-onset neck pain following trauma or manipulation, with ipsilateral face or head pain, dizziness, visual changes, or other posterior circulation symptoms?",
"rationale": "Vertebral artery dissection can occur spontaneously or after manipulation and presents as sudden posterior neck pain often with brainstem or cerebellar symptoms.",
"action": "Emergency medical referral. MRI/MRA cervical vessels urgently. No cervical manipulation."
}
]
},
"nodes": {
"agg-1": {
"type": "choice",
"question": "Where is the back-of-neck pain primarily located, and which direction does it extend?",
"clinical_rationale": "Five muscles contribute to back-of-neck pain. They separate naturally by location and direction of referral. Angle-of-neck and posterolateral pain (upper trapezius TrP₁, levator scapulae, splenius cervicis) extends from the posterior-lateral neck toward the occiput or shoulder. Posterior midline and base-of-skull pain (upper trapezius TrP₂, cervical multifidi) is located centrally at the posterior neck midline or suboccipital. Scapular border and shoulder-connected pain (upper trapezius TrP₃, infraspinatus spillover) extends from the posterior neck toward the upper scapular border or into the shoulder. This spatial first split routes efficiently without premature diagnostic commitment.",
"options": [
{
"label": "Angle-of-neck or posterolateral — pain at the side of the neck, angle between neck and shoulder, or sweeping up to the occiput",
"sublabel": "Lateral posterior neck; may restrict rotation; shoulder loading or head tilt may aggravate",
"next": "angle-neck-split-1"
},
{
"label": "Posterior midline or base of skull — pain along or near the midline of the posterior neck, or burning at the base of the skull",
"sublabel": "Central posterior neck; possibly bilateral; spinous process region; may have burning quality",
"next": "midline-split-1"
},
{
"label": "Upper scapular border or shoulder connection — pain at the posterior neck extending toward or from the scapular border or shoulder",
"sublabel": "Pain extends toward the top of the scapula or upper back; shoulder movement or scapular winging may be present",
"next": "scapular-split-1"
}
]
},
"angle-neck-split-1": {
"type": "symptom",
"question": "Is cervical rotation to the SAME side as the pain severely restricted — the patient cannot look over their shoulder on the painful side without significant pain or block?",
"symptom_name": "Ipsilateral rotation restriction — stiff neck",
"muscles_implicated": ["Levator Scapulae", "Splenius Cervicis"],
"muscles_excluded": ["Upper Trapezius TrP₁"],
"clinical_rationale": "Levator scapulae TrPs produce the classic stiff neck presentation — markedly restricted rotation to the IPSILATERAL side (cannot turn toward the pain side). This is the defining functional sign and distinguishes levator scapulae from upper trapezius TrP₁, whose primary restriction is rotation AWAY from the TrP side with side-bending away restricted. Splenius cervicis also restricts ipsilateral rotation but adds the specific feature of near-vision blurring. If ipsilateral rotation is primarily restricted, the key differential is levator scapulae vs splenius cervicis.",
"yes": "near-vision-split-1",
"no": "exam-trapezius-trp1-1"
},
"near-vision-split-1": {
"type": "symptom",
"question": "Is there ipsilateral blurring of NEAR vision — transient difficulty focusing on close objects on the same side as the neck pain — alongside the restricted rotation?",
"symptom_name": "Ipsilateral near-vision blurring",
"muscles_implicated": ["Splenius Cervicis"],
"muscles_excluded": ["Levator Scapulae"],
"clinical_rationale": "Near-vision blurring is pathognomonic for splenius cervicis and is not produced by levator scapulae or any other muscle in the back-of-neck group. Its presence makes splenius cervicis the leading candidate. Its absence in the presence of stiff neck (ipsilateral rotation restriction) routes directly to levator scapulae — the most common cause of acute stiff neck in clinical practice.",
"yes": "exam-splenius-cervicis-1",
"no": "exam-levator-scapulae-1"
},
"exam-levator-scapulae-1": {
"type": "examination",
"question": "Does palpation of the levator scapulae — at its central TrP near the angle of the neck (C3–C4 level posterolaterally), and at its lower attachment TrP at the superior angle of the scapula — reproduce the angle-of-neck pain with radiation toward the vertebral scapular border?",
"exam_type": "palpation",
"landmark": "Central (upper) TrP: palpate at the posterior-lateral neck, approximately at C3–C4 level, just medial to the leading edge of the SCM — the levator scapulae is accessible here between the SCM and the trapezius. Attachment (lower) TrP: palpate at the superior angle of the scapula, pressing firmly into the superior angle. Mouth Wrap-around Test: ask the patient to reach the hand of the uninvolved side over the head and touch the opposite cheek — if they cannot reach the cheek due to neck restriction from the uninvolved side, the test is positive for levator scapulae involvement. Rotation test: confirm that ipsilateral rotation (looking toward the pain side) is the most restricted movement.",
