DiagnosticTree/AnteriorShoulder
{
"model": "bayesian_lr_scoring",
"version": "1.0",
"description": "Probabilistic scoring model for anterior 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) and individual chapters. Bold muscles carry higher priors (0.1); regular-weight muscles carry lower priors (0.066667). Subclavius is addressed within the pectoralis major entry per T&S chapter structure but scored separately here due to its clinically distinct radial skip pattern.",
"thresholds": {
"early_exit_posterior": 0.55,
"early_exit_gap": 0.18,
"pairwise_trigger": 0.22
},
"muscles": {
"infraspinatus": {
"label": "Infraspinatus",
"prior": 0.09090909,
"page": "Muscle:Infraspinatus",
"key_trp_note": "Infraspinatus TrPs drive satellite TrPs in the anterior deltoid, biceps brachii, and supraspinatus. The supraspinatus-infraspinatus team is the most common co-active pairing in shoulder pain. Treat infraspinatus before its satellites.",
"subtitle": "Deep inside the front of the joint; patient covers anterior shoulder with hand; cannot sleep either side"
},
"deltoid_anterior": {
"label": "Anterior Deltoid",
"prior": 0.09090909,
"page": "Muscle:Deltoid",
"key_trp_note": "Anterior deltoid TrPs are almost always satellites of infraspinatus, supraspinatus, or pectoralis major key TrPs — the anterior deltoid lies in the pain reference zone of all three. Treat the key TrP source first; anterior deltoid TrPs usually resolve without direct treatment.",
"subtitle": "Local anterior shoulder only; no arm referral; history of direct impact or injection"
},
"pec_major_sternal": {
"label": "Pectoralis Major — Sternal Section",
"prior": 0.09090909,
"page": "Muscle:Pectoralis_Major",
"key_trp_note": "Pectoralis major TrPs are almost always co-active with pectoralis minor TrPs — examine both. Scalene TrPs refer pain to the pectoral region and may be a key source. Left-sided pectoral TrPs can co-exist with cardiac disease and must not be attributed to myofascial origin without cardiac assessment. Inactivate pec major TrPs before treating pec minor.",
"subtitle": "Anterior chest and anterior shoulder; medial arm and forearm; ulnar digits; cardiac mimic"
},
"pec_major_clavicular": {
"label": "Pectoralis Major — Clavicular Section",
"prior": 0.09090909,
"page": "Muscle:Pectoralis_Major",
"key_trp_note": "The clavicular section and anterior deltoid work very closely together and are separated only by the cephalic vein groove. Clavicular section TrPs and subclavius TrPs almost always coexist — the subclavius lies immediately beneath the clavicular section.",
"subtitle": "Anterior deltoid region; subclavicular area; no arm or hand referral"
},
"pec_minor": {
"label": "Pectoralis Minor",
"prior": 0.09090909,
"page": "Muscle:Pectoralis_Minor",
"key_trp_note": "Active pectoralis minor TrPs are almost never found without active pectoralis major TrPs. Inactivate pectoralis major first — pec minor TrPs often resolve without direct treatment. Pec minor taut fibres can compress the brachial plexus and axillary artery when the arm is abducted and laterally rotated (Wright manoeuvre).",
"subtitle": "Anterior shoulder at coracoid region; forward shoulder elevation; cannot reach fully behind back; 4th–5th finger involvement"
},
"subclavius": {
"label": "Subclavius",
