DiagnosticTree/UpperThoracic
{
"tree_id": "upper-thoracic-back-pain", "region": "Upper Thoracic Back Pain", "version": "1.0", "start": "screen-1",
"redflags": {
"emergency": [
{
"id": "rf-e1",
"label": "Spinal cord compression / Myelopathy",
"question": "Is there bilateral arm weakness or numbness, difficulty walking, loss of bladder or bowel control, or a sense of a band of tightness around the chest?",
"rationale": "Upper thoracic cord compression must be excluded before any spinal palpation or manual treatment",
"action": "Emergency referral — call emergency services or send directly to Emergency Department"
},
{
"id": "rf-e2",
"label": "Aortic dissection",
"question": "Is there sudden severe tearing or ripping interscapular pain, particularly with a history of hypertension or connective tissue disorder?",
"rationale": "Aortic dissection classically presents as severe tearing upper back pain — must be excluded before any musculoskeletal assessment",
"action": "Call emergency services immediately"
},
{
"id": "rf-e3",
"label": "Pulmonary embolism / Cardiac referral",
"question": "Is there interscapular pain with shortness of breath, pleuritic chest pain, or an exertional component?",
"rationale": "PE and myocardial ischaemia refer to the interscapular region — must be excluded",
"action": "Call emergency services immediately"
}
],
"urgent": [
{
"id": "rf-u1",
"label": "Vertebral fracture",
"question": "Is there a history of significant trauma, or is the patient osteoporotic (post-menopausal, long-term corticosteroid use, age > 70) with sudden-onset thoracic pain?",
"rationale": "Compression fracture is common in this population and must be excluded before manual therapy",
"action": "Urgent GP referral for imaging before any manual treatment"
},
{
"id": "rf-u2",
"label": "Serious spinal pathology (tumour, infection)",
"question": "Is there thoracic pain that is constant, progressive, worse at night when lying down, and not clearly related to posture or movement? Is there unexplained weight loss, fever, or a history of cancer?",
"rationale": "Upper thoracic back pain that is unrelated to position and progressive requires imaging to exclude malignancy or infection",
"action": "Urgent GP referral for imaging"
},
{
"id": "rf-u3",
"label": "Cervical instability",
"question": "Is there a history of trauma to the head or neck, combined with bilateral upper limb symptoms, gait disturbance, or upper cervical pain?",
"rationale": "Odontoid fracture or cervical instability can refer to the upper thoracic region. Manual therapy is contraindicated until cleared.",
"action": "Urgent spinal assessment — no manual therapy until cleared"
},
{
"id": "rf-u4",
"label": "Temporal arteritis",
"question": "Is the patient aged 50+ with jaw claudication (jaw pain that builds with chewing and eases with rest), temporal headache, or scalp tenderness alongside the upper back pain?",
"rationale": "Temporal arteritis involving the occipital and cervical arteries can produce upper posterior pain. Same-day ESR required.",
"action": "Same-day GP referral + ESR and CRP. Do not delay for myofascial assessment."
}
]
},
"nodes": {
"screen-1": {
"type": "rom",
"question": "Is cervical rotation restricted or painful — can the patient NOT turn their head to look fully over the shoulder on the painful side?",
"movement": "Active cervical rotation",
"direction": "restriction or pain on rotation toward painful side",
"clinical_rationale": "Restricted cervical rotation with upper thoracic pain is the single most efficient first branch. It immediately separates the two most common causes of combined stiff neck and upper thoracic pain — levator scapulae (rotation restricted toward the painful side) and splenius cervicis (rotation restricted away from the painful side, top of shoulder pain) — from the larger group of upper thoracic muscles that do not restrict neck rotation.",
"yes": "neck-rotation-side",
"no": "pain-location-1"
},
"neck-rotation-side": {
"type": "choice",
"question": "In which direction is cervical rotation most restricted or painful?",
"clinical_rationale": "Levator scapulae shortening restricts rotation TOWARD the painful side (the patient cannot look over the sore shoulder). Splenius cervicis shortening restricts rotation AWAY from the painful side (the patient cannot look over the opposite shoulder). These two directions are reliably distinct.",
"options": [
{
"label": "Cannot fully turn the head TOWARD the painful side",
"sublabel": "The sore shoulder side is where the rotation restriction is — the patient cannot look in the direction of the pain",
"next": "exam-levator-1"
},
{
"label": "Cannot fully turn the head AWAY from the painful side",
"sublabel": "The rotation restriction is toward the opposite side; OR pain at the top of the shoulder/neck on the sore side",
"next": "exam-splenius-1"
}
]
},
"exam-levator-1": {
"type": "examination",
"question": "Does palpation of the levator scapulae — along the posterior border of the upper trapezius from the upper scapular angle to the posterolateral cervical column — reproduce the upper back and neck angle pain? Is the upper medial corner of the scapula tender on direct pressure?",
"exam_type": "palpation",
"landmark": "Levator scapulae TrPs are found: (1) in the angle between the neck and shoulder, accessible just posterior to the upper trapezius; (2) at the attachment on the upper medial angle of the scapula. Palpation is most effective with the patient seated, arm of the affected side resting in the lap or on a pillow to de-weight the scapula. Ask the patient to retract the scapula slightly to bring the upper angle into reach.",
"positive_finding": "Reproduction of the characteristic upper back and neck angle pain and stiffness; tenderness at the upper medial scapular angle attachment",
"muscles_implicated": ["Levator Scapulae"],
"yes": "result-levator",
"no": "exam-splenius-1"
},
"exam-splenius-1": {
"type": "examination",
"question": "Is the pain centred at the top of the shoulder or upper neck on the painful side — not at the scapular angle — and is the pain referred to the back of the head or described as a diffuse ache at the top of the shoulder? Does the patient report any blurring of vision on the same side?",
"exam_type": "palpation",
"landmark": "Splenius cervicis TrP: found by deep palpation in the posterolateral neck, deep to the upper trapezius, at approximately the C4–C6 level. The referred pain from splenius cervicis projects to the TOP of the shoulder on the same side and to the back of the head. Key differentiating feature: visual blurring (from referral to the eye region) is unique to splenius cervicis among upper thoracic back pain muscles.",
"positive_finding": "Top-of-shoulder pain on the same side; possible ipsilateral visual blurring; cervical rotation restricted toward the opposite side; deep posterolateral neck tenderness reproduces the symptom",