"positive_finding": "Angle-of-neck and upper scapular border pain reproduced. Ipsilateral rotation restricted. Mouth Wrap-around Test may be positive.",
"muscles_implicated": ["Levator Scapulae"],
"yes": "result-levator-scapulae",
"no": "exam-trapezius-trp1-1"
},
"exam-splenius-cervicis-1": {
"type": "examination",
"question": "Does deep palpation through the trapezius at the C1–C3 level — approximately 3–4 cm lateral to the midline — reproduce the neck angle pain and near-vision blurring? Is ipsilateral cervical rotation restricted?",
"exam_type": "palpation",
"landmark": "The splenius cervicis lies beneath the trapezius and is not directly accessible from behind. Press firmly through the trapezius at C1–C3, 3–4 cm lateral to the midline. The upper TrP produces the intracranial and orbital referral with near-vision blurring; the lower TrP at approximately C3–C6 level (more lateral) produces pain at the angle of the neck and upper shoulder rather than intracranial pain. Rotation restriction toward the involved side is consistent. The muscle typically becomes accessible only after levator scapulae and upper trapezius TrPs have been inactivated.",
"positive_finding": "Deep palpation reproduces neck angle pain or near-vision blurring. Ipsilateral cervical rotation restricted.",
"muscles_implicated": ["Splenius Cervicis"],
"yes": "result-splenius-cervicis",
"no": "exam-levator-scapulae-1"
},
"exam-trapezius-trp1-1": {
"type": "examination",
"question": "Does pincer palpation of upper trapezius TrP₁ — at the most vertical midportion of the anterior border of the upper trapezius — reproduce the posterolateral neck or occiput pain?",
"exam_type": "palpation",
"landmark": "TrP₁ is at the midportion of the anterior border of the upper trapezius in the most vertical fibres. Grasp with a firm pincer grip — the TrP often produces a local twitch response. TrP₁ refers upward along the posterolateral neck to the mastoid process and over the temple. Note: ipsilateral head tilt (ear toward the TrP shoulder) is a consistent postural sign. Confirm that shoulder carrying on the same side or neck elevation reproduces or worsens the posterolateral neck pain. Also check whether rotation AWAY from the TrP side (and side-bending away) is the most restricted movement.",
"positive_finding": "Posterolateral neck-to-occiput pain reproduced by TrP₁ pincer palpation. Ipsilateral head tilt. Shoulder loading aggravates.",
"muscles_implicated": ["Upper Trapezius (TrP₁)"],
"yes": "result-trapezius-trp1",
"no": "midline-split-1"
},
"midline-split-1": {
"type": "symptom",
"question": "Is there a BURNING quality to the posterior neck pain — specifically a burning or hot sensation at the base of the skull or posterior neck, possibly with referred pain to the top of the head?",
"symptom_name": "Burning posterior neck pain — base of skull",
"muscles_implicated": ["Upper Trapezius (TrP₂)"],
"muscles_excluded": ["Cervical Multifidi"],
"clinical_rationale": "Trapezius TrP₂ is the only muscle in the back-of-neck group that produces a burning quality of pain. It refers a burning sensation to the back of the neck and the posterior base of the skull and occipital region, and sometimes forward to the top of the head. This burning quality is the cardinal separator from multifidi, which produce a deep aching spinous-process-centred pain with associated midline tenderness on percussion but without the burning quality.",
"yes": "exam-trapezius-trp2-1",
"no": "exam-multifidi-1"
},
"exam-trapezius-trp2-1": {
"type": "examination",
"question": "Does deep palpation at TrP₂ — in the posterior cervical region near the midline at the cervicothoracic junction, at the junction of the trapezius and cervical paraspinals — reproduce the burning posterior neck pain or base-of-skull referral?",
"exam_type": "palpation",
"landmark": "TrP₂ is located in the posterior paraspinal area adjacent to the midline at approximately the C7/T1 level in the upper trapezius fibres overlying the posterior cervical paraspinals. Palpate with flat or deep pressure bilaterally — TrP₂ is typically bilateral and produces a bilateral burning sensation at the posterior neck and base of skull. The pain may spread upward toward the occiput or vertex. Distinguish from multifidi by the burning quality and the mid-to-upper trapezius fibre location (rather than the deep spinous process adjacent zone of multifidi).",
"positive_finding": "Deep palpation reproduces burning posterior neck pain or base-of-skull burning referral. Pattern is often bilateral.",
"muscles_implicated": ["Upper Trapezius (TrP₂)"],
"yes": "result-trapezius-trp2",
"no": "exam-multifidi-1"
},
"exam-multifidi-1": {
"type": "examination",
"question": "Does systematic percussion or deep palpation of each cervical spinous process in succession reveal a specific MIDLINE spinous process that is focally tender and whose tenderness disappears after local TrP inactivation? Is there associated cervical zygapophyseal joint stiffness?",
"exam_type": "palpation",
