DiagnosticTree/BackofShoulder
{
"model": "bayesian_lr_scoring",
"version": "1.0",
"description": "Probabilistic scoring model for posterior shoulder pain using Bayesian likelihood ratio updating with Thurstonian pairwise tiebreakers. Muscles drawn from T&S Vol.1 Ch.18 (Overview: Upper Back, Shoulder, and Arm). Bold muscles in Ch.18 carry higher priors (0.0857); regular-weight muscles carry lower priors (0.0571).",
"thresholds": {
"early_exit_posterior": 0.55,
"early_exit_gap": 0.18,
"pairwise_trigger": 0.22
},
"muscles": {
"subscapularis": {
"label": "Subscapularis",
"prior": 0.08571429,
"page": "Muscle:Subscapularis",
"key_trp_note": "Subscapularis is the key TrP driving the frozen shoulder cascade. Secondary TrPs in pectoralis major, teres major, latissimus dorsi, triceps brachii (long head), and anterior deltoid develop sequentially. Until subscapularis TrPs are identified and corrected, these satellite TrPs persistently recur.",
"subtitle": "Posterior shoulder pain + wrist strap band; frozen shoulder"
},
"infraspinatus": {
"label": "Infraspinatus",
"prior": 0.05714286,
"page": "Muscle:Infraspinatus",
"key_trp_note": "Infraspinatus TrPs drive satellite TrPs in the anterior deltoid, biceps brachii, and supraspinatus. Treat infraspinatus before its satellites. The supraspinatus-infraspinatus team is the most common co-active pairing in shoulder pain.",
"subtitle": "Deep anterior joint pain + behind-back severely restricted; cannot sleep either side"
},
"teres_minor": {
"label": "Teres Minor",
"prior": 0.08571429,
"page": "Muscle:Teres_Minor",
"key_trp_note": "Teres minor TrPs are almost always uncovered after infraspinatus treatment. Infraspinatus anterior shoulder pain dominates and masks the teres minor presentation. Treat infraspinatus first; teres minor TrPs emerge as the next layer.",
"subtitle": "Posterior deltoid near attachment (prune-sized); 4th/5th finger tingling"
},
"teres_major": {
"label": "Teres Major",
"prior": 0.08571429,
"page": "Muscle:Teres_Major",
"key_trp_note": "Teres major almost always develops TrPs concurrently with latissimus dorsi — treat as a unit. Rhomboid TrPs that are refractory to direct treatment are often maintained by teres major as the key TrP — inactivate teres major first.",
"subtitle": "Posterior deltoid aching; reaches forward but not back; driving heavy steering"
},
"deltoid_posterior": {
"label": "Posterior Deltoid",
"prior": 0.08571429,
"page": "Muscle:Deltoid",
"key_trp_note": "Posterior deltoid TrPs are almost never isolated — infraspinatus is the most common key TrP source. Check infraspinatus and supraspinatus before treating posterior deltoid directly. Also check latissimus dorsi and teres major as co-activating muscles.",
"subtitle": "Local posterior shoulder only; no distant referral; history of direct impact"
},
"supraspinatus": {
"label": "Supraspinatus",
"prior": 0.08571429,
"page": "Muscle:Supraspinatus",
"key_trp_note": "Infraspinatus TrPs are often the key TrP source driving supraspinatus satellites. If supraspinatus TrPs recur, examine infraspinatus. Inactivating supraspinatus TrPs (which lie in the deltoid referral zone) usually resolves middle deltoid satellite TrPs without direct treatment.",
"subtitle": "Mid-deltoid ache + lateral epicondyle; painful arc 60\u2013120\u00b0"
},
"serratus_posterior_sup": {
"label": "Serratus Posterior Superior",
"prior": 0.08571429,
"page": "Muscle:Serratus_Posterior",
"key_trp_note": "Scalene TrPs are the key TrP source driving serratus posterior superior satellite TrPs. Always examine the neck for scalene TrPs when a serratus posterior superior TrP is found.",
"subtitle": "Deep under scapula, unreachable; triceps/elbow/little finger; mimics C8 radiculopathy"
},
"triceps": {
"label": "Triceps Brachii",
"prior": 0.08571429,
"page": "Muscle:Triceps_Brachii",