"muscles_implicated": ["Splenius Cervicis"],
"yes": "result-splenius",
"no": "pain-location-1"
},
"pain-location-1": {
"type": "choice",
"question": "Where is the upper thoracic back pain most intense?",
"clinical_rationale": "Pain location separates the remaining muscles efficiently. Medial scapular border = rhomboids (unique at-rest burning). Interscapular / between shoulder blades = trapezius TrP2/TrP3. Paraspinal deep unilateral = multifidi. Upper thoracic with arm/hand symptoms = scaleni. Mid-deltoid + upper thoracic = supraspinatus. Posterior arm with scapular aching = triceps TrP1. Anterior shoulder ache spilling to suprascapular = biceps.",
"options": [
{
"label": "Along the medial border of the scapula — the inner edge, between spine and shoulder blade",
"sublabel": "A burning, gnawing pain specifically along the edge of the scapula itself",
"next": "exam-rhomboid-1"
},
{
"label": "Between the shoulder blades — diffuse interscapular or upper thoracic paraspinal aching",
"sublabel": "Aching between or below the scapulae, often bilateral or crossing the midline; burning quality is possible",
"next": "pain-aggravation-1"
},
{
"label": "Deep unilateral paraspinal ache — beside the spine, not reaching the scapula",
"sublabel": "Strictly paraspinal, one side, feels deep; may be worse on spinal extension or after sustained posture",
"next": "exam-multifidi-1"
},
{
"label": "Upper thoracic back pain with arm, forearm, or hand symptoms",
"sublabel": "Upper back pain accompanied by arm numbness, hand swelling, nocturnal arm symptoms, or arm heaviness",
"next": "exam-scalene-1"
},
{
"label": "Upper back aching with mid-deltoid or lateral shoulder pain",
"sublabel": "The lateral upper arm ache (mid-deltoid area) is a co-dominant complaint alongside the upper back pain",
"next": "exam-supraspinatus-1"
},
{
"label": "Posterior arm and shoulder ache — the back of the arm and posterior shoulder are the main complaint",
"sublabel": "Upper thoracic or scapular aching is present but secondary to a posterior arm or posterior shoulder pain",
"next": "exam-triceps-1"
}
]
},
"exam-rhomboid-1": {
"type": "examination",
"question": "Is the medial scapular border pain present predominantly AT REST — not clearly worsened by shoulder or arm movement — and does it have a burning or gnawing quality that is NOT reproduced by palpation of a distinct taut band?",
"exam_type": "palpation",
"landmark": "Rhomboid TrPs: flat palpation along the medial border of the scapula, from the spine of the scapula to the inferior angle. The muscle lies deep to the middle trapezius. Characteristic feature: rhomboid TrP pain is felt at rest and is NOT particularly worsened by active movement — this is unusual and distinguishes it from other muscles in this region. The pain is a superficial burning or gnawing along the medial border itself. Taut bands may be difficult to palpate clearly due to the overlying middle trapezius.",
"positive_finding": "Burning pain along the medial scapular border, present at rest; not clearly movement-dependent; palpation along the medial border between the scapula and spine reproduces the familiar burning quality",
"muscles_implicated": ["Rhomboids"],
"yes": "result-rhomboid",
"no": "pain-aggravation-1"
},
"pain-aggravation-1": {
"type": "choice",
"question": "What is the PRIMARY aggravating pattern for the interscapular or upper thoracic pain?",
"clinical_rationale": "Within the interscapular / between-the-shoulder-blades group, the aggravating pattern is the most efficient separator. Sustained sitting or forward head posture is the hallmark of trapezius TrP2 and TrP3. Both of these are postural and occupation-driven. The distinction between TrP2 (classic interscapular burning) and TrP3 (more paraspinal near the spine) relies on the exact pain location within the interscapular region.",
"options": [
{
"label": "Sustained sitting, working at a desk, or forward head posture — postural or occupational loading",
"sublabel": "Pain builds over the course of a sitting work session; relieved by moving or lying down",
"next": "trap-location-1"
},
{
"label": "Carrying weight on the shoulder or arm — load-bearing on the shoulder girdle",
"sublabel": "Carrying a bag, briefcase, or sustained load through the arm reproduces the upper thoracic pain",
"next": "exam-scalene-1"
},
{
"label": "No clear aggravating posture or activity — pain present at rest and with movement equally",
"sublabel": "The pain does not have a strong postural or movement component",
"next": "exam-multifidi-1"
}
]
},
"trap-location-1": {
"type": "choice",
"question": "Where exactly is the interscapular pain located?",
"clinical_rationale": "Trapezius TrP2 and TrP3 are often grouped as interscapular but are anatomically and clinically distinct. TrP2 (upper trapezius / mid-belly) refers to the interscapular region with a distinct burning quality, and is associated with ipsilateral neck and temple pain in the same patient. TrP3 (mid-trapezius belly, horizontal fibres) refers pain to the medial upper thoracic area, closer to the spine and sometimes described as a paraspinal or between-the-shoulder-blades ache. TrP4 (lower trapezius) refers upward to the suprascapular and cervical area, but is less relevant to upper thoracic back pain as the primary complaint.",
"options": [
{
"label": "Midscapular or between the shoulder blades — interscapular, somewhat lateral; the burning extends toward the acromion or mid-scapular region",
"sublabel": "Classic burning between the shoulder blades, extending outward",
"next": "exam-trap-trp2"
},
{
"label": "Close to the spine in the upper thoracic region — medial, paraspinal, near the thoracic vertebrae",
"sublabel": "The burning or aching is felt close to the spine, in the upper thoracic paraspinal area",
"next": "exam-trap-trp3"
}
]
},
"exam-trap-trp2": {
"type": "examination",
"question": "Does flat palpation of the mid-portion of the upper trapezius — between the neck and the acromion, at the fullest part of the shoulder slope — reproduce the interscapular burning? Is there a co-existing ipsilateral neck or temporal ache in the same patient that suggests upper trapezius TrP1 involvement?",
"exam_type": "palpation",
"landmark": "Trapezius TrP2: found in the mid-belly of the upper trapezius fibres, roughly midway between the spinous processes and the acromion along the shoulder slope. Flat palpation — press across the fibres. A taut band may be identified and an LTR elicited on snapping. Reproduces the interscapular referred pain, which is somewhat lateral and burning in character. The same patient often has TrP1 in the upper trapezius (which refers to the temple and neck) — both are postural and perpetuated by the same factors.",
"positive_finding": "Interscapular burning reproduced by palpation of the mid-upper trapezius belly; postural aggravation confirmed; taut band present",