"landmark": "Spinous process tap test: use a finger or reflex hammer to tap each cervical spinous process in succession from C2 downward — a focally tender spinous process (distinct from generalised tenderness) identifies the segment of multifidus involvement. The tender spinous process corresponds to the vertebral level adjacent to the active TrP. Deep palpation 1–2 cm lateral to the spinous process at the same level confirms the multifidus belly TrP. Zygapophyseal joint screen: accessory movement testing at the identified segment — multifidus TrPs are closely associated with segmental articular dysfunction at the same level.",
"positive_finding": "Focal spinous process tenderness at a specific level reproducing the local neck pain. Deep palpation adjacent to that spinous process confirms multifidus belly TrP. Tenderness resolves after TrP inactivation.",
"muscles_implicated": ["Cervical Multifidi"],
"yes": "result-multifidi",
"no": "scapular-split-1"
},
"scapular-split-1": {
"type": "symptom",
"question": "Is there ANTERIOR shoulder pain — deeply inside the front of the shoulder joint — in addition to the posterior neck or upper scapular border pain?",
"symptom_name": "Anterior shoulder joint pain — deep inside the shoulder",
"muscles_implicated": ["Infraspinatus"],
"muscles_excluded": ["Upper Trapezius (TrP₃)"],
"clinical_rationale": "Infraspinatus TrPs produce anterior shoulder joint pain as their ESSENTIAL pattern — the patient characteristically covers the front of the shoulder with their hand to indicate the pain location. In 14% of patients there is spillover to the suboccipital and upper posterior cervical region that brings infraspinatus into the back-of-neck differential. The presence of anterior shoulder joint pain alongside posterior neck or scapular border pain is the key feature identifying infraspinatus. Its absence routes to trapezius TrP₃, which produces scapular border pain and posterior neck pain without the anterior shoulder component.",
"yes": "exam-infraspinatus-1",
"no": "exam-trapezius-trp3-1"
},
"exam-trapezius-trp3-1": {
"type": "examination",
"question": "Does deep palpation at trapezius TrP₃ — in the upper trapezius fibres toward the acromion, or within the muscle belly in the lateral shoulder girdle — reproduce the posterior neck and upper scapular border pain?",
"exam_type": "palpation",
"landmark": "TrP₃ is more lateral in the upper trapezius fibres toward the acromion. Palpate with deep flat pressure in the muscle belly between the base of the neck and the acromion. TrP₃ refers pain to the upper scapular border, the posterior neck laterally, and sometimes toward the mastoid or vertex. It is less specific than TrP₁ and TrP₂ and often coexists with them. Distinguish from levator scapulae by the more lateral muscle location and the less restricted ipsilateral rotation.",
"positive_finding": "Posterior neck and upper scapular border pain reproduced by TrP₃ palpation. Less ipsilateral rotation restriction than levator scapulae.",
"muscles_implicated": ["Upper Trapezius (TrP₃)"],
"yes": "result-trapezius-trp3",
"no": "exam-infraspinatus-1"
},
"exam-infraspinatus-1": {
"type": "examination",
"question": "Does deep flat palpation of the infraspinatus — in the infraspinous fossa of the scapula below the spine of the scapula — reproduce the anterior shoulder pain AND the posterior cervical or suboccipital component? Is reaching behind the back (internal rotation) restricted or painful?",
"exam_type": "palpation",
"landmark": "Palpate firmly in the infraspinous fossa below the spine of the scapula. The TrPs are typically found in the medial two-thirds of the fossa. Ask the patient to indicate where the pain is referred — the essential referral is to the FRONT of the shoulder joint (the patient points to the anterior deltoid or puts a hand over the front of the shoulder). A separate trigger area near the vertebral border of the scapula may refer to the interscapular rhomboid region. Reaching behind the back test: ask the patient to reach the back of the hand up the spine toward the opposite shoulder blade — restriction of internal rotation and posterior reach is consistent with infraspinatus TrPs.",
"positive_finding": "Infraspinous fossa palpation reproduces anterior shoulder pain. Posterior cervical or suboccipital referral confirmed. Reaching behind the back restricted.",
"muscles_implicated": ["Infraspinatus"],
"yes": "result-infraspinatus",
"no": "result-overlap"
},
"result-levator-scapulae": {
"type": "result",
"diagnosis": "Levator Scapulae Trigger Point — Stiff Neck",
"confidence": "high",
"wiki_page": "Muscle:Levator_Scapulae",
"chapter_ref": "Travell & Simons Vol.1 — Ch.19 Levator Scapulae",
"notes": "Levator scapulae TrPs are responsible for the classic stiff neck presentation — markedly restricted rotation to the IPSILATERAL side with essential pain at the angle of the neck and along the vertebral border of the scapula. The angle-of-neck pain is distinct from the more posterolateral pattern of upper trapezius TrP₁. It is one of the first muscles to become vulnerable during respiratory infections, motor vehicle accidents, and occupational postural strain. Bursae between the two insertion layers at the superior scapular angle are present in approximately 38% of subjects and can perpetuate pain independently of TrP activity. The levator scapulae is the second most common muscle producing referred shoulder pain in clinical series (after infraspinatus) and is the most common source of scapulocostal syndrome.",