"key_trp_note": "Triceps TrPs are frequently satellites of scalene, teres major, or latissimus dorsi key TrPs. Long head TrPs skipping the elbow are a distinguishing feature. Treat key TrPs first — scalenes and teres major.",
"subtitle": "Posterior arm to posterior shoulder; skips the elbow"
},
"levator": {
"label": "Levator Scapulae",
"prior": 0.08571429,
"page": "Muscle:Levator_Scapulae",
"key_trp_note": "Lower trapezius TrP3 is the key TrP most commonly driving levator scapulae satellites. Treat lower trapezius TrP3 first if levator TrPs recur or respond poorly.",
"subtitle": "Stiff neck; cannot look over sore shoulder; restricted toward side"
},
"trapezius_trp3_6": {
"label": "Trapezius (TrP3/TrP6)",
"prior": 0.08571429,
"page": "Muscle:Trapezius",
"key_trp_note": "Lower trapezius TrP3 refers to the suprascapular region and is the most clinically important and most commonly overlooked of the trapezius TrPs. It is often the key TrP maintaining upper trapezius and levator scapulae satellites. TrP6 (mid-trapezius) refers to the interscapular region.",
"subtitle": "Suprascapular referral (TrP3) or interscapular (TrP6); postural aggravation"
},
"latissimus": {
"label": "Latissimus Dorsi",
"prior": 0.05714286,
"page": "Muscle:Latissimus_Dorsi",
"key_trp_note": "Latissimus dorsi TrPs are a key driver of iliocostalis thoracis satellite TrPs and teres major TrPs. Treat latissimus before these satellites. Latissimus is part of the pseudothoracic outlet quadrad (with teres major, subscapularis, pectoralis major).",
"subtitle": "Inferior scapular angle; mid-back; ulnar hand referral (ring and little fingers)"
},
"iliocostalis": {
"label": "Iliocostalis Thoracis",
"prior": 0.05714286,
"page": "Muscle:Iliocostalis_Thoracis",
"key_trp_note": "Iliocostalis thoracis TrPs at the midthoracic level refer upward toward the posterior shoulder and may be satellites of key TrPs in the latissimus dorsi. Treat latissimus dorsi before iliocostalis when both are active.",
"subtitle": "Midthoracic-level TrP referring up toward posterior shoulder; left side mimics angina"
},
"scalene": {
"label": "Scalene",
"prior": 0.05714286,
"page": "Muscle:Scalene",
"key_trp_note": "Scalene TrPs drive satellite TrPs in the serratus posterior superior, upper trapezius, triceps long head, pectoralis major and minor. Treat scalenes before their satellites. SCM should be treated concurrently.",
"subtitle": "Posterior shoulder + arm/hand symptoms; nocturnal arm aching"
}
},
"questions": [
{
"id": "q_wrist_pain",
"text": "Is there a strap-like band of pain or tenderness around the wrist \u2014 particularly the back of the wrist?",
"sublabel": "The patient may have moved their wristwatch to the other wrist because the band is uncomfortable",
"type": "binary",
"answers": [
{
"id": "yes",
"label": "Yes \u2014 strap-like wrist pain or tenderness, mainly on the dorsum",
"lr": {
"subscapularis": 12.0,
"infraspinatus": 0.3,
"teres_minor": 0.4,
"teres_major": 0.3,
"deltoid_posterior": 0.2,
"supraspinatus": 0.3,
"serratus_posterior_sup": 0.3,
"triceps": 0.3,
"levator": 0.2,
"trapezius_trp3_6": 0.2,
"latissimus": 0.4,
"iliocostalis": 0.2,
"scalene": 0.3
}
},
{
"id": "no",
"label": "No \u2014 no wrist band pain",
"lr": {
"subscapularis": 0.25,
"infraspinatus": 1.1,
"teres_minor": 1.1,
"teres_major": 1.2,
"deltoid_posterior": 1.2,
"supraspinatus": 1.2,
"serratus_posterior_sup": 1.2,
"triceps": 1.2,
"levator": 1.2,
"trapezius_trp3_6": 1.2,
"latissimus": 1.1,
"iliocostalis": 1.2,
"scalene": 1.1
}
}
]
},
{
"id": "q_abduction_lat_rot",
"text": "Is shoulder abduction AND lateral rotation simultaneously reduced \u2014 yet near-full lateral rotation is possible with the arm adducted at the side?",