"prior": 0.06060606,
"page": "Muscle:Pectoralis_Major",
"key_trp_note": "Subclavius TrPs almost always coexist with clavicular pectoralis major TrPs. Subclavius shortening draws the clavicle down toward the subclavian neurovascular structures — a cause of vascular thoracic outlet syndrome. Treat clavicular pectoralis major TrPs first.",
"subtitle": "Radial forearm and hand SKIPPING the elbow and wrist; thumb, index, and middle finger"
},
"biceps": {
"label": "Biceps Brachii",
"prior": 0.09090909,
"page": "Muscle:Biceps_Brachii",
"key_trp_note": "Biceps brachii TrPs refer to the anterior shoulder and biceps region. Infraspinatus is the most common key TrP driving biceps satellite TrPs. Scalene TrPs also drive biceps. The diagnosis of bicipital tendinitis is often due to unrecognised TrPs in the biceps brachii or infraspinatus.",
"subtitle": "Anterior shoulder and biceps region; cannot comfortably lie on affected side"
},
"coracobrachialis": {
"label": "Coracobrachialis",
"prior": 0.09090909,
"page": "Muscle:Coracobrachialis",
"key_trp_note": "Coracobrachialis TrPs are satellites of key TrPs in anterior deltoid, biceps brachii (short head), supraspinatus, and triceps long head. This muscle is typically the last to be found after surrounding muscles have been treated. Treat key TrPs first.",
"subtitle": "Anterior shoulder + posterior arm to dorsal hand skipping elbow and wrist; residual after surrounding muscles cleared"
},
"supraspinatus": {
"label": "Supraspinatus",
"prior": 0.09090909,
"page": "Muscle:Supraspinatus",
"key_trp_note": "Infraspinatus TrPs are often the key TrP source driving supraspinatus satellites. Inactivating supraspinatus TrPs (which lie in the deltoid referral zone) usually resolves middle deltoid satellite TrPs without direct treatment.",
"subtitle": "Lateral shoulder to lateral upper arm; lateral epicondyle referral; painful arc 60–120°"
},
"scalene": {
"label": "Scalene",
"prior": 0.09090909,
"page": "Muscle:Scalene",
"key_trp_note": "Scalene TrPs drive satellite TrPs in pectoralis major/minor, upper trapezius, serratus posterior superior, and triceps long head. Treat scalenes before their satellites. SCM should be treated concurrently. Scalenus minimus (when present) compresses the lower brachial plexus.",
"subtitle": "Anterior chest and anterior shoulder + arm/hand symptoms; nocturnal arm aching"
},
"sternalis": {
"label": "Sternalis",
"prior": 0.06060606,
"page": "Muscle:Sternalis",
"key_trp_note": "Sternalis TrPs are almost always co-active with pectoralis major TrPs — one rarely observes sternalis TrPs alone. The sternal division of SCM (lower end) may refer pain downward over the sternum and activate sternalis as a satellite. Treat pectoralis major and SCM TrPs before or alongside sternalis. Present in only ~4–5% of the population.",
"subtitle": "Deep substernal ache; pain is movement-independent; mimics MI; no arm referral past elbow"
},
"latissimus": {
"label": "Latissimus Dorsi",
"prior": 0.06060606,
"page": "Muscle:Latissimus_Dorsi",
"key_trp_note": "Latissimus dorsi TrPs produce a constant aching that is unchanged by position — the position-independence is a key distinguishing feature. Latissimus is part of the pseudothoracic outlet quadrad. Treat latissimus before teres major and iliocostalis satellites.",