"treatment_hint": "Spray and stretch with contralateral side-bending, rotation away, and chin tuck. Central TrP injection at C3–C4 posterolateral neck. Attachment TrP at superior scapular angle. Address phone cradling, sustained elevation postures, and armrest height. Treat upper trapezius concurrently — these two muscles frequently co-activate.",
"also_consider": ["Upper Trapezius (synergist)", "Splenius Cervicis", "SCM", "Scalene muscles"],
"less_likely": [
{ "muscle": "Splenius Cervicis", "reason": "No near-vision blurring — ipsilateral rotation restriction with angle-of-neck pain and no visual symptoms argues for levator scapulae" },
{ "muscle": "Upper Trapezius TrP₁", "reason": "Ipsilateral rotation restricted — trapezius TrP₁ restricts rotation AWAY and side-bending away; levator scapulae restricts rotation TOWARD the pain side" },
{ "muscle": "Cervical Multifidi", "reason": "Angle-of-neck with stiff neck pattern is distinct from the spinous process midline tenderness of multifidi" }
],
"confirmatory": [
"Markedly restricted ipsilateral rotation — cannot turn toward the pain side; the defining sign of stiff neck from levator scapulae",
"Essential pain at the angle of the neck and along the vertebral border of the scapula",
"Mouth Wrap-around Test positive — cannot reach opposite cheek due to neck restriction",
"Central TrP tenderness at C3–C4 posterolateral neck and attachment TrP at superior scapular angle",
"History of recent respiratory infection, MVC, sustained elevation posture, or phone cradling"
],
"satellite_trps": ["Upper Trapezius", "Rhomboids", "Splenius Cervicis", "SCM"],
"landing_page_topics": [
"Stiff neck — ipsilateral vs contralateral rotation restriction (levator vs upper trapezius distinction)",
"Mouth Wrap-around Test and Hand-to-Shoulder-Blade Test",
"Bursae at the superior scapular angle — perpetuating factor",
"Scapulocostal syndrome",
"C4–C5 zygapophyseal joint differential",
"Occupational perpetuating factors — phone cradling, armrest height, sustained elevation"
],
"related_pages": [
{ "label": "Upper Trapezius TrPs →", "page": "Muscle:Trapezius/Upper" },
{ "label": "Splenius Cervicis TrP →", "page": "Muscle:Splenius_Cervicis" },
{ "label": "Scalene TrPs →", "page": "Muscle:Scalene" }
]
},
"result-splenius-cervicis": {
"type": "result",
"diagnosis": "Splenius Cervicis Trigger Point",
"confidence": "high",
"wiki_page": "Muscle:Splenius_Cervicis",
"chapter_ref": "Travell & Simons Vol.1 — Ch.15 Splenius Cervicis",
"notes": "The lower TrP of the splenius cervicis refers pain to the angle of the neck and upper shoulder — the back-of-neck component in this algorithm. The upper TrP refers diffusely through the inside of the head to the back of the eye, with the pathognomonic feature of ipsilateral near-vision blurring. Both TrPs restrict cervical rotation toward the involved side. The muscle lies beneath the trapezius and levator scapulae and is often only accessible after those overlying muscles have been treated. Sustained ipsilateral rotation postures (monitor to one side, overhead work) and chilling of the exposed posterior neck are the primary perpetuating factors.",
"treatment_hint": "Treat levator scapulae and upper trapezius first — splenius cervicis is often their satellite and may resolve without direct treatment. Spray and stretch with contralateral rotation and slight flexion. Correct sustained ipsilateral rotation postures.",
"also_consider": ["Upper Trapezius (key TrP)", "Levator Scapulae (key TrP)", "Splenius Capitis", "Suboccipital Group"],
"less_likely": [
{ "muscle": "Levator Scapulae", "reason": "Near-vision blurring is pathognomonic for splenius cervicis; levator scapulae produces stiff neck without visual symptoms" },
{ "muscle": "Upper Trapezius TrP₁", "reason": "Near-vision blurring and intracranial referral distinguish splenius cervicis from trapezius" },
{ "muscle": "Cervical Multifidi", "reason": "Rotation restriction and visual symptoms argue for splenius cervicis; multifidi produce midline spinous process tenderness" }
],
"confirmatory": [
"Ipsilateral near-vision blurring — pathognomonic for splenius cervicis upper TrP",
"Ipsilateral cervical rotation restricted — consistent with splenius cervicis involvement",
"Deep palpation through trapezius at C1–C3 reproduces neck angle or intracranial pain",
"Lower TrP: neck angle and upper shoulder pain; upper TrP: intracranial and orbital referral",
"Becomes accessible after levator scapulae and upper trapezius TrPs treated"
],
"satellite_trps": ["Suboccipital Group", "Splenius Capitis", "Levator Scapulae (key TrP)"],
"landing_page_topics": [
"Near-vision blurring mechanism and clinical significance",
"Upper TrP (orbital/intracranial) vs lower TrP (angle of neck) patterns",