"sublabel": "With the arm out to 90\u00b0, the forearm cannot swing upward (no lateral rotation in abduction). With the elbow tucked in and bent to 90\u00b0, the forearm swings outward freely.",
"type": "binary",
"answers": [
{
"id": "yes",
"label": "Yes \u2014 lateral rotation lost in abduction, but present with arm adducted",
"lr": {
"subscapularis": 14.0,
"infraspinatus": 0.3,
"teres_minor": 0.5,
"teres_major": 0.4,
"deltoid_posterior": 0.2,
"supraspinatus": 0.4,
"serratus_posterior_sup": 0.3,
"triceps": 0.2,
"levator": 0.3,
"trapezius_trp3_6": 0.2,
"latissimus": 0.3,
"iliocostalis": 0.2,
"scalene": 0.3
}
},
{
"id": "no",
"label": "No \u2014 lateral rotation not reciprocally limited in this pattern",
"lr": {
"subscapularis": 0.2,
"infraspinatus": 1.1,
"teres_minor": 1.1,
"teres_major": 1.2,
"deltoid_posterior": 1.2,
"supraspinatus": 1.2,
"serratus_posterior_sup": 1.2,
"triceps": 1.2,
"levator": 1.2,
"trapezius_trp3_6": 1.2,
"latissimus": 1.1,
"iliocostalis": 1.2,
"scalene": 1.1
}
}
]
},
{
"id": "q_sleep",
"text": "How does the pain affect sleep?",
"sublabel": "Which sleeping position is tolerated?",
"type": "choice",
"answers": [
{
"id": "neither_side",
"label": "Cannot sleep on EITHER side \u2014 may sleep sitting up or propped in a chair",
"sublabel": "Even the unaffected side is painful; every lying position wakes the patient",
"lr": {
"infraspinatus": 9.0,
"subscapularis": 3.0,
"teres_minor": 0.5,
"teres_major": 0.5,
"deltoid_posterior": 0.3,
"supraspinatus": 0.4,
"serratus_posterior_sup": 0.5,
"triceps": 0.4,
"levator": 0.4,
"trapezius_trp3_6": 0.3,
"latissimus": 0.4,
"iliocostalis": 0.3,
"scalene": 0.4
}
},
{
"id": "not_affected",
"label": "Cannot sleep on the AFFECTED side only",
"sublabel": "Lying on the painful shoulder wakes the patient; unaffected side and supine are tolerated",
"lr": {
"teres_major": 1.8,
"deltoid_posterior": 1.8,
"teres_minor": 1.5,
"supraspinatus": 1.5,
"triceps": 1.5,
"serratus_posterior_sup": 1.4,
"subscapularis": 0.7,
"infraspinatus": 0.4,
"levator": 1.0,
"trapezius_trp3_6": 1.0,
"latissimus": 1.2,
"iliocostalis": 1.0,
"scalene": 1.0
}
},
{
"id": "sleep_ok",
"label": "Sleep is unaffected or only mildly disturbed",
"sublabel": "Patient finds a comfortable position without significant waking",
"lr": {
"teres_major": 1.2,
"deltoid_posterior": 1.5,
"trapezius_trp3_6": 1.5,
"levator": 1.5,
"iliocostalis": 1.5,
"scalene": 1.3,
"supraspinatus": 1.0,
"teres_minor": 0.8,
"triceps": 0.8,
"serratus_posterior_sup": 0.8,
"subscapularis": 0.5,
"infraspinatus": 0.3,
"latissimus": 1.0
}
}
]
},
{
"id": "q_behind_back",
"text": "Can the patient reach behind their back?",
"sublabel": "Can the patient reach the wallet pocket or brassiere hooks, or bring the arm behind the back to waist level?",
"type": "choice",
"answers": [
{
"id": "cannot",
"label": "Cannot reach behind back at all \u2014 cannot reach the hip pocket or brassiere hooks",
"sublabel": "Severely restricted: arm will not go behind the back or to the gluteal region",
"lr": {
"infraspinatus": 8.0,
"subscapularis": 4.0,
"teres_minor": 1.5,
"teres_major": 1.0,
"deltoid_posterior": 0.5,
"supraspinatus": 1.5,
"serratus_posterior_sup": 0.5,
"triceps": 0.5,
"levator": 0.5,
"trapezius_trp3_6": 0.4,
"latissimus": 0.5,
"iliocostalis": 0.3,
"scalene": 0.5
}
},
{
"id": "restricted_few_cm",
"label": "Slightly restricted \u2014 reaches behind but 3\u20135 cm short of normal wrap-around",
"sublabel": "Can get the arm behind the back but cannot fully wrap or reach up to shoulder level from behind",
"lr": {
"teres_major": 7.0,
"teres_minor": 3.0,
"supraspinatus": 1.5,
"deltoid_posterior": 1.0,
"infraspinatus": 1.0,
"subscapularis": 0.7,
"serratus_posterior_sup": 0.5,
"triceps": 0.7,
"levator": 0.5,
"trapezius_trp3_6": 0.5,
"latissimus": 1.0,
"iliocostalis": 0.4,
"scalene": 0.5
}
},
{
"id": "normal",
"label": "Normal behind-back reach \u2014 no restriction",
"lr": {