"muscles_implicated": ["Trapezius (TrP2)"],
"yes": "result-trap-trp2",
"no": "exam-trap-trp3"
},
"exam-trap-trp3": {
"type": "examination",
"question": "Does flat palpation of the mid-trapezius — the horizontal fibres between the spine of the scapula and the thoracic spinous processes, at approximately T3–T5 level — reproduce the upper thoracic paraspinal burning?",
"exam_type": "palpation",
"landmark": "Trapezius TrP3: found in the mid-trapezius horizontal fibres, between the medial border of the scapula and the thoracic spinous processes. Flat palpation across these fibres at the level of T3–T5 identifies the TrP. The referred pain is felt close to the thoracic spine, medial to the scapula — more paraspinal than TrP2. Taut bands in this region may be more difficult to isolate due to the overlying skin and the broad flat nature of this fibre direction.",
"positive_finding": "Upper thoracic paraspinal burning reproduced by mid-trapezius horizontal fibre palpation; postural aggravation confirmed",
"muscles_implicated": ["Trapezius (TrP3)"],
"yes": "result-trap-trp3",
"no": "exam-multifidi-1"
},
"exam-multifidi-1": {
"type": "examination",
"question": "Does firm deep palpation immediately lateral to the upper thoracic spinous processes — pressing into the paraspinal gutter at T2–T6 level on the painful side — reproduce a deep unilateral ache? Is the pain worsened by thoracic extension (bending backward) or after sustained sitting?",
"exam_type": "palpation",
"landmark": "Multifidi TrPs: palpate the paraspinal gutter immediately adjacent to the spinous processes, 1–2 cm lateral to the midline, at each segmental level from T2 to T6. These TrPs are deep and require firm sustained pressure directed slightly toward the vertebra. The referred pain is felt locally and in the adjacent segments — it is deep, unilateral, and does not extend to the scapula or deltoid. Extension of the thoracic spine loads the multifidi; flexion relieves it.",
"positive_finding": "Deep unilateral paraspinal ache reproduced by segmental palpation immediately lateral to the thoracic spinous processes; worsened on thoracic extension",
"muscles_implicated": ["Multifidi"],
"yes": "result-multifidi",
"no": "result-overlap"
},
"exam-scalene-1": {
"type": "examination",
"question": "Are there arm or hand symptoms alongside the upper thoracic back pain — any of: nocturnal arm aching (wakes the patient at night), hand or finger swelling, arm heaviness, or forearm and hand numbness/tingling?",
"exam_type": "history",
"landmark": "Scaleni TrPs are the most important myofascial cause of combined upper back pain and arm symptoms. The nocturnal arm symptom pattern is the single most characteristic feature: the patient is woken at night by deep aching or numbness in the arm and must hang the arm over the side of the bed or shake it to get relief. Hand oedema (diffuse, not dependent) is caused by compression of the subclavian vein by taut scalene bands. These features distinguish scaleni from all other muscles in this algorithm.",
"positive_finding": "Nocturnal arm aching; OR hand/finger swelling; OR forearm and hand numbness; alongside upper thoracic back and anterior chest pain",
"muscles_implicated": ["Scaleni"],
"yes": "exam-scalene-2",
"no": "pain-location-1"
},
"exam-scalene-2": {
"type": "examination",
"question": "Does pincer palpation or flat palpation of the scaleni — just lateral to the sternocleidomastoid in the posterior triangle of the neck, palpating the anterior, middle, and posterior scalene from the transverse processes of C3–C7 toward the first and second ribs — reproduce the upper thoracic and/or arm pain?",
"exam_type": "palpation",
"landmark": "Scalene TrPs: with the patient supine, head slightly turned away from the side being examined. Palpate posterolateral to the SCM, in the posterior triangle of the neck. The anterior scalene is found between the SCM and the sternohyoid; the middle scalene more posterolaterally. Firm pressure perpendicular to the fibre direction reproduces the referred pain into the upper thoracic back and anterior chest, and/or down the arm. The first rib is a useful bony landmark — the scaleni attach here and are often tender at this point.",
"positive_finding": "Reproduction of upper thoracic back and anterior chest pain, and/or arm/hand symptoms, on scalene palpation in the posterior triangle of the neck",
"muscles_implicated": ["Scaleni"],
"yes": "result-scalene",
"no": "pain-location-1"
},
"exam-supraspinatus-1": {
"type": "rom",
"question": "Is there a painful arc of shoulder abduction — pain that appears as the arm is raised between approximately 60° and 120° of abduction, then diminishes above 120°?",
"movement": "Active shoulder abduction arc",
"direction": "painful arc between 60–120 degrees",
"clinical_rationale": "The painful arc during shoulder abduction is the most important examination finding for supraspinatus TrPs. It distinguishes supraspinatus from all other muscles in this algorithm that do not restrict or produce pain in shoulder abduction. The supraspinatus refers pain to the mid-deltoid (lateral upper arm) and, as a spillover, to the upper thoracic back and suprascapular region. A patient presenting with upper thoracic back pain who also complains of lateral arm aching and has a painful arc on abduction is almost certainly describing supraspinatus TrP referral.",
"yes": "exam-supraspinatus-2",
"no": "pain-location-1"
},
"exam-supraspinatus-2": {
"type": "examination",
"question": "Does deep flat palpation in the supraspinous fossa — above the spine of the scapula, pressing the supraspinatus muscle belly against the scapular floor — reproduce the lateral arm and/or upper thoracic aching? Is the mid-deltoid region (lateral upper arm) the dominant pain zone rather than the upper back?",
"exam_type": "palpation",
"landmark": "Supraspinatus TrP: lies in the supraspinous fossa, accessible above the spine of the scapula. With the patient seated, the arm hanging at rest, palpate the supraspinous fossa with firm flat pressure directed into the fossa. The TrP is usually in the mid-belly, slightly medial to the midpoint of the supraspinous fossa. LTRs are difficult to elicit here due to the depth of the muscle. The essential referral zone is the lateral deltoid region; upper thoracic / suprascapular pain is spillover.",
"positive_finding": "Lateral deltoid pain reproduced by supraspinous fossa palpation; painful arc confirmed on abduction; upper thoracic aching present as spillover",
"muscles_implicated": ["Supraspinatus"],
"yes": "result-supraspinatus",
"no": "pain-location-1"
},
"exam-triceps-1": {
"type": "rom",
"question": "Is posterior arm pain the dominant complaint — aching in the back of the arm, posterior shoulder, or posterior forearm — with the upper thoracic / scapular pain as a secondary or spillover zone? Does the pain SKIP the elbow (pain in posterior arm above AND/OR below the elbow but not at the elbow itself)?",