"Palpation through trapezius technique",
"Sustained ipsilateral rotation — workstation and driving correction"
],
"related_pages": [
{ "label": "Levator Scapulae TrP →", "page": "Muscle:Levator_Scapulae" },
{ "label": "Splenius Capitis TrP →", "page": "Muscle:Splenius_Capitis" }
]
},
"result-trapezius-trp1": {
"type": "result",
"diagnosis": "Upper Trapezius TrP₁ — Posterolateral Neck Referral",
"confidence": "high",
"wiki_page": "Muscle:Trapezius",
"chapter_ref": "Travell & Simons Vol.1 — Ch.6 Trapezius",
"notes": "TrP₁ at the anterior border of the upper trapezius is the most frequently identified myofascial TrP in the entire body. It refers pain upward along the posterolateral neck to the mastoid and at higher intensity over the temple and back of the orbit. Ipsilateral head tilt — the ear drawn toward the shoulder on the TrP side — is the consistent postural sign. Shoulder loading (carrying a bag on the same side) is the most common daily perpetuating factor. Upper trapezius TrP₁ is a key TrP that drives temporalis, SCM, and semispinalis capitis as satellites.",
"treatment_hint": "Pincer palpation and spray and stretch with side-bending away and contralateral rotation. Correct shoulder elevation — ipsilateral bag or purse is the dominant perpetuating factor. Treat levator scapulae concurrently if present.",
"also_consider": ["Levator Scapulae", "SCM", "Temporalis (satellite)", "Semispinalis Capitis (satellite)"],
"less_likely": [
{ "muscle": "Levator Scapulae", "reason": "Restriction is rotation AWAY from TrP side (not toward) — shoulder loading as primary aggravator; head tilt toward TrP side distinguishes from stiff neck" },
{ "muscle": "Splenius Cervicis", "reason": "No near-vision blurring; shoulder loading distinguishes trapezius from splenius cervicis" },
{ "muscle": "Cervical Multifidi", "reason": "Posterolateral referral to mastoid is distinct from the midline spinous process pattern of multifidi" }
],
"confirmatory": [
"TrP₁ at anterior border of upper trapezius reproduces posterolateral neck pain",
"Ipsilateral head tilt — ear toward TrP shoulder",
"Shoulder carrying on same side worsens the posterolateral neck pain",
"Rotation AWAY from TrP side is restricted — distinguishes from levator scapulae ipsilateral restriction"
],
"satellite_trps": ["Temporalis", "SCM", "Semispinalis Capitis", "Levator Scapulae"],
"landing_page_topics": [
"TrP₁ through TrP₇ — full referral catalogue",
"TrP₁ vs levator scapulae — ipsilateral vs contralateral rotation restriction distinction",
"Shoulder carry and workstation correction",
"Satellite relationship with temporalis and SCM"
],
"related_pages": [
{ "label": "Levator Scapulae TrP →", "page": "Muscle:Levator_Scapulae" },
{ "label": "SCM TrP →", "page": "Muscle:Sternocleidomastoid" }
]
},
"result-trapezius-trp2": {
"type": "result",
"diagnosis": "Upper Trapezius TrP₂ — Burning Posterior Neck and Base-of-Skull Pain",
"confidence": "high",
"wiki_page": "Muscle:Trapezius",
"chapter_ref": "Travell & Simons Vol.1 — Ch.6 Trapezius",
"notes": "TrP₂ in the posterior paraspinal region of the upper trapezius refers a burning sensation to the back of the neck and the posterior base of the skull and occipital region — the burning quality is the cardinal distinguishing feature from all other muscles in this group. Pain may spread upward toward the occiput or vertex. The pattern is commonly bilateral. TrP₂ is located in a different fibre zone from TrP₁ — it is found in the posterior cervical region adjacent to the midline rather than at the anterior border of the upper trapezius. Both TrPs may be active simultaneously.",
"treatment_hint": "Spray and stretch, flat palpation, and ischemic compression at TrP₂. Address forward head posture — a consistent perpetuating factor for this TrP zone. Treat TrP₁ concurrently if present.",
"also_consider": ["Upper Trapezius TrP₁ (may coexist)", "Semispinalis Capitis", "Cervical Multifidi"],
"less_likely": [
{ "muscle": "Cervical Multifidi", "reason": "Burning quality is specific to trapezius TrP₂; multifidi produce deep aching spinous process tenderness without burning" },
{ "muscle": "Upper Trapezius TrP₁", "reason": "TrP₂ is more medial and posterior than TrP₁; burning base-of-skull pattern is distinct from posterolateral mastoid referral of TrP₁" },
{ "muscle": "Levator Scapulae", "reason": "No ipsilateral rotation restriction as primary feature; burning posterior neck quality is specific to TrP₂" }
],
"confirmatory": [
"Burning quality of posterior neck pain — distinct from the deep aching of other muscles in this group",
"Base-of-skull burning referral — may spread toward the occiput or vertex",
"Pattern is commonly bilateral",
"TrP₂ palpation in the posterior paraspinal region reproduces the burning sensation",
"TrP₁ may also be active — examine anterior border of upper trapezius as well"
],
"satellite_trps": ["Upper Trapezius TrP₁ (may coexist)", "Semispinalis Capitis"],
"landing_page_topics": [
"TrP₂ location vs TrP₁ — medial posterior vs anterior border",
"Burning quality — distinguishing feature from other posterior neck muscles",
"Bilateral presentation pattern",