"deltoid_posterior": 1.5,
"trapezius_trp3_6": 1.5,
"levator": 1.5,
"serratus_posterior_sup": 1.3,
"triceps": 1.3,
"iliocostalis": 1.5,
"scalene": 1.3,
"latissimus": 1.3,
"supraspinatus": 0.7,
"teres_major": 0.3,
"teres_minor": 0.5,
"infraspinatus": 0.3,
"subscapularis": 0.4
}
}
]
},
{
"id": "q_finger_symptoms",
"text": "Are there tingling, numbness, or dysesthesia in the fingers?",
"sublabel": "Which fingers are affected?",
"type": "choice",
"answers": [
{
"id": "ring_little",
"label": "4th and/or 5th finger \u2014 ring and little finger tingling or numbness",
"sublabel": "Dysesthesia in the ring and little fingers; may be brought on by reaching above or behind the shoulder",
"lr": {
"teres_minor": 9.0,
"serratus_posterior_sup": 4.0,
"scalene": 2.5,
"latissimus": 2.0,
"subscapularis": 0.5,
"infraspinatus": 0.4,
"teres_major": 0.5,
"deltoid_posterior": 0.3,
"supraspinatus": 0.3,
"triceps": 0.5,
"levator": 0.3,
"trapezius_trp3_6": 0.3,
"iliocostalis": 0.3
}
},
{
"id": "radial_thumb",
"label": "Thumb and index finger (radial side) \u2014 or lateral forearm",
"sublabel": "Tingling or numbness in the thumb, index finger, or lateral forearm",
"lr": {
"infraspinatus": 4.0,
"scalene": 3.0,
"supraspinatus": 1.5,
"teres_minor": 0.4,
"teres_major": 0.4,
"serratus_posterior_sup": 0.4,
"subscapularis": 0.4,
"deltoid_posterior": 0.3,
"triceps": 0.4,
"levator": 0.3,
"trapezius_trp3_6": 0.3,
"latissimus": 0.3,
"iliocostalis": 0.3
}
},
{
"id": "no_finger",
"label": "No finger symptoms",
"lr": {
"deltoid_posterior": 1.5,
"teres_major": 1.5,
"trapezius_trp3_6": 1.4,
"levator": 1.4,
"supraspinatus": 1.3,
"subscapularis": 1.0,
"iliocostalis": 1.3,
"triceps": 1.0,
"latissimus": 0.9,
"infraspinatus": 0.8,
"serratus_posterior_sup": 0.5,
"teres_minor": 0.4,
"scalene": 0.6
}
}
]
},
{
"id": "q_scapula_pain",
"text": "Is the pain felt UNDER the upper portion of the scapula \u2014 as though deep to the shoulder blade and unreachable?",
"sublabel": "Patient reaches back with the opposite arm but cannot touch the sore spot; the shoulder blade seems to cover it",
"type": "binary",
"answers": [
{
"id": "yes",
"label": "Yes \u2014 deep under the scapula, seemingly inaccessible",
"lr": {
"serratus_posterior_sup": 10.0,
"infraspinatus": 2.0,
"subscapularis": 1.5,
"teres_minor": 0.6,
"teres_major": 0.5,
"deltoid_posterior": 0.3,
"supraspinatus": 0.5,
"triceps": 0.4,
"levator": 0.4,
"trapezius_trp3_6": 0.5,
"latissimus": 0.5,
"iliocostalis": 0.5,
"scalene": 0.5
}
},
{
"id": "no",
"label": "No \u2014 pain is accessible on the shoulder surface",
"lr": {
"serratus_posterior_sup": 0.2,
"infraspinatus": 0.9,
"subscapularis": 1.0,
"teres_minor": 1.2,
"teres_major": 1.2,
"deltoid_posterior": 1.3,
"supraspinatus": 1.2,
"triceps": 1.2,
"levator": 1.2,
"trapezius_trp3_6": 1.1,
"latissimus": 1.1,
"iliocostalis": 1.1,
"scalene": 1.1
}
}
]
},
{
"id": "q_elbow_pain",
"text": "Is there elbow pain or pain specifically at the lateral epicondyle?",
"sublabel": "Pain at or around the outer elbow; or pain that extends to the elbow from the shoulder",
"type": "binary",
"answers": [
{
"id": "yes",
"label": "Yes \u2014 elbow pain or lateral epicondyle referral present",
"lr": {
"supraspinatus": 6.0,
"triceps": 2.5,
"serratus_posterior_sup": 2.0,
"scalene": 1.5,
"infraspinatus": 0.8,
"teres_minor": 0.6,
"teres_major": 0.4,
"deltoid_posterior": 0.3,
"subscapularis": 0.3,
"levator": 0.3,
"trapezius_trp3_6": 0.3,
"latissimus": 0.4,
"iliocostalis": 0.3
}
},
{
"id": "no",
"label": "No \u2014 no elbow pain",
"lr": {
"supraspinatus": 0.3,
"triceps": 0.7,
"serratus_posterior_sup": 0.8,
"scalene": 0.9,
"infraspinatus": 1.1,
"teres_minor": 1.2,
"teres_major": 1.2,
"deltoid_posterior": 1.3,
"subscapularis": 1.2,
"levator": 1.2,
"trapezius_trp3_6": 1.2,
"latissimus": 1.1,
"iliocostalis": 1.2
}
}
]
},
{