"movement": "Pattern recognition — posterior arm pain with elbow skip",
"direction": "posterior arm dominant; elbow skip",
"clinical_rationale": "Triceps TrP1 (long head) is the only muscle in this algorithm whose referral skips the elbow — producing posterior arm and/or forearm pain without elbow pain. The suprascapular and upper thoracic aching is a spillover from TrP1. This skipped-elbow pattern, when present, is highly specific. If posterior arm pain is dominant with upper thoracic spillover, and the elbow is NOT painful, triceps TrP1 is the primary candidate.",
"yes": "exam-triceps-2",
"no": "pain-location-1"
},
"exam-triceps-2": {
"type": "examination",
"question": "Does the Positive Triceps Brachii Test show restriction — when the patient tries to bring the arm tight against the ear with the elbow straight, can they NOT do so on the painful side? Does deep pincer palpation of the long head of the triceps at mid-muscle (adjacent to the humerus, a few centimetres distal to where the long head crosses the teres major) reproduce the posterior arm and scapular aching?",
"exam_type": "palpation",
"landmark": "Triceps TrP1 — Long head: the TrP lies deep in the long head at approximately mid-muscle, requiring pincer palpation (fingernails must be cut short). Fingers encircle the triceps reaching in to the humerus; the long head is lifted from the humerus and rolled between the digits. Clusters of TrPs are common. The Positive Triceps Brachii Test: the patient cannot bring the arm tight against the ear with the elbow fully straight — the shortened long head prevents full shoulder elevation.",
"positive_finding": "Cannot adduct arm against ear with elbow straight (Positive Triceps Brachii Test); palpation of long head at mid-muscle reproduces posterior arm and scapular pain; elbow skip pattern confirmed",
"muscles_implicated": ["Triceps Brachii (TrP1 — Long Head)"],
"yes": "result-triceps-trp1",
"no": "exam-biceps-check"
},
"exam-biceps-check": {
"type": "examination",
"question": "Is the pain primarily in the ANTERIOR shoulder with spillover to the suprascapular region — not in the posterior arm? Does the Biceps-extension Test show restriction — when the arm is abducted to 45°, elbow fully extended, forearm pronated, and moved into horizontal extension, does the elbow flex to compensate rather than the shoulder yielding?",
"exam_type": "palpation",
"landmark": "Biceps TrP suprascapular spillover: the essential referral of biceps TrPs is to the anterior shoulder; the suprascapular region is a spillover zone. The Biceps-extension Test stretches across all three joints simultaneously — elbow compensation (elbow flexes as the arm is moved into extension) confirms biceps shortening. Midmuscle pincer palpation of the biceps with the elbow slightly flexed reproduces the anterior shoulder aching. Key differentiator: the patient with biceps TrPs can lie comfortably on the affected side and can reach behind the waistline without pain.",
"positive_finding": "Anterior shoulder pain primary; suprascapular aching as spillover; Biceps-extension Test positive (elbow flexes to compensate); midmuscle biceps TrPs reproduced on pincer palpation; patient can lie on the affected side",
"muscles_implicated": ["Biceps Brachii"],
"yes": "result-biceps",
"no": "result-overlap"
},
"result-levator": {
"type": "result",
"diagnosis": "Levator Scapulae Trigger Point",
"confidence": "high",
"wiki_page": "Muscle:Levator_Scapulae",
"chapter_ref": "Travell & Simons Vol.1 — Ch.19 Levator Scapulae",
"notes": "Levator scapulae TrPs produce the classic 'stiff neck' presentation: restricted cervical rotation toward the painful side (the patient cannot look over the sore shoulder) combined with upper thoracic and neck angle pain. The pain is concentrated at the angle of the neck and shoulder and at the upper medial corner of the scapula. The patient typically holds the head slightly toward the sore side. Levator scapulae is one of the most common causes of acute-onset neck stiffness with upper thoracic back pain.",
"treatment_hint": "Spray and stretch: vapocoolant from the occiput downward over the neck angle and upper medial scapular region. Postisometric relaxation: resist lateral flexion away, then direct the head into full contralateral rotation on exhale. Address perpetuating postures — forward head position, shoulder carried too high. Correct any lower limb length discrepancy.",
"also_consider": ["Trapezius (Upper, TrP1)", "Splenius Cervicis", "SCM"],
"less_likely": [
{ "muscle": "Splenius Cervicis", "reason": "Splenius cervicis restricts rotation AWAY from the painful side, not toward it; top-of-shoulder referral rather than scapular angle" },
{ "muscle": "Trapezius TrP2", "reason": "Trapezius does not restrict cervical rotation; interscapular burning without stiff neck" },
{ "muscle": "Rhomboids", "reason": "No cervical rotation restriction; rhomboid pain is at-rest burning along the medial scapular border without neck stiffness" }
],
"confirmatory": [
"Cervical rotation restricted toward the painful side — cannot look over the sore shoulder",
"Upper medial scapular angle tenderness on direct pressure",
"Palpation in the neck-shoulder angle reproduces the familiar stiff neck and upper thoracic pain",
"Patient holds head slightly tilted toward the painful side"
],
"satellite_trps": ["Trapezius (Upper)", "SCM", "Scaleni", "Splenius Cervicis"],
"related_pages": [
{ "label": "Trapezius TrPs →", "page": "Muscle:Trapezius" },
{ "label": "Splenius Cervicis →", "page": "Muscle:Splenius_Cervicis" },
{ "label": "SCM →", "page": "Muscle:Sternocleidomastoid" }
]
},
"result-splenius": {
"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": "Splenius cervicis TrPs refer pain to the top of the shoulder on the same side and to the back of the head (occiput). Cervical rotation is restricted AWAY from the painful side — the patient cannot look over the opposite shoulder. A distinctive feature among all upper back muscles: ipsilateral visual blurring may accompany splenius cervicis TrPs, caused by referral affecting the eye region. The pain at the top of the shoulder (not the scapular angle) distinguishes splenius cervicis from levator scapulae.",
"treatment_hint": "Spray and stretch in the direction of restricted rotation. Vapocoolant over the posterior neck from the occiput downward and over the top of the shoulder. Correct forward head posture. Address sleeping position — prone sleeping perpetuates splenius cervicis TrPs.",
"also_consider": ["Levator Scapulae", "Upper Trapezius", "Semispinalis Cervicis"],
"less_likely": [
{ "muscle": "Levator Scapulae", "reason": "Levator scapulae restricts rotation TOWARD the painful side; pain at the scapular angle rather than the top of the shoulder" },