"subtitle": "Inferior scapular angle; mid-thoracic back; medial arm to ulnar hand; constant aching unrelated to position"
}
},
"questions": [
{
"id": "q_pain_location_primary",
"text": "Where is the anterior shoulder pain most concentrated?",
"sublabel": "Choose the best description of where the pain is felt most intensely",
"type": "choice",
"answers": [
{
"id": "deep_inside_joint",
"label": "Deep INSIDE the front of the shoulder joint — the patient places the hand over the anterior shoulder",
"sublabel": "The pain is felt inside the joint itself, not on the surface; deep aching quality",
"lr": {
"infraspinatus": 10.0,
"biceps": 2.0,
"pec_major_sternal": 1.5,
"pec_minor": 1.5,
"coracobrachialis": 1.5,
"supraspinatus": 1.0,
"deltoid_anterior": 0.3,
"pec_major_clavicular": 0.5,
"subclavius": 0.4,
"scalene": 0.8,
"sternalis": 0.3,
"latissimus": 0.3
}
},
{
"id": "anterior_deltoid_surface",
"label": "Over the SURFACE of the anterior deltoid muscle — the front of the shoulder bulge",
"sublabel": "Superficial pain on the front of the shoulder; not felt inside the joint",
"lr": {
"deltoid_anterior": 8.0,
"pec_major_clavicular": 4.0,
"supraspinatus": 2.0,
"pec_minor": 2.0,
"biceps": 1.5,
"infraspinatus": 0.3,
"pec_major_sternal": 0.8,
"subclavius": 1.5,
"scalene": 1.0,
"coracobrachialis": 0.8,
"sternalis": 0.4,
"latissimus": 0.3
}
},
{
"id": "anterior_chest_shoulder",
"label": "Anterior chest AND anterior shoulder — both the chest and front of the shoulder ache",
"sublabel": "Pain spreads across the chest and shoulder together",
"lr": {
"pec_major_sternal": 6.0,
"pec_minor": 4.0,
"scalene": 3.0,
"sternalis": 3.0,
"pec_major_clavicular": 2.0,
"subclavius": 1.5,
"deltoid_anterior": 0.4,
"infraspinatus": 0.4,
"biceps": 0.5,
"supraspinatus": 0.5,
"coracobrachialis": 0.5,
"latissimus": 0.4
}
},
{
"id": "substernal_deep",
"label": "Deep SUBSTERNAL — under the breastbone; a deep internal ache",
"sublabel": "The pain is behind or beneath the sternum itself, not on the surface of the chest",
"lr": {
"sternalis": 12.0,
"pec_major_sternal": 2.0,
"scalene": 1.5,
"pec_minor": 1.0,
"deltoid_anterior": 0.2,
"infraspinatus": 0.2,
"biceps": 0.2,
"supraspinatus": 0.2,
"pec_major_clavicular": 0.3,
"subclavius": 0.3,
"coracobrachialis": 0.2,
"latissimus": 0.2
}
},
{
"id": "biceps_region",
"label": "In the BICEPS MUSCLE or biceps tendon region — front of the upper arm",
"sublabel": "Pain along the front of the upper arm, in or near the biceps muscle belly or its tendon",
"lr": {
"biceps": 8.0,
"coracobrachialis": 3.0,
"infraspinatus": 1.5,
"pec_major_sternal": 0.8,
"supraspinatus": 1.0,
"deltoid_anterior": 0.6,
"pec_major_clavicular": 0.4,
"scalene": 0.8,
"pec_minor": 0.6,
"subclavius": 0.5,
"sternalis": 0.2,
"latissimus": 0.4
}
}
]
},
{
"id": "q_sleep",
"text": "How does the shoulder pain affect sleep?",
"sublabel": "Which sleeping position is tolerated?",
"type": "choice",
"answers": [
{
"id": "neither_side",
"label": "Cannot sleep on EITHER side — may sleep upright or propped in a chair",
"sublabel": "Even the unaffected side is intolerable; every lying position causes pain",
"lr": {
"infraspinatus": 10.0,
"pec_major_sternal": 2.0,
"biceps": 1.5,
"pec_minor": 1.0,
"scalene": 0.8,
"supraspinatus": 0.5,
"deltoid_anterior": 0.3,