"id": "q_painful_arc",
"text": "Is there a painful arc during shoulder abduction \u2014 pain that appears between approximately 60\u00b0 and 120\u00b0 of raising the arm sideways, then diminishes above that?",
"sublabel": "The patient can raise the arm but pain appears then disappears as the arm reaches overhead",
"type": "binary",
"answers": [
{
"id": "yes",
"label": "Yes \u2014 painful arc between 60\u00b0 and 120\u00b0 of abduction",
"lr": {
"supraspinatus": 8.0,
"deltoid_posterior": 1.5,
"infraspinatus": 0.8,
"teres_minor": 0.6,
"teres_major": 0.5,
"subscapularis": 0.5,
"serratus_posterior_sup": 0.4,
"triceps": 0.4,
"levator": 0.5,
"trapezius_trp3_6": 0.4,
"latissimus": 0.4,
"iliocostalis": 0.4,
"scalene": 0.5
}
},
{
"id": "no",
"label": "No \u2014 no arc pattern; abduction is uniformly painful or pain-free throughout",
"lr": {
"supraspinatus": 0.2,
"deltoid_posterior": 1.0,
"infraspinatus": 1.1,
"teres_minor": 1.2,
"teres_major": 1.2,
"subscapularis": 1.1,
"serratus_posterior_sup": 1.2,
"triceps": 1.2,
"levator": 1.1,
"trapezius_trp3_6": 1.2,
"latissimus": 1.2,
"iliocostalis": 1.2,
"scalene": 1.1
}
}
]
},
{
"id": "q_onset",
"text": "How did the posterior shoulder pain begin?",
"sublabel": "Choose the onset pattern that best describes this episode",
"type": "choice",
"answers": [
{
"id": "acute_incident",
"label": "Sudden onset from a specific remembered incident \u2014 MVA, fall, catching a fall, reaching jerk",
"sublabel": "Patient can name the exact moment pain started; often reaching backward or bracing in a crash",
"lr": {
"infraspinatus": 5.0,
"teres_minor": 3.0,
"teres_major": 2.0,
"subscapularis": 2.5,
"deltoid_posterior": 2.0,
"supraspinatus": 1.0,
"triceps": 1.5,
"serratus_posterior_sup": 0.7,
"levator": 1.0,
"trapezius_trp3_6": 0.7,
"latissimus": 0.8,
"iliocostalis": 0.5,
"scalene": 0.8
}
},
{
"id": "gradual_loading",
"label": "Gradual onset from sustained or repetitive loading \u2014 carrying heavy bags, overhead work",
"sublabel": "No single incident; pain crept in over days or weeks with repeated activity",
"lr": {
"supraspinatus": 4.0,
"subscapularis": 2.0,
"serratus_posterior_sup": 2.0,
"scalene": 2.0,
"levator": 1.5,
"trapezius_trp3_6": 2.0,
"teres_major": 0.8,
"teres_minor": 0.6,
"infraspinatus": 0.5,
"deltoid_posterior": 0.5,
"triceps": 0.8,
"latissimus": 1.0,
"iliocostalis": 1.5
}
},
{
"id": "driving",
"label": "Gradual onset associated with prolonged driving \u2014 especially heavy or non-power-assisted steering",
"sublabel": "Pain developed after weeks or months of driving a vehicle requiring significant steering effort",
"lr": {
"teres_major": 8.0,
"latissimus": 3.0,
"subscapularis": 1.5,
"scalene": 1.5,
"deltoid_posterior": 1.0,
"supraspinatus": 0.7,
"infraspinatus": 0.6,
"teres_minor": 0.5,
"triceps": 0.8,
"serratus_posterior_sup": 0.5,
"levator": 0.7,
"trapezius_trp3_6": 0.7,
"iliocostalis": 0.5
}
},
{
"id": "immobilisation",
"label": "After immobilisation or prolonged shoulder rest \u2014 sling, post-surgical, or long inactivity",
"sublabel": "Pain developed or worsened following a period of shoulder immobility or disuse",
"lr": {
"subscapularis": 5.0,
"teres_major": 2.0,
"latissimus": 1.5,
"infraspinatus": 1.5,
"teres_minor": 1.0,
"deltoid_posterior": 0.8,
"supraspinatus": 0.8,
"triceps": 0.7,
"serratus_posterior_sup": 0.7,
"levator": 0.7,
"trapezius_trp3_6": 0.7,
"scalene": 0.7,
"iliocostalis": 0.5
}
}
]
},
{
"id": "q_nocturnal_arm",
"text": "Is the patient woken at night by arm aching or numbness requiring the arm to hang over the bed or be shaken?",
"sublabel": "Nocturnal arm symptoms relieved by hanging the arm over the side of the bed",
"type": "binary",
"answers": [
{
"id": "yes",
"label": "Yes \u2014 woken at night; arm must hang over bed side for relief",
"lr": {
"scalene": 9.0,
"serratus_posterior_sup": 1.5,