{ "muscle": "Trapezius TrP2", "reason": "No cervical rotation restriction; interscapular burning rather than top-of-shoulder aching" },
{ "muscle": "Multifidi", "reason": "No cervical rotation restriction; strictly paraspinal deep ache without top-of-shoulder referral" }
],
"confirmatory": [
"Cervical rotation restricted AWAY from the painful side — cannot look over the opposite shoulder",
"Pain at the top of the shoulder on the same side as the TrP",
"Possible ipsilateral visual blurring — unique to splenius cervicis among this group",
"Deep posterolateral neck palpation at C4–C6 level reproduces the top-of-shoulder aching"
],
"satellite_trps": ["Levator Scapulae", "Upper Trapezius", "Splenius Capitis"],
"related_pages": [
{ "label": "Levator Scapulae →", "page": "Muscle:Levator_Scapulae" },
{ "label": "Trapezius →", "page": "Muscle:Trapezius" }
]
},
"result-rhomboid": {
"type": "result",
"diagnosis": "Rhomboid Trigger Point",
"confidence": "high",
"wiki_page": "Muscle:Rhomboids",
"chapter_ref": "Travell & Simons Vol.1 — Ch.27 Rhomboids",
"notes": "Rhomboid TrPs produce a superficial burning or gnawing pain along the medial border of the scapula — uniquely, this pain is present at rest and is not clearly movement-dependent. This rest-pain character is the single most important distinguishing feature of rhomboid TrPs. The overlying middle trapezius may harbour TrPs simultaneously; middle trapezius TrPs must also be examined and treated. Rhomboid TrPs frequently coexist with serratus anterior dysfunction (winging scapula) and with lower trapezius weakness.",
"treatment_hint": "Spray and stretch: arm across the chest to protract the scapula, opening the rhomboid fibres. Postisometric relaxation. Address serratus anterior weakness. Correct rounded shoulder posture.",
"also_consider": ["Middle Trapezius (TrP3)", "Serratus Anterior", "Infraspinatus"],
"less_likely": [
{ "muscle": "Trapezius TrP3", "reason": "Mid-trapezius TrP3 pain is not specifically along the scapular border and is more clearly postural/movement-aggravated than rhomboid rest pain" },
{ "muscle": "Multifidi", "reason": "Multifidi pain is deep and paraspinal — not superficial and not along the scapular border" },
{ "muscle": "Levator Scapulae", "reason": "No cervical rotation restriction; pain is along the scapular border not the neck-shoulder angle" }
],
"confirmatory": [
"Burning or gnawing pain along the medial border of the scapula — the inner edge of the shoulder blade",
"Pain present predominantly at rest — not clearly worsened by arm or shoulder movement",
"Palpation along the medial scapular border between the scapula and spine reproduces the familiar burning",
"Absence of cervical rotation restriction — no 'stiff neck'"
],
"satellite_trps": ["Middle Trapezius", "Serratus Anterior", "Infraspinatus"],
"related_pages": [
{ "label": "Trapezius TrPs →", "page": "Muscle:Trapezius" },
{ "label": "Serratus Anterior →", "page": "Muscle:Serratus_Anterior" }
]
},
"result-trap-trp2": {
"type": "result",
"diagnosis": "Trapezius — TrP2 (Upper Trapezius Mid-belly)",
"confidence": "high",
"wiki_page": "Muscle:Trapezius",
"chapter_ref": "Travell & Simons Vol.1 — Ch.6 Trapezius",
"notes": "Trapezius TrP2 lies in the mid-belly of the upper trapezius and refers burning pain to the interscapular region and toward the acromion. It is postural in character — driven by sustained forward head posture, carrying a shoulder bag, or prolonged desk work. The same patient almost always also has TrP1 in the upper trapezius (which refers to the temple and back of the neck). TrP2 is one of the most common single sources of upper back burning between the shoulder blades. Treating TrP1 first often reduces TrP2 activity as they are part of the same muscle under the same postural load.",
"treatment_hint": "Spray and stretch in the direction of neck lateral flexion away from the TrP while the arm hangs dependently. PIR cycles. Correct forward head posture and shoulder bag carrying. Address lower limb length discrepancy. Eliminate shoulder bracing habits.",
"also_consider": ["Trapezius TrP1", "Trapezius TrP3", "Levator Scapulae"],
"less_likely": [
{ "muscle": "Rhomboids", "reason": "Rhomboid pain is along the scapular border and at rest; trapezius TrP2 is interscapular burning with postural aggravation" },
{ "muscle": "Multifidi", "reason": "Multifidi pain is deep unilateral paraspinal — not the lateral burning interscapular quality of trapezius TrP2" },
{ "muscle": "Levator Scapulae", "reason": "No cervical rotation restriction; no neck-angle stiffness" }
],
"confirmatory": [
"Burning pain in the interscapular region, somewhat lateral, extending toward the acromion",
"Postural aggravation — builds with sustained forward head posture, desk work, or shoulder bag carrying",
"Palpation of mid-upper trapezius belly reproduces the interscapular burning",
"Taut band with spot tenderness; LTR possible on snapping"
],
"satellite_trps": ["Trapezius TrP1", "Levator Scapulae", "Sternalis"],
"related_pages": [
{ "label": "Levator Scapulae →", "page": "Muscle:Levator_Scapulae" },
{ "label": "SCM →", "page": "Muscle:Sternocleidomastoid" }
]
},
"result-trap-trp3": {
"type": "result",
"diagnosis": "Trapezius — TrP3 (Mid-trapezius, Horizontal Fibres)",
"confidence": "high",
"wiki_page": "Muscle:Trapezius",
"chapter_ref": "Travell & Simons Vol.1 — Ch.6 Trapezius",
"notes": "Trapezius TrP3 lies in the horizontal mid-trapezius fibres between the medial scapular border and the thoracic spinous processes. It refers burning pain to the upper thoracic paraspinal region, close to the spine — more medial than TrP2 and more superficial than multifidi. The postural aggravation pattern is shared with TrP2. TrP3 is often associated with acne-like skin changes (gooseflesh, piloerection, or skin irritability) directly over the TrP due to autonomic activity — a useful corroborating finding.",
"treatment_hint": "Spray and stretch with arm protraction (reaching forward across the chest) to separate the scapula from the spine and open the horizontal fibres. Address rounded-shoulder posture and scapular winging.",
"also_consider": ["Trapezius TrP2", "Rhomboids", "Multifidi"],
"less_likely": [
{ "muscle": "Multifidi", "reason": "Multifidi pain is strictly deep and unilateral immediately lateral to the spinous processes; trapezius TrP3 is more superficial and horizontal in character" },
{ "muscle": "Rhomboids", "reason": "Rhomboid pain is along the scapular border at rest; TrP3 is more medial and postural" },
{ "muscle": "Trapezius TrP2", "reason": "TrP2 is more lateral (toward the acromion); TrP3 is closer to the thoracic spine" }
],
"confirmatory": [
"Upper thoracic paraspinal burning close to the spine",
"Postural aggravation — desk work, forward head posture",
"Palpation of horizontal mid-trapezius fibres at T3–T5 level reproduces the medial thoracic burning",