"Forward head posture correction"
],
"related_pages": [
{ "label": "Trapezius full page →", "page": "Muscle:Trapezius" },
{ "label": "Semispinalis Capitis →", "page": "Muscle:Semispinalis_Capitis" }
]
},
"result-trapezius-trp3": {
"type": "result",
"diagnosis": "Upper Trapezius TrP₃ — Upper Scapular Border Referral",
"confidence": "moderate",
"wiki_page": "Muscle:Trapezius",
"chapter_ref": "Travell & Simons Vol.1 — Ch.6 Trapezius",
"notes": "TrP₃ is more lateral in the upper trapezius fibres toward the acromion. It refers pain to the upper scapular border, the posterior neck laterally, and sometimes toward the mastoid or vertex. TrP₃ often coexists with TrP₁ and TrP₂ as part of a multi-TrP upper trapezius involvement. Distinguish from levator scapulae by the more lateral muscle location, less marked ipsilateral rotation restriction, and the more prominent upper scapular border referral. Always examine TrP₁ concurrently — the two TrPs commonly co-activate.",
"treatment_hint": "Pincer palpation and spray and stretch. Address shoulder elevation and forward head posture. Treat TrP₁ concurrently.",
"also_consider": ["Upper Trapezius TrP₁ (often coexists)", "Levator Scapulae", "Rhomboids"],
"less_likely": [
{ "muscle": "Levator Scapulae", "reason": "TrP₃ location is more lateral toward the acromion; levator scapulae is more medial at the angle of the neck with marked ipsilateral rotation restriction" },
{ "muscle": "Infraspinatus", "reason": "No anterior shoulder joint pain; scapular border pain without anterior shoulder component argues for trapezius TrP₃" }
],
"confirmatory": [
"Lateral upper trapezius TrP₃ tenderness toward the acromion reproducing posterior neck and upper scapular border pain",
"Often coexists with TrP₁ — examine both",
"Less marked ipsilateral rotation restriction than levator scapulae"
],
"satellite_trps": ["Upper Trapezius TrP₁ (coexisting)", "Levator Scapulae", "Rhomboids"],
"landing_page_topics": [
"TrP₁, TrP₂, TrP₃ — relationship and co-activation",
"TrP₃ vs levator scapulae — location and rotation restriction distinction",
"Scapular winging — trapezius inhibition from TrP activity"
],
"related_pages": [
{ "label": "Trapezius full page →", "page": "Muscle:Trapezius" },
{ "label": "Levator Scapulae TrP →", "page": "Muscle:Levator_Scapulae" }
]
},
"result-multifidi": {
"type": "result",
"diagnosis": "Cervical Multifidi Trigger Points",
"confidence": "high",
"wiki_page": "Muscle:Multifidi",
"chapter_ref": "Travell & Simons Vol.1 — Ch.16 Multifidi",
"notes": "Cervical multifidi TrPs refer pain to the region around the spinous process of the vertebra adjacent to the TrP. Focal midline spinous process tenderness — identified by tapping each cervical spinous process in succession — is the defining clinical finding and disappears after inactivation of the responsible TrPs. This spinous process tap test is highly efficient: it localises the involved segment and distinguishes multifidus involvement from the more lateral and diffuse patterns of the other back-of-neck muscles. Multifidus TrPs are closely associated with segmental cervical zygapophyseal joint dysfunction at the same level — the two conditions frequently coexist and may perpetuate each other.",
"treatment_hint": "Spray and stretch in rotation and extension. Deep palpation TrP release. Address the associated segmental articular dysfunction — zygapophyseal mobilisation at the identified segment. Correct forward head posture as the primary postural perpetuating factor.",
"also_consider": ["Upper Trapezius (overlying)", "Semispinalis Capitis", "Rotatores", "Zygapophyseal Joint Dysfunction"],
"less_likely": [
{ "muscle": "Upper Trapezius TrP₂", "reason": "No burning quality; focal spinous process tenderness on tap test is specific to multifidi" },
{ "muscle": "Levator Scapulae", "reason": "Midline spinous process tenderness is distinct from the angle-of-neck pattern with ipsilateral rotation restriction" },
{ "muscle": "Splenius Cervicis", "reason": "No near-vision blurring; midline segmental tenderness argues for multifidi" }
],
"confirmatory": [
"Spinous process tap test positive — focal tenderness at a specific cervical spinous process level, distinct from general tenderness",
"Deep palpation 1–2 cm lateral to the tender spinous process confirms the multifidus belly TrP",
"Spinous process tenderness disappears after TrP inactivation — confirms myofascial origin",
"Associated zygapophyseal joint stiffness at the same segmental level",
"No burning quality — distinguishes from upper trapezius TrP₂"
],
"satellite_trps": ["Rotatores", "Semispinalis Cervicis", "Upper Trapezius (overlying)"],
"landing_page_topics": [
"Spinous process tap test — technique and interpretation",
"Segmental specificity — unisegmental innervation and articular association",
"Cervical vs lumbar multifidi — different clinical presentations",
"Zygapophyseal joint dysfunction relationship",
"Deep paraspinal TrP identification technique"
],
"related_pages": [
{ "label": "Trapezius TrPs →", "page": "Muscle:Trapezius" },
{ "label": "Semispinalis Capitis →", "page": "Muscle:Semispinalis_Capitis" }
]