"infraspinatus": 0.5,
"subscapularis": 0.5,
"teres_minor": 0.5,
"teres_major": 0.4,
"deltoid_posterior": 0.3,
"supraspinatus": 0.4,
"triceps": 0.5,
"levator": 0.4,
"trapezius_trp3_6": 0.4,
"latissimus": 0.5,
"iliocostalis": 0.4
}
},
{
"id": "no",
"label": "No \u2014 no nocturnal arm hanging symptom",
"lr": {
"scalene": 0.25,
"serratus_posterior_sup": 1.0,
"infraspinatus": 1.1,
"subscapularis": 1.1,
"teres_minor": 1.1,
"teres_major": 1.2,
"deltoid_posterior": 1.2,
"supraspinatus": 1.1,
"triceps": 1.1,
"levator": 1.1,
"trapezius_trp3_6": 1.1,
"latissimus": 1.0,
"iliocostalis": 1.1
}
}
]
},
{
"id": "q_neck_rotation",
"text": "Is cervical rotation restricted or painful toward the PAINFUL shoulder side?",
"sublabel": "The patient cannot fully look over the sore shoulder",
"type": "binary",
"answers": [
{
"id": "yes",
"label": "Yes \u2014 cannot look fully over the sore shoulder",
"lr": {
"levator": 7.0,
"trapezius_trp3_6": 2.0,
"scalene": 2.0,
"serratus_posterior_sup": 1.0,
"infraspinatus": 0.7,
"subscapularis": 0.6,
"teres_minor": 0.6,
"teres_major": 0.5,
"deltoid_posterior": 0.5,
"supraspinatus": 0.5,
"triceps": 0.5,
"latissimus": 0.5,
"iliocostalis": 0.5
}
},
{
"id": "no",
"label": "No \u2014 cervical rotation is not restricted toward the sore side",
"lr": {
"levator": 0.15,
"trapezius_trp3_6": 0.9,
"scalene": 0.8,
"serratus_posterior_sup": 1.1,
"infraspinatus": 1.2,
"subscapularis": 1.2,
"teres_minor": 1.2,
"teres_major": 1.2,
"deltoid_posterior": 1.2,
"supraspinatus": 1.2,
"triceps": 1.2,
"latissimus": 1.2,
"iliocostalis": 1.2
}
}
]
},
{
"id": "q_ulnar_hand",
"text": "Is there pain, tingling, or heaviness in the ULNAR side of the forearm, hand, or specific referral to the inferior angle of the scapula?",
"sublabel": "Ring and little fingers, ulnar forearm; OR pain centred at the bottom tip of the shoulder blade",
"type": "binary",
"answers": [
{
"id": "yes",
"label": "Yes \u2014 ulnar hand/forearm symptoms or inferior scapular angle pain",
"lr": {
"latissimus": 7.0,
"serratus_posterior_sup": 3.0,
"teres_minor": 2.0,
"scalene": 2.5,
"subscapularis": 0.5,
"infraspinatus": 0.4,
"teres_major": 0.5,
"deltoid_posterior": 0.3,
"supraspinatus": 0.3,
"triceps": 0.5,
"levator": 0.3,
"trapezius_trp3_6": 0.3,
"iliocostalis": 0.5
}
},
{
"id": "no",
"label": "No \u2014 no ulnar hand symptoms or inferior scapular angle pain",
"lr": {
"latissimus": 0.3,
"serratus_posterior_sup": 0.8,
"teres_minor": 0.9,
"scalene": 0.7,
"subscapularis": 1.1,
"infraspinatus": 1.2,
"teres_major": 1.2,
"deltoid_posterior": 1.2,
"supraspinatus": 1.2,
"triceps": 1.1,
"levator": 1.2,
"trapezius_trp3_6": 1.2,
"iliocostalis": 1.1
}
}
]
},
{
"id": "q_local_only",
"text": "Is the pain ENTIRELY LOCAL to the posterior deltoid region \u2014 with NO referral to the arm, hand, elbow, wrist, or neck?",
"sublabel": "Pain stays within and around the back of the shoulder muscle; never travels down the arm or to the neck",
"type": "binary",
"answers": [
{
"id": "yes",
"label": "Yes \u2014 pain is entirely local to the posterior deltoid area; no arm referral at all",
"lr": {
"deltoid_posterior": 9.0,
"teres_minor": 2.5,
"teres_major": 1.5,
"subscapularis": 0.4,
"infraspinatus": 0.3,
"supraspinatus": 0.4,
"serratus_posterior_sup": 0.2,
"triceps": 0.3,
"levator": 0.3,
"trapezius_trp3_6": 0.4,
"latissimus": 0.4,
"iliocostalis": 0.4,
"scalene": 0.3
}
},
{
"id": "no",
"label": "No \u2014 there is some arm, hand, elbow, wrist, or neck referral",
"lr": {
"deltoid_posterior": 0.2,
"teres_minor": 0.9,
"teres_major": 0.9,
"subscapularis": 1.2,
"infraspinatus": 1.3,
"supraspinatus": 1.2,
"serratus_posterior_sup": 1.3,
"triceps": 1.3,
"levator": 1.2,
"trapezius_trp3_6": 1.1,
"latissimus": 1.1,
"iliocostalis": 1.1,
"scalene": 1.2
}
}
]
}
],
"pairwise": [
{
"id": "pw_subscap_infra",