"Possible skin changes (piloerection, acne-like irritability) directly over the TrP — autonomic sign"
],
"satellite_trps": ["Trapezius TrP2", "Rhomboids", "Serratus Anterior"],
"related_pages": [
{ "label": "Rhomboids →", "page": "Muscle:Rhomboids" },
{ "label": "Trapezius TrP2 →", "page": "Muscle:Trapezius" }
]
},
"result-multifidi": {
"type": "result",
"diagnosis": "Multifidi Trigger Point",
"confidence": "high",
"wiki_page": "Muscle:Multifidi",
"chapter_ref": "Travell & Simons Vol.1 — Ch.48 Multifidi",
"notes": "Multifidi TrPs produce a deep, unilateral paraspinal ache immediately adjacent to the thoracic spinous processes. The pain is strictly segmental and local — it does not project to the scapula, shoulder, or arm. It is worsened by thoracic extension and by sustained sitting. A characteristic feature: multifidi TrP tenderness is found by pressing firmly into the paraspinal gutter immediately lateral to the spinous processes, not more than 2 cm from the midline. The deep segmental nature and the absence of any referred zone beyond the immediate paraspinal region distinguishes multifidi from all other muscles in this algorithm.",
"treatment_hint": "Dry needling or trigger point injection for deep access. Thoracic extension stretching and thoracic mobility exercises. Address sustained sitting posture.",
"also_consider": ["Trapezius TrP3", "Rotatores", "Semispinalis Thoracis"],
"less_likely": [
{ "muscle": "Trapezius TrP3", "reason": "Trapezius TrP3 is more superficial and bilateral in character; multifidi are deep, segmental, and strictly paraspinal" },
{ "muscle": "Rhomboids", "reason": "Rhomboid pain is along the scapular border — lateral to the paraspinal region; multifidi pain does not reach the scapula" },
{ "muscle": "Scaleni", "reason": "No arm symptoms; no anterior chest referral; strictly paraspinal localisation" }
],
"confirmatory": [
"Deep unilateral ache immediately lateral to thoracic spinous processes",
"No referral to the scapula, shoulder, or arm",
"Worsened by thoracic extension and sustained sitting",
"Firm segmental palpation 1–2 cm lateral to the spinous processes reproduces the pain at that level"
],
"satellite_trps": ["Rotatores", "Semispinalis Thoracis"],
"related_pages": [
{ "label": "Trapezius TrPs →", "page": "Muscle:Trapezius" }
]
},
"result-scalene": {
"type": "result",
"diagnosis": "Scaleni Trigger Points",
"confidence": "high",
"wiki_page": "Muscle:Scalene",
"chapter_ref": "Travell & Simons Vol.1 — Ch.20 Scaleni",
"notes": "Scaleni TrPs have the broadest referred pain distribution of any muscle in this algorithm — projecting to the upper thoracic back, anterior chest, medial border of the scapula, deltoid region, and down the arm into the hand. The nocturnal arm symptom pattern (woken at night, must hang the arm over the side of the bed) is the single most characteristic feature, distinguishing scaleni from thoracic outlet syndrome, cervical radiculopathy, and all other muscles here. Diffuse hand oedema (not dependent) caused by compression of the subclavian vein by taut scalene bands is another distinguishing feature. Anterior chest wall pain from scaleni is often mistaken for cardiac or pulmonary disease.",
"treatment_hint": "Spray and stretch: cervical lateral flexion away from the TrPs, with slight contralateral rotation. Ischemic compression. Correct forward head posture — the most important perpetuating factor. Address first rib restriction. Treat SCM concurrently. Eliminate sustained shoulder elevation (phone cradling, raised armrests).",
"also_consider": ["SCM", "Trapezius Upper", "Levator Scapulae"],
"less_likely": [
{ "muscle": "Trapezius TrP2", "reason": "No arm or hand symptoms; no nocturnal arm pattern; no hand oedema" },
{ "muscle": "Levator Scapulae", "reason": "Levator scapulae does not produce arm or hand symptoms; no nocturnal arm pattern" },
{ "muscle": "Supraspinatus", "reason": "Supraspinatus does not produce arm numbness, hand oedema, or nocturnal arm symptoms" }
],
"confirmatory": [
"Nocturnal arm aching — woken at night; must hang arm over side of bed or shake it for relief",
"Diffuse hand or finger swelling (not dependent oedema) — subclavian vein compression",
"Arm numbness and tingling involving the forearm and hand (variable dermatomal distribution, often C8-T1 dominant)",
"Upper thoracic back AND anterior chest pain — the combination is characteristic of scaleni",
"Scalene palpation in the posterior triangle of the neck reproduces all of the above symptoms"
],
"satellite_trps": ["SCM", "Upper Trapezius", "Pectoralis Minor", "Subclavius"],
"related_pages": [
{ "label": "SCM →", "page": "Muscle:Sternocleidomastoid" },
{ "label": "Pectoralis Minor →", "page": "Muscle:Pectoralis_Minor" }
]
},
"result-supraspinatus": {
"type": "result",
"diagnosis": "Supraspinatus Trigger Point",
"confidence": "high",
"wiki_page": "Muscle:Supraspinatus",
"chapter_ref": "Travell & Simons Vol.1 — Ch.21 Supraspinatus",
"notes": "Supraspinatus TrPs are the most common myofascial cause of painful arc during shoulder abduction. The essential referral zone is the mid-deltoid (lateral upper arm); the upper thoracic and suprascapular pain is a spillover zone. A deep aching pain at the lateral upper arm, combined with a painful arc between 60° and 120° of abduction, with upper thoracic aching as a secondary complaint, is the characteristic presentation. Supraspinatus TrPs are frequently diagnosed as 'rotator cuff tendinitis' or 'impingement syndrome' — the key distinction is that TrP inactivation resolves the painful arc and deltoid aching.",
"treatment_hint": "Spray and stretch across the full abduction arc. Supraspinatus fossa palpation and ischemic compression. Address shoulder girdle posture. Injection into the supraspinous fossa TrP is often highly effective. Treat infraspinatus and deltoid concurrently.",
"also_consider": ["Infraspinatus", "Deltoid", "Biceps Brachii"],
"less_likely": [
{ "muscle": "Trapezius TrP2", "reason": "Trapezius TrP2 does not produce lateral arm pain or a painful abduction arc" },
{ "muscle": "Biceps Brachii", "reason": "Biceps refers to the anterior shoulder — not the lateral deltoid; no painful abduction arc" },
{ "muscle": "Scaleni", "reason": "Scaleni do not produce a painful arc; arm symptoms from scaleni are neurological/vascular, not arc-type" }
],
"confirmatory": [
"Painful arc of shoulder abduction between approximately 60° and 120° — pain diminishes above 120°",
"Mid-deltoid (lateral upper arm) aching is the dominant pain zone",
"Upper thoracic and suprascapular aching as a spillover, not the primary complaint",
"Deep palpation in the supraspinous fossa reproduces lateral arm aching"
],
"satellite_trps": ["Infraspinatus", "Deltoid", "Biceps Brachii", "Upper Trapezius"],
"related_pages": [
{ "label": "Infraspinatus →", "page": "Muscle:Infraspinatus" },