"pec_major_clavicular": 0.4,
"subclavius": 0.4,
"coracobrachialis": 0.5,
"sternalis": 0.4,
"latissimus": 0.4
}
},
{
"id": "not_affected_side",
"label": "Cannot sleep on the AFFECTED side only",
"sublabel": "Lying on the painful shoulder wakes the patient; unaffected side and supine are tolerated",
"lr": {
"biceps": 5.0,
"pec_major_sternal": 3.0,
"pec_minor": 2.0,
"supraspinatus": 2.0,
"deltoid_anterior": 2.0,
"pec_major_clavicular": 1.5,
"subclavius": 1.0,
"coracobrachialis": 1.5,
"scalene": 0.8,
"infraspinatus": 0.5,
"sternalis": 0.8,
"latissimus": 1.0
}
},
{
"id": "sleep_unaffected",
"label": "Sleep is largely unaffected or only mildly disturbed",
"sublabel": "Patient finds a comfortable position without significant waking",
"lr": {
"sternalis": 3.0,
"latissimus": 2.5,
"scalene": 1.5,
"supraspinatus": 1.5,
"pec_major_clavicular": 1.2,
"subclavius": 1.2,
"deltoid_anterior": 1.5,
"coracobrachialis": 1.0,
"pec_major_sternal": 0.6,
"pec_minor": 0.7,
"biceps": 0.4,
"infraspinatus": 0.2
}
}
]
},
{
"id": "q_arm_referral",
"text": "Does the pain extend into the arm or hand?",
"sublabel": "Where does the arm pain go — choose the best match",
"type": "choice",
"answers": [
{
"id": "ulnar_forearm_hand",
"label": "Down the INNER (ulnar) side of the arm — medial epicondyle, ulnar forearm, ring and little fingers",
"sublabel": "Pain accents the inner elbow and extends to the ulnar forearm and last two or three fingers",
"lr": {
"pec_major_sternal": 8.0,
"pec_minor": 5.0,
"scalene": 3.0,
"latissimus": 2.5,
"sternalis": 2.0,
"infraspinatus": 0.4,
"biceps": 0.5,
"supraspinatus": 0.4,
"deltoid_anterior": 0.2,
"pec_major_clavicular": 0.5,
"subclavius": 0.5,
"coracobrachialis": 0.5
}
},
{
"id": "radial_skip",
"label": "Down the RADIAL (thumb) side of the forearm, SKIPPING the elbow and wrist — thumb, index, and middle fingers",
"sublabel": "The elbow and wrist are pain-free; the radial forearm and/or thumb/index/middle finger are the distal targets",
"lr": {
"subclavius": 12.0,
"coracobrachialis": 3.0,
"scalene": 2.0,
"pec_major_clavicular": 1.5,
"supraspinatus": 1.0,
"infraspinatus": 1.0,
"pec_major_sternal": 0.4,
"pec_minor": 0.4,
"biceps": 0.4,
"deltoid_anterior": 0.3,
"sternalis": 0.2,
"latissimus": 0.4
}
},
{
"id": "lateral_arm_elbow",
"label": "Down the LATERAL arm to the LATERAL EPICONDYLE or lateral forearm",
"sublabel": "Pain runs down the outside of the arm toward or beyond the lateral elbow",
"lr": {
"supraspinatus": 8.0,
"infraspinatus": 2.0,
"scalene": 1.5,
"deltoid_anterior": 1.0,
"biceps": 0.8,
"pec_major_sternal": 0.4,
"pec_minor": 0.4,
"pec_major_clavicular": 0.4,
"subclavius": 0.4,
"coracobrachialis": 0.5,
"sternalis": 0.2,
"latissimus": 0.5
}
},
{
"id": "posterior_arm_skip",
"label": "To the POSTERIOR arm or back of the hand, SKIPPING the elbow and wrist",
"sublabel": "Back of the upper arm and/or dorsum of the hand; the elbow region itself is not painful",
"lr": {
"coracobrachialis": 10.0,
"scalene": 2.0,
"subclavius": 1.5,
"infraspinatus": 1.0,
"pec_major_sternal": 0.4,
"pec_minor": 0.4,
"biceps": 0.4,
"supraspinatus": 0.4,
"deltoid_anterior": 0.3,
"pec_major_clavicular": 0.3,
"sternalis": 0.2,
"latissimus": 0.4
}
},
{
"id": "no_arm_referral",
"label": "No arm referral — pain stays in the shoulder region",