},
"result-infraspinatus": {
"type": "result",
"diagnosis": "Infraspinatus Trigger Point — Posterior Cervical Spillover",
"confidence": "moderate",
"wiki_page": "Muscle:Infraspinatus",
"chapter_ref": "Travell & Simons Vol.1 — Ch.22 Infraspinatus",
"notes": "Infraspinatus is primarily the 'Shoulder Joint Pain' muscle — its essential referral is deep inside the anterior shoulder joint, producing pain that the patient characteristically indicates by placing a hand over the front of the shoulder. In 14% of patients there is spillover to the suboccipital and upper posterior cervical region that brings infraspinatus into the back-of-neck differential. The posterior cervical component should never be treated in isolation — the infraspinous fossa TrPs must be identified and treated. Reaching behind the back (internal rotation — putting the back of the hand up the spine) is characteristically restricted and painful. Suprascapular nerve entrapment is a differential that must be excluded when shoulder weakness is prominent.",
"treatment_hint": "Spray and stretch with arm in internal rotation and adduction across the body. Self-stretch: patient lies on unaffected side with painful arm across the body. Do not sleep on the affected side — pressure on the infraspinous fossa activates TrPs. Address overhead reaching habits.",
"also_consider": ["Suprascapular Nerve Entrapment (exclusion)", "Upper Trapezius TrP₃", "Teres Minor", "Posterior Deltoid"],
"less_likely": [
{ "muscle": "Upper Trapezius TrP₃", "reason": "Anterior shoulder joint pain is the essential pattern of infraspinatus — not present with trapezius TrP₃" },
{ "muscle": "Levator Scapulae", "reason": "Posterior cervical spillover is secondary — anterior shoulder pain is the primary complaint for infraspinatus" },
{ "muscle": "Cervical Multifidi", "reason": "Anterior shoulder joint pain and posterior reach restriction are specific to infraspinatus" }
],
"confirmatory": [
"Anterior shoulder joint pain — patient places hand over the front of the shoulder to indicate the most painful area; this is the essential referral",
"Infraspinous fossa palpation reproduces anterior shoulder pain and posterior cervical spillover",
"Posterior reach restricted — cannot place back of hand up the spine toward the shoulder blade",
"Posterior cervical component is spillover (14% of patients) — always treat the infraspinous fossa TrPs, not just the neck"
],
"satellite_trps": ["Teres Minor", "Posterior Deltoid", "Upper Trapezius", "Biceps Brachii"],
"landing_page_topics": [
"Anterior shoulder joint pain — the essential pattern of infraspinatus",
"14% posterior cervical spillover — recognition and treatment sequence",
"Suprascapular nerve entrapment exclusion",
"Sleep positioning — do not sleep on affected side",
"Mouth Wrap-around Test and Hand-to-Shoulder-Blade Test",
"Pseudo-TOS / myofascial pseudothoracic outlet syndrome"
],
"related_pages": [
{ "label": "Infraspinatus full page →", "page": "Muscle:Infraspinatus" },
{ "label": "Upper Trapezius TrPs →", "page": "Muscle:Trapezius/Upper" }
]
},
"result-overlap": {
"type": "overlap",
"text": "Findings are inconclusive. Multi-muscle involvement is common in back-of-neck pain — upper trapezius and levator scapulae frequently co-activate, and untreated upper trapezius TrPs will keep levator scapulae TrPs active. Perform a systematic screen in order of clinical priority.",
"screen_these": [
"Upper Trapezius TrP₁ — anterior border pincer palpation; shoulder loading; ipsilateral head tilt; rotation AWAY restricted",
"Upper Trapezius TrP₂ — deep palpation posterior paraspinal adjacent to midline; burning quality assessment",
"Upper Trapezius TrP₃ — lateral upper trapezius toward acromion; upper scapular border referral",
"Levator Scapulae — central TrP at C3–C4 posterolateral; attachment TrP at superior scapular angle; Mouth Wrap-around Test; ipsilateral rotation restriction",
"Splenius Cervicis — deep palpation through trapezius at C1–C3; near-vision blurring; ipsilateral rotation restriction",
"Cervical Multifidi — spinous process tap test all cervical levels; deep palpation adjacent to spinous processes; zygapophyseal joint screen",
"Infraspinatus — infraspinous fossa palpation; anterior shoulder joint pain; posterior reach restriction"
],
"wiki_page": "Differential:Back_Of_Neck_Pain"
}
},
"broad_differential": [
{
"id": "bd-1",
"condition": "Cervical Spondylosis / Degenerative Disc Disease",
"confidence": "common",
"mimics": "Posterior neck pain — overlaps with all muscles in this algorithm",
"distinguishing_feature": "Radiographic degenerative changes are near-universal in middle-aged and older adults and do not correlate well with pain severity. Myofascial TrPs frequently coexist with cervical spondylosis and may be the dominant pain source even when radiographs show significant changes. Hard end-feel on accessory movement testing (articular) vs soft end-feel (TrP) helps distinguish.",
"action": "TrP examination is essential alongside radiographic assessment. Treat TrPs first — assess residual pain after TrP inactivation to determine the articular contribution."