{ "label": "Biceps Brachii →", "page": "Muscle:Biceps_Brachii" }
]
},
"result-triceps-trp1": {
"type": "result",
"diagnosis": "Triceps Brachii — TrP1 (Long Head)",
"confidence": "high",
"wiki_page": "Muscle:Triceps_Brachii",
"chapter_ref": "Travell & Simons Vol.1 — Ch.32 Triceps Brachii",
"notes": "Triceps TrP1 in the long head refers pain upward over the posterior arm to the back of the shoulder and occasionally to the base of the neck in the upper trapezius region — and sometimes downward to the dorsum of the forearm, skipping the elbow. This elbow-skip pattern (posterior arm and/or forearm pain without elbow pain) is the clinical signature of TrP1 and does not occur with any other muscle in this algorithm. The upper thoracic and scapular aching is a spillover from TrP1 — the posterior arm and shoulder are the dominant complaint. The Positive Triceps Brachii Test (cannot adduct arm to ear with elbow straight) confirms long head shortening.",
"treatment_hint": "Spray and stretch: simultaneous elbow flexion and full shoulder elevation/adduction. PIR with the patient pressing elbow forward against resistance, then actively moving the arm posteriorly. Treat latissimus dorsi and serratus posterior superior as key TrP sources if triceps TrPs recur — these are the key muscles driving triceps satellite TrPs.",
"also_consider": ["Latissimus Dorsi", "Serratus Posterior Superior", "Teres Major"],
"less_likely": [
{ "muscle": "Trapezius TrP2", "reason": "Posterior arm pain is absent in trapezius TrP2; no elbow-skip pattern; no restriction of arm adduction to ear" },
{ "muscle": "Supraspinatus", "reason": "Supraspinatus does not produce posterior arm pain or an elbow-skip pattern; no Positive Triceps Brachii Test" },
{ "muscle": "Biceps Brachii", "reason": "Biceps refers to the anterior shoulder — the posterior arm location distinguishes TrP1 conclusively" }
],
"confirmatory": [
"Posterior arm and posterior shoulder aching — posterior location is essential",
"Elbow-skip pattern: pain in posterior arm above and/or below the elbow but NOT at the elbow",
"Positive Triceps Brachii Test: cannot bring arm tight against ear with elbow straight on the painful side",
"Deep pincer palpation of long head at mid-muscle reproduces the posterior arm and scapular pain"
],
"satellite_trps": ["Biceps Brachii", "Brachialis", "Latissimus Dorsi"],
"related_pages": [
{ "label": "Latissimus Dorsi →", "page": "Muscle:Latissimus_Dorsi" },
{ "label": "Biceps Brachii →", "page": "Muscle:Biceps_Brachii" }
]
},
"result-biceps": {
"type": "result",
"diagnosis": "Biceps Brachii Trigger Point (Suprascapular Spillover)",
"confidence": "moderate",
"wiki_page": "Muscle:Biceps_Brachii",
"chapter_ref": "Travell & Simons Vol.1 — Ch.30 Biceps Brachii",
"notes": "Biceps TrPs refer primarily to the anterior shoulder, with a spillover zone to the suprascapular region — it is this spillover that brings biceps into the upper thoracic back pain differential. When the suprascapular aching is the presenting complaint, biceps TrPs are an easily missed contributor. The anterior shoulder location of the primary referral, the absence of posterior arm pain, and the ability to lie on the affected side (distinguishing it from infraspinatus) are the key clinical pointers. The Biceps-extension Test (elbow flexes to compensate as the arm is moved into extension) confirms biceps shortening. The most common error is treating the suprascapular region without examining the biceps.",
"treatment_hint": "Treat infraspinatus first — it is the most common key TrP driving satellite biceps TrPs. Spray and stretch across all three joints simultaneously. Correct any sustained supinated carrying habits. Treat brachialis concurrently.",
"also_consider": ["Infraspinatus", "Trapezius TrP2", "Supraspinatus"],
"less_likely": [
{ "muscle": "Trapezius TrP2", "reason": "Trapezius TrP2 does not produce anterior shoulder pain; no Biceps-extension Test restriction" },
{ "muscle": "Supraspinatus", "reason": "Supraspinatus refers to the lateral deltoid and produces a painful arc; biceps refers to the anterior shoulder without a painful arc" },
{ "muscle": "Triceps TrP1", "reason": "Triceps TrP1 is posterior arm; biceps is anterior shoulder — location distinguishes conclusively" }
],
"confirmatory": [
"Anterior shoulder aching primary — suprascapular region is spillover only",
"No posterior arm pain; no elbow-skip pattern",
"Can lie comfortably on the affected side — distinguishes from infraspinatus",
"Can reach behind the waistline without pain — distinguishes from infraspinatus",
"Biceps-extension Test positive: elbow flexes to compensate as arm moves into extension",
"Midmuscle biceps pincer palpation reproduces anterior shoulder and suprascapular aching"
],
"satellite_trps": ["Infraspinatus", "Brachialis", "Triceps Brachii", "Supraspinatus"],
"related_pages": [
{ "label": "Infraspinatus →", "page": "Muscle:Infraspinatus" },
{ "label": "Triceps Brachii →", "page": "Muscle:Triceps_Brachii" }
]
},
"result-overlap": {
"type": "overlap",
"text": "Findings are inconclusive or multi-muscle involvement is likely. Perform a systematic palpation screen of the most prevalent muscles for this region, in order of likelihood.",
"screen_these": [
"Trapezius TrP2 — mid-upper trapezius belly flat palpation; look for interscapular burning with postural aggravation",
"Levator scapulae — neck-shoulder angle palpation; confirm cervical rotation restriction toward the painful side",
"Trapezius TrP3 — horizontal mid-trapezius fibres at T3–T5 level palpation; paraspinal burning close to the spine",
"Rhomboids — medial scapular border flat palpation; confirm rest-pain burning quality",
"Multifidi — deep segmental palpation 1–2 cm lateral to thoracic spinous processes",
"Scaleni — posterior triangle of neck palpation; confirm arm/hand symptoms and nocturnal pattern",
"Supraspinatus — supraspinous fossa palpation; confirm painful abduction arc and lateral deltoid pain",
"Splenius cervicis — deep posterolateral neck at C4–C6; confirm rotation restriction away from painful side"
],
"wiki_page": "Differential:Upper_Thoracic_Back_Pain"
}
},
"broad_differential": [
{
"id": "bd-1",
"condition": "Cervical disc herniation (C5–C6, C6–C7)",
"confidence": "common",
"mimics": "Upper thoracic and interscapular pain from C6–C7 disc herniation is referred via the scapular dorsal rami; overlaps with trapezius and rhomboid TrP referral",
"distinguishing_feature": "Dermatomal sensory deficit in the arm; reflex change (biceps reflex at C5–C6, triceps reflex at C7); true myotomal weakness; Spurling's test positive; pain often radiates from the neck through the arm to the hand. TrP pain does not produce reflex changes or true dermatomal sensory deficit.",
"action": "Cervical spine imaging (MRI) if neurological signs are present. TrPs and disc pathology frequently coexist — treat TrPs and reassess."