"sublabel": "Pain does not travel into the arm or hand",
"lr": {
"deltoid_anterior": 3.0,
"sternalis": 3.0,
"latissimus": 2.0,
"pec_major_clavicular": 2.0,
"supraspinatus": 1.0,
"infraspinatus": 0.5,
"biceps": 0.5,
"pec_major_sternal": 0.5,
"pec_minor": 0.6,
"scalene": 0.5,
"subclavius": 0.4,
"coracobrachialis": 0.4
}
}
]
},
{
"id": "q_movement_independence",
"text": "Is the pain INDEPENDENT of movement — present at rest, unaffected by movement of the shoulder, arm, or breathing?",
"sublabel": "No position, movement, or activity clearly makes it better or worse",
"type": "binary",
"answers": [
{
"id": "yes",
"label": "Yes — pain is present at rest and not clearly changed by movement",
"lr": {
"sternalis": 10.0,
"latissimus": 4.0,
"pec_major_sternal": 2.0,
"scalene": 1.5,
"infraspinatus": 0.5,
"biceps": 0.4,
"pec_minor": 0.6,
"supraspinatus": 0.4,
"deltoid_anterior": 0.4,
"pec_major_clavicular": 0.5,
"subclavius": 0.4,
"coracobrachialis": 0.4
}
},
{
"id": "no",
"label": "No — pain varies with position, activity, or movement",
"lr": {
"sternalis": 0.2,
"latissimus": 0.5,
"pec_major_sternal": 0.9,
"scalene": 0.9,
"infraspinatus": 1.2,
"biceps": 1.2,
"pec_minor": 1.1,
"supraspinatus": 1.2,
"deltoid_anterior": 1.2,
"pec_major_clavicular": 1.1,
"subclavius": 1.1,
"coracobrachialis": 1.1
}
}
]
},
{
"id": "q_behind_back",
"text": "Can the patient reach comfortably behind the back?",
"sublabel": "Test: reaching the arm behind the back to the hip pocket or brassiere hooks",
"type": "choice",
"answers": [
{
"id": "cannot_at_all",
"label": "Cannot reach behind the back at all — severely restricted",
"sublabel": "Arm will not go behind the body; cannot reach the hip pocket",
"lr": {
"infraspinatus": 8.0,
"pec_minor": 4.0,
"pec_major_sternal": 3.0,
"biceps": 2.0,
"coracobrachialis": 2.0,
"supraspinatus": 2.0,
"scalene": 1.0,
"deltoid_anterior": 0.5,
"pec_major_clavicular": 0.6,
"subclavius": 0.5,
"sternalis": 0.4,
"latissimus": 0.6
}
},
{
"id": "restricted_painful",
"label": "Can reach behind but it is painful or restricted — cannot reach fully across the back",
"sublabel": "Hand gets behind the body but limited by pain before completing full reach",
"lr": {
"pec_minor": 6.0,
"coracobrachialis": 5.0,
"pec_major_sternal": 3.0,
"biceps": 2.0,
"supraspinatus": 1.5,
"infraspinatus": 1.5,
"deltoid_anterior": 0.8,
"scalene": 0.8,
"pec_major_clavicular": 0.7,
"subclavius": 0.5,
"sternalis": 0.5,
"latissimus": 0.8
}
},
{
"id": "normal",
"label": "Full behind-back reach — no restriction",
"lr": {
"deltoid_anterior": 2.0,
"pec_major_clavicular": 2.0,
"subclavius": 2.0,
"scalene": 1.5,
"sternalis": 1.5,
"latissimus": 1.5,
"supraspinatus": 1.0,
"biceps": 0.7,
"coracobrachialis": 0.4,
"pec_major_sternal": 0.4,
"pec_minor": 0.3,
"infraspinatus": 0.3
}
}
]
},
{
"id": "q_painful_arc",
"text": "Is there a painful arc during shoulder abduction — pain appearing between 60° and 120° of raising the arm sideways, then diminishing above that?",
"sublabel": "Pain appears then disappears as the arm reaches overhead",
"type": "binary",
"answers": [
{
"id": "yes",
"label": "Yes — painful arc between 60° and 120° of abduction",
"lr": {
"supraspinatus": 8.0,
"deltoid_anterior": 2.0,
"infraspinatus": 0.7,
"biceps": 0.7,
"pec_major_sternal": 0.5,
"pec_minor": 0.5,