},
{
"id": "bd-2",
"condition": "Cervical Zygapophyseal Joint Pain",
"confidence": "uncommon",
"mimics": "Posterior neck pain — directly associated with cervical multifidi TrPs at the same segment",
"distinguishing_feature": "Segmental tenderness on accessory movement testing with a hard end-feel. Cervical multifidi TrPs and zygapophyseal joint dysfunction coexist at the same segment and perpetuate each other. Treat TrPs first — articular dysfunction often resolves with TrP inactivation. If hard end-feel persists, joint mobilisation is indicated.",
"action": "Segmental accessory movement testing at all cervical levels. Treat multifidi TrPs and reassess joint mobility. Combined TrP and articular treatment often required."
},
{
"id": "bd-3",
"condition": "Cervical Radiculopathy",
"confidence": "uncommon",
"mimics": "Posterior neck pain with arm referral — overlaps with levator scapulae and upper trapezius patterns",
"distinguishing_feature": "True radiculopathy: dermatomal arm pain with neurological signs (weakness, reflex loss, paraesthesia in a dermatomal distribution). Myofascial neck pain may refer to the arm in a non-dermatomal pattern without neurological deficits. Myofascial TrPs are frequently activated secondarily by nerve root irritation.",
"action": "Neurological examination including upper limb reflexes, power, and sensation. MRI cervical spine if neurological signs present. Treat TrPs alongside nerve root management."
},
{
"id": "bd-4",
"condition": "Tension-type Headache with Posterior Neck Component",
"confidence": "uncommon",
"mimics": "Bilateral posterior neck pain — overlaps with bilateral upper trapezius TrP₂ and cervical multifidi patterns",
"distinguishing_feature": "Very high probability of myofascial TrP involvement. Posterior neck muscle tenderness is the consistent finding in tension-type headache. The pressing or tightening quality of tension headache matches the steady aching of myofascial pain.",
"action": "Systematic TrP examination of all posterior cervical and upper shoulder girdle muscles. Myofascial treatment with perpetuating factor correction is first-line."
},
{
"id": "bd-5",
"condition": "Scapulocostal Syndrome",
"confidence": "uncommon",
"mimics": "Posterior neck and upper scapular border pain — overlaps with levator scapulae and upper trapezius TrP₃ patterns",
"distinguishing_feature": "A clinical syndrome characterised by persistent pain and stiffness at the angle of the neck and the vertebral border of the scapula. The levator scapulae is the muscle most frequently producing scapulocostal syndrome. The inferior angle bursa (present in ~38% of subjects) may perpetuate pain independently of TrPs.",
"action": "Treat levator scapulae and upper trapezius TrPs. If pain persists after TrP inactivation, consider bursae injection at the superior scapular angle."
},
{
"id": "bd-6",
"condition": "Suprascapular Nerve Entrapment",
"confidence": "rare",
"mimics": "Posterior neck and shoulder pain — overlaps with infraspinatus spillover pattern",
"distinguishing_feature": "Pain at the posterior shoulder and neck with weakness and wasting of infraspinatus and supraspinatus. Infraspinatus TrPs may contribute to suprascapular nerve entrapment at the spinoglenoid notch. Suprascapular nerve block relieves pain but does not address underlying TrPs.",
"action": "Assess infraspinatus and supraspinatus strength. Refer to orthopaedics or neurology if significant weakness present. Treat infraspinatus TrPs regardless."
},
{
"id": "bd-7",
"condition": "Post-traumatic Neck Pain (Whiplash)",
"confidence": "uncommon",
"mimics": "Posterior neck pain following MVC — all muscles in this algorithm may be activated",
"distinguishing_feature": "History of trauma. The levator scapulae and upper trapezius are among the most commonly activated muscles in motor vehicle accidents. Myofascial TrPs are activated by acute overload and are a major component of post-traumatic neck pain.",
"action": "Systematic TrP screen with priority on levator scapulae, upper trapezius, semispinalis capitis, SCM, and splenius cervicis. Address perpetuating factors. Refer if neurological signs or instability suspected."
},
{
"id": "bd-8",
"condition": "Fibromyalgia",
"confidence": "uncommon",
"mimics": "Widespread posterior neck and shoulder pain — overlaps with all muscles in this algorithm",
"distinguishing_feature": "Fibromyalgia: widespread pain (≥3 months, multiple body regions), diffuse tenderness without specific TrP referral patterns, sleep disturbance, fatigue. Myofascial TrPs commonly coexist with fibromyalgia and are a treatable component. Distinction: TrPs produce specific referred pain patterns; fibromyalgia tenderness is diffuse without referred patterns.",
"action": "Systematic TrP examination alongside fibromyalgia management. Treating active TrPs reduces the overall pain burden in fibromyalgia patients."
}
]
}