},
{
"id": "bd-2",
"condition": "Thoracic outlet syndrome (TOS)",
"confidence": "uncommon",
"mimics": "Arm and hand symptoms with upper thoracic and anterior chest pain — closely mimics scaleni TrP presentation",
"distinguishing_feature": "Roos test (EAST test) positive at 3 minutes; Adson's test; vascular changes (radial pulse diminution); confirmed by EMG, nerve conduction, or vascular studies. Scaleni TrPs frequently coexist with and contribute to TOS.",
"action": "Vascular and neurological assessment. Inactivate scaleni TrPs first — this often resolves or substantially reduces TOS symptoms. Refer for TOS workup if symptoms persist after TrP treatment."
},
{
"id": "bd-3",
"condition": "Rotator cuff tendinopathy / subacromial impingement",
"confidence": "common",
"mimics": "Painful arc and lateral upper arm aching overlapping with supraspinatus TrP referral",
"distinguishing_feature": "Tenderness directly at the supraspinatus tendon insertion on the greater tuberosity; positive Neer's or Hawkins-Kennedy sign; imaging (ultrasound/MRI) shows tendon changes. TrPs and tendinopathy frequently coexist and may be causally related (TrP taut bands sustain enthesopathic tension). Inactivate TrPs first and reassess tendon imaging findings.",
"action": "Ultrasound or MRI if clinical findings suggest tendon pathology. Treat supraspinatus TrPs first."
},
{
"id": "bd-4",
"condition": "Glenohumeral osteoarthritis",
"confidence": "uncommon",
"mimics": "Diffuse shoulder girdle pain with upper thoracic spillover, especially in older patients",
"distinguishing_feature": "Restricted glenohumeral range in a capsular pattern (external rotation > abduction > internal rotation); crepitus; confirmed on radiograph. TrPs can coexist and should be treated; arthritis does not produce spot-tender taut bands in muscle.",
"action": "Shoulder radiograph. Inactivate TrPs concurrently with joint management."
},
{
"id": "bd-5",
"condition": "Thoracic zygapophyseal (facet) joint pain",
"confidence": "common",
"mimics": "Deep upper thoracic paraspinal pain overlapping with multifidi TrP referral",
"distinguishing_feature": "Pain reproduced by passive intersegmental provocation testing (PA pressures on the facet joints); tenderness directly over the facet joint rather than in the paraspinal gutter. May coexist with multifidi TrPs. Distinction matters for choosing injection target.",
"action": "Physiotherapy PA provocation testing. Multifidi TrPs and facet pain frequently coexist — treat both."
},
{
"id": "bd-6",
"condition": "First rib dysfunction",
"confidence": "uncommon",
"mimics": "Upper thoracic and arm symptoms overlapping with scaleni TrP presentation; scaleni attach to the first rib",
"distinguishing_feature": "First rib elevated and tender on posterior superior palpation; restricted first rib caudal glide. Scaleni TrPs are almost always present concurrently.",
"action": "First rib mobilisation in conjunction with scaleni TrP treatment."
},
{
"id": "bd-7",
"condition": "Herpes zoster (shingles — thoracic dermatome)",
"confidence": "uncommon",
"mimics": "Unilateral upper thoracic pain, burning quality, can mimic multifidi or rhomboid TrP pain before the rash appears",
"distinguishing_feature": "Dermatomal distribution; allodynia (light touch painful); vesicular eruption appearing 1–4 days after onset of pain. Pain precedes the rash.",
"action": "Examine the skin carefully at every visit in any patient with unilateral burning upper thoracic pain. If vesicles appear, refer urgently — antiviral window is 72 hours from rash onset."
},
{
"id": "bd-8",
"condition": "Winged scapula (serratus anterior weakness)",
"confidence": "uncommon",
"mimics": "Medial scapular border pain and upper thoracic aching overlapping with rhomboid TrP presentation",
"distinguishing_feature": "Scapular winging observed on push-up against a wall or forward arm elevation; serratus anterior weakness on manual muscle testing. Rhomboid TrPs frequently develop secondary to serratus anterior inhibition.",
"action": "Serratus anterior rehabilitation. Treat rhomboid TrPs concurrently but address the serratus anterior as the underlying cause."
},
{
"id": "bd-9",
"condition": "Myofascial pain persisting after spinal manipulation / injection",
"confidence": "common",
"mimics": "Residual upper thoracic pain after spinal treatment, often re-attributed to the joint",
"distinguishing_feature": "After a spinal intervention, if pain persists or recurs at a lower level than before, active TrPs in the muscles of the treated region should be re-examined. TrPs that were masked by the dominant segmental pain become apparent as the joint pain resolves.",
"action": "Re-examine muscles systematically after any spinal intervention. The muscles most commonly harbouring residual TrPs after thoracic or cervical manipulation: trapezius, levator scapulae, rhomboids, multifidi."
}
]
}