"scalene": 0.5,
"pec_major_clavicular": 0.5,
"subclavius": 0.4,
"coracobrachialis": 0.4,
"sternalis": 0.3,
"latissimus": 0.4
}
},
{
"id": "no",
"label": "No — no arc pattern; abduction is uniformly painful or pain-free",
"lr": {
"supraspinatus": 0.2,
"deltoid_anterior": 0.9,
"infraspinatus": 1.1,
"biceps": 1.1,
"pec_major_sternal": 1.2,
"pec_minor": 1.2,
"scalene": 1.1,
"pec_major_clavicular": 1.1,
"subclavius": 1.1,
"coracobrachialis": 1.1,
"sternalis": 1.2,
"latissimus": 1.2
}
}
]
},
{
"id": "q_nocturnal_arm",
"text": "Is the patient woken at night by arm aching or numbness — requiring the arm to hang over the side of the bed or be shaken for relief?",
"sublabel": "Nocturnal arm symptoms specifically relieved by hanging the arm over the bed edge",
"type": "binary",
"answers": [
{
"id": "yes",
"label": "Yes — woken at night; arm must hang over bed side for relief",
"lr": {
"scalene": 9.0,
"pec_minor": 1.5,
"subclavius": 1.5,
"pec_major_sternal": 0.7,
"infraspinatus": 0.5,
"biceps": 0.5,
"supraspinatus": 0.4,
"deltoid_anterior": 0.3,
"pec_major_clavicular": 0.5,
"coracobrachialis": 0.4,
"sternalis": 0.3,
"latissimus": 0.4
}
},
{
"id": "no",
"label": "No — no nocturnal arm hanging symptom",
"lr": {
"scalene": 0.25,
"pec_minor": 1.0,
"subclavius": 0.9,
"pec_major_sternal": 1.1,
"infraspinatus": 1.1,
"biceps": 1.1,
"supraspinatus": 1.1,
"deltoid_anterior": 1.2,
"pec_major_clavicular": 1.1,
"coracobrachialis": 1.1,
"sternalis": 1.1,
"latissimus": 1.1
}
}
]
},
{
"id": "q_round_shoulder",
"text": "Does the patient have a visibly round-shouldered or forward-slumped posture?",
"sublabel": "Shoulders rolled forward, flat-chested appearance; the patient cannot stand fully upright without effort",
"type": "binary",
"answers": [
{
"id": "yes",
"label": "Yes — clearly round-shouldered or forward-slumped posture",
"lr": {
"pec_major_sternal": 5.0,
"pec_minor": 5.0,
"pec_major_clavicular": 3.0,
"subclavius": 2.0,
"scalene": 1.5,
"sternalis": 1.5,
"deltoid_anterior": 0.8,
"infraspinatus": 0.7,
"biceps": 0.7,
"supraspinatus": 0.7,
"coracobrachialis": 0.6,
"latissimus": 0.8
}
},
{
"id": "no",
"label": "No — posture is not particularly round-shouldered",
"lr": {
"pec_major_sternal": 0.4,
"pec_minor": 0.4,
"pec_major_clavicular": 0.6,
"subclavius": 0.7,
"scalene": 0.9,
"sternalis": 0.8,
"deltoid_anterior": 1.2,
"infraspinatus": 1.2,
"biceps": 1.2,
"supraspinatus": 1.2,
"coracobrachialis": 1.2,
"latissimus": 1.2
}
}
]
},
{
"id": "q_wright_manoeuvre",
"text": "Does abducting and laterally rotating the arm reproduce or worsen the anterior shoulder or arm symptoms?",
"sublabel": "Placing the arm in the raised, palm-up position — does this position worsen the shoulder, arm, or hand symptoms?",
"type": "binary",
"answers": [
{
"id": "yes",
"label": "Yes — symptoms worsen with arm raised and laterally rotated (Wright position)",
"lr": {
"pec_minor": 8.0,
"subclavius": 5.0,
"scalene": 3.0,
"pec_major_sternal": 2.0,
"pec_major_clavicular": 2.0,
"infraspinatus": 0.6,
"biceps": 0.6,
"supraspinatus": 0.5,
"deltoid_anterior": 0.4,
"coracobrachialis": 0.5,
"sternalis": 0.3,
"latissimus": 0.5
}
},
{
"id": "no",
"label": "No — arm elevation and rotation does not specifically worsen symptoms",
"lr": {
"pec_minor": 0.3,
"subclavius": 0.4,
"scalene": 0.6,