"pair": ["subscapularis", "infraspinatus"],
"text": "Tiebreaker \u2014 Subscapularis vs Infraspinatus",
"question": "Is the primary pain zone at the POSTERIOR shoulder (back), or DEEP INSIDE the front of the joint?",
"answers": [
{
"id": "posterior",
"label": "Posterior shoulder \u2014 the back of the shoulder is the worst",
"lr": {
"subscapularis": 4.0,
"infraspinatus": 0.25
}
},
{
"id": "deep_anterior",
"label": "Deep inside the front of the joint \u2014 patient places hand over the front of the shoulder",
"lr": {
"subscapularis": 0.25,
"infraspinatus": 4.0
}
}
]
},
{
"id": "pw_teres_minor_major",
"pair": ["teres_minor", "teres_major"],
"text": "Tiebreaker \u2014 Teres Minor vs Teres Major",
"question": "Which feature is more prominent?",
"answers": [
{
"id": "finger_dysesthesia",
"label": "Tingling or numbness in the 4th or 5th finger",
"lr": {
"teres_minor": 5.0,
"teres_major": 0.2
}
},
{
"id": "reach_restriction",
"label": "Pain specifically when reaching FORWARD and up \u2014 but shoulder does not freeze",
"lr": {
"teres_minor": 0.3,
"teres_major": 4.0
}
}
]
},
{
"id": "pw_deltoid_teres_minor",
"pair": ["deltoid_posterior", "teres_minor"],
"text": "Tiebreaker \u2014 Posterior Deltoid vs Teres Minor",
"question": "Is the pain entirely local (no finger symptoms, no arm referral), or does it include 4th/5th finger dysesthesia?",
"answers": [
{
"id": "local_only",
"label": "Entirely local \u2014 no finger symptoms, no arm referral",
"lr": {
"deltoid_posterior": 5.0,
"teres_minor": 0.2
}
},
{
"id": "finger_symptoms",
"label": "4th/5th finger tingling or numbness accompanies the shoulder pain",
"lr": {
"deltoid_posterior": 0.2,
"teres_minor": 5.0
}
}
]
},
{
"id": "pw_supraspinatus_infraspinatus",
"pair": ["supraspinatus", "infraspinatus"],
"text": "Tiebreaker \u2014 Supraspinatus vs Infraspinatus",
"question": "Is the shoulder pain in the MID-DELTOID (lateral arm), or does it refer to the FRONT of the joint?",
"answers": [
{
"id": "mid_deltoid",
"label": "Mid-deltoid (lateral shoulder) \u2014 patient points to the outside of the arm",
"lr": {
"supraspinatus": 4.0,
"infraspinatus": 0.25
}
},
{
"id": "deep_anterior",
"label": "Deep inside the front of the shoulder \u2014 patient covers the anterior joint",
"lr": {
"supraspinatus": 0.25,
"infraspinatus": 4.0
}
}
]
},
{
"id": "pw_teres_major_latissimus",
"pair": ["teres_major", "latissimus"],
"text": "Tiebreaker \u2014 Teres Major vs Latissimus Dorsi",
"question": "Where is the pain centred \u2014 in the POSTERIOR DELTOID region, or at the INFERIOR SCAPULAR ANGLE or mid-back?",
"answers": [
{
"id": "posterior_deltoid",
"label": "Posterior deltoid region \u2014 back of the shoulder",
"lr": {
"teres_major": 4.0,
"latissimus": 0.25
}
},
{
"id": "inferior_scapula",
"label": "Inferior scapular angle or mid-thoracic back \u2014 lower or more central than the shoulder",
"lr": {
"teres_major": 0.25,
"latissimus": 4.0
}
}
]
},
{
"id": "pw_scalene_serratus",
"pair": ["scalene", "serratus_posterior_sup"],
"text": "Tiebreaker \u2014 Scalene vs Serratus Posterior Superior",
"question": "Is the nocturnal arm symptom the dominant feature, or is the deep inaccessible scapular pain the dominant feature?",
"answers": [
{
"id": "nocturnal_arm",
"label": "Nocturnal arm aching requiring the arm to hang over the bed \u2014 the dominant complaint",
"lr": {
"scalene": 5.0,
"serratus_posterior_sup": 0.3
}
},
{
"id": "deep_scapula",
"label": "Deep pain under the scapula that cannot be touched \u2014 the dominant complaint",
"lr": {
"scalene": 0.3,
"serratus_posterior_sup": 5.0
}
}
]
},
{
"id": "pw_infraspinatus_teres_minor",
"pair": ["infraspinatus", "teres_minor"],
"text": "Tiebreaker \u2014 Infraspinatus vs Teres Minor",
"question": "Is this a first presentation, or has infraspinatus treatment already been done with partial improvement?",