"pec_major_sternal": 0.8,
"pec_major_clavicular": 0.8,
"infraspinatus": 1.2,
"biceps": 1.2,
"supraspinatus": 1.2,
"deltoid_anterior": 1.2,
"coracobrachialis": 1.2,
"sternalis": 1.2,
"latissimus": 1.2
}
}
]
},
{
"id": "q_onset",
"text": "How did the anterior shoulder pain begin?",
"sublabel": "Choose the onset pattern that best describes this episode",
"type": "choice",
"answers": [
{
"id": "acute_overload",
"label": "Acute overload — a specific remembered incident: fall, reaching backward, catching oneself",
"sublabel": "Patient can name the exact moment it started",
"lr": {
"infraspinatus": 6.0,
"biceps": 3.0,
"deltoid_anterior": 3.0,
"supraspinatus": 2.0,
"pec_major_sternal": 1.5,
"coracobrachialis": 1.0,
"scalene": 1.0,
"pec_minor": 0.7,
"pec_major_clavicular": 0.8,
"subclavius": 0.6,
"sternalis": 0.5,
"latissimus": 0.5
}
},
{
"id": "post_cardiac",
"label": "During or after a cardiac event — myocardial infarction or sustained angina",
"sublabel": "Chest and shoulder pain began or intensified around the time of a cardiac event",
"lr": {
"sternalis": 8.0,
"pec_major_sternal": 6.0,
"pec_minor": 3.0,
"scalene": 1.5,
"pec_major_clavicular": 1.0,
"subclavius": 0.5,
"infraspinatus": 0.3,
"biceps": 0.3,
"supraspinatus": 0.3,
"deltoid_anterior": 0.3,
"coracobrachialis": 0.3,
"latissimus": 0.4
}
},
{
"id": "gradual_postural",
"label": "Gradual onset — sustained sitting, desk work, poor posture, or round-shouldered positioning",
"sublabel": "No single incident; pain crept in over days or weeks",
"lr": {
"pec_major_sternal": 5.0,
"pec_minor": 5.0,
"pec_major_clavicular": 3.0,
"scalene": 2.5,
"subclavius": 2.0,
"sternalis": 1.5,
"latissimus": 1.5,
"deltoid_anterior": 0.6,
"infraspinatus": 0.4,
"biceps": 0.5,
"supraspinatus": 0.5,
"coracobrachialis": 0.5
}
},
{
"id": "post_immobilisation",
"label": "After immobilisation — sling, cast, or prolonged shoulder rest",
"sublabel": "Pain developed or worsened following a period of shoulder immobility or disuse",
"lr": {
"infraspinatus": 4.0,
"pec_major_sternal": 3.0,
"biceps": 2.0,
"pec_minor": 2.0,
"supraspinatus": 2.0,
"coracobrachialis": 1.5,
"scalene": 1.0,
"deltoid_anterior": 0.8,
"pec_major_clavicular": 0.8,
"subclavius": 0.7,
"sternalis": 0.7,
"latissimus": 0.8
}
}
]
},
{
"id": "q_residual",
"text": "Has the patient already been treated for surrounding shoulder muscles and anterior shoulder pain persists — is this residual pain after other treatment?",
"sublabel": "Prior treatment cleared other muscles but this anterior shoulder pain remains unexplained",
"type": "binary",
"answers": [
{
"id": "yes",
"label": "Yes — surrounding muscles already treated; this is the residual anterior pain",
"lr": {
"coracobrachialis": 10.0,
"sternalis": 3.0,
"latissimus": 2.0,
"pec_minor": 2.0,
"scalene": 1.5,
"infraspinatus": 1.0,
"biceps": 1.0,
"pec_major_sternal": 0.7,
"pec_major_clavicular": 0.7,
"subclavius": 0.7,
"supraspinatus": 0.8,
"deltoid_anterior": 0.7
}
},
{
"id": "no",
"label": "No — first presentation; no prior treatment of surrounding muscles",
"lr": {
"coracobrachialis": 0.25,
"sternalis": 0.8,
"latissimus": 0.8,
"pec_minor": 0.9,
"scalene": 0.9,
"infraspinatus": 1.1,
"biceps": 1.1,
"pec_major_sternal": 1.1,
"pec_major_clavicular": 1.1,
"subclavius": 1.1,
"supraspinatus": 1.1,