"answers": [
{
"id": "first_presentation",
"label": "First presentation \u2014 no prior treatment of the infraspinatus",
"lr": {
"infraspinatus": 4.0,
"teres_minor": 0.3
}
},
{
"id": "after_infra_treatment",
"label": "Infraspinatus has already been treated \u2014 anterior shoulder pain resolved but posterior shoulder and finger symptoms remain",
"lr": {
"infraspinatus": 0.3,
"teres_minor": 4.0
}
}
]
}
],
"treatment_dag": {
"edges": [
{
"from": "infraspinatus",
"to": "teres_minor",
"type": "key_satellite",
"label": "Infraspinatus TrPs dominate and mask teres minor \u2014 treat infraspinatus first; teres minor TrPs emerge as the next layer"
},
{
"from": "infraspinatus",
"to": "deltoid_posterior",
"type": "key_satellite",
"label": "Infraspinatus is the most important key TrP driving posterior deltoid satellite TrPs"
},
{
"from": "supraspinatus",
"to": "deltoid_posterior",
"type": "key_satellite",
"label": "Supraspinatus drives middle and anterior deltoid satellite TrPs"
},
{
"from": "subscapularis",
"to": "teres_major",
"type": "key_satellite",
"label": "Subscapularis is the key TrP initiating the frozen shoulder cascade; teres major develops as a secondary TrP early"
},
{
"from": "subscapularis",
"to": "latissimus",
"type": "key_satellite",
"label": "Latissimus develops secondary TrPs as part of the frozen shoulder cascade driven by subscapularis"
},
{
"from": "subscapularis",
"to": "triceps",
"type": "key_satellite",
"label": "Triceps long head develops secondary TrPs in the frozen shoulder cascade"
},
{
"from": "scalene",
"to": "serratus_posterior_sup",
"type": "key_satellite",
"label": "Scalene TrPs are the key TrP source driving serratus posterior superior satellite TrPs \u2014 always examine the neck"
},
{
"from": "scalene",
"to": "triceps",
"type": "key_satellite",
"label": "Scalene TrPs drive triceps long head satellite TrPs"
},
{
"from": "latissimus",
"to": "teres_major",
"type": "functional_unit",
"label": "Latissimus dorsi and teres major share the posterior axillary fold and humeral insertion \u2014 treat as a unit in the same session"
},
{
"from": "latissimus",
"to": "iliocostalis",
"type": "key_satellite",
"label": "Latissimus dorsi TrPs drive iliocostalis thoracis satellite TrPs \u2014 treat latissimus before iliocostalis"
},
{
"from": "teres_major",
"to": "infraspinatus",
"type": "functional_unit",
"label": "Teres major and infraspinatus share the scapular lateral border functional unit \u2014 treat concurrently"
},
{
"from": "infraspinatus",
"to": "supraspinatus",
"type": "functional_unit",
"label": "Infraspinatus-supraspinatus team \u2014 almost always develop TrPs together; treat in the same session"
},
{
"from": "subscapularis",
"to": "infraspinatus",
"type": "antagonist_risk",
"label": "\u26a0 Subscapularis release may reactively activate infraspinatus (unaccustomed shortening) \u2014 lengthen and spray infraspinatus immediately if sudden sharp shoulder pain occurs during subscapularis release"
},
{
"from": "teres_major",
"to": "triceps",
"type": "functional_unit",
"label": "Teres major and long head of triceps share the posterior axillary fold \u2014 treat concurrently"
},
{
"from": "teres_major",
"to": "deltoid_posterior",
"type": "secondary_load",
"label": "Posterior deltoid develops secondary TrPs when teres major is chronically shortened \u2014 treat teres major first"
},
{
"from": "scalene",
"to": "levator",
"type": "secondary_load",
"label": "Levator scapulae overloaded secondarily when scaleni are in protective splinting"
}
],
"edge_type_labels": {
"key_satellite": "Treat first \u2014 key TrP driving satellites",
"functional_unit": "Treat concurrently in same session",
"secondary_load": "Treat after primary resolves",
"antagonist_risk": "\u26a0 Treat in alternating cycles \u2014 reactive activation risk"
}
}
}