"deltoid_anterior": 1.1
}
}
]
}
],
"pairwise": [
{
"id": "pw_infraspinatus_biceps",
"pair": [
"infraspinatus",
"biceps"
],
"text": "Tiebreaker — Infraspinatus vs Biceps Brachii",
"question": "Is the pain felt DEEP INSIDE the joint (patient covers the front of the joint with the hand), OR along the BICEPS MUSCLE BELLY in the front of the upper arm?",
"answers": [
{
"id": "deep_inside_joint",
"label": "Deep inside the front of the joint — not in the arm",
"lr": {
"infraspinatus": 5.0,
"biceps": 0.2
}
},
{
"id": "biceps_belly",
"label": "Along the biceps muscle belly in the upper arm",
"lr": {
"infraspinatus": 0.2,
"biceps": 5.0
}
}
]
},
{
"id": "pw_pec_major_sternal_pec_minor",
"pair": [
"pec_major_sternal",
"pec_minor"
],
"text": "Tiebreaker — Pectoralis Major (Sternal) vs Pectoralis Minor",
"question": "Is the anterior chest and arm pain present without restriction of arm abduction, OR does raising the arm sideways produce pulling on the ribs at its limit?",
"answers": [
{
"id": "no_rib_pull",
"label": "No rib-pulling sensation at end of abduction — pec major TrP without significant pec minor restriction",
"lr": {
"pec_major_sternal": 3.5,
"pec_minor": 0.3
}
},
{
"id": "rib_pull_abduction",
"label": "Pulling on the ribs at the limit of abduction — pectoralis minor restriction",
"lr": {
"pec_major_sternal": 0.3,
"pec_minor": 3.5
}
}
]
},
{
"id": "pw_subclavius_pec_major_clav",
"pair": [
"subclavius",
"pec_major_clavicular"
],
"text": "Tiebreaker — Subclavius vs Pectoralis Major Clavicular Section",
"question": "Does the arm pain skip the elbow and wrist to reach the radial forearm and thumb/index/middle fingers, OR does it stay in the anterior shoulder and deltoid region?",
"answers": [
{
"id": "radial_skip_pattern",
"label": "Radial forearm/thumb/index/middle finger pain SKIPPING the elbow and wrist",
"lr": {
"subclavius": 5.0,
"pec_major_clavicular": 0.2
}
},
{
"id": "local_shoulder_only",
"label": "Anterior shoulder and deltoid region only — no skip pattern to hand",
"lr": {
"subclavius": 0.2,
"pec_major_clavicular": 5.0
}
}
]
},
{
"id": "pw_scalene_pec_major_sternal",
"pair": [
"scalene",
"pec_major_sternal"
],
"text": "Tiebreaker — Scalene vs Pectoralis Major (Sternal)",
"question": "Is nocturnal arm aching (requiring the arm to hang over the bed) present, OR is the arm pain primarily a daytime complaint during activity?",
"answers": [
{
"id": "nocturnal_arm",
"label": "Nocturnal arm aching — must hang arm over bed for relief",
"lr": {
"scalene": 5.0,
"pec_major_sternal": 0.3
}
},
{
"id": "daytime_activity",
"label": "Daytime pain during activity — no nocturnal arm hanging symptom",
"lr": {
"scalene": 0.3,
"pec_major_sternal": 4.0
}
}
]
},
{
"id": "pw_sternalis_pec_major_sternal",
"pair": [
"sternalis",
"pec_major_sternal"
],
"text": "Tiebreaker — Sternalis vs Pectoralis Major (Sternal)",
"question": "Is the pain deep beneath the sternum and unaffected by any movement, OR does the pain vary with arm position or activity?",
"answers": [
{
"id": "substernal_movement_independent",
"label": "Deep substernal ache — completely unaffected by any movement",
"lr": {
"sternalis": 5.0,
"pec_major_sternal": 0.3
}
},
{
"id": "varies_with_movement",
"label": "Varies with arm position, activity, or posture",
"lr": {
"sternalis": 0.2,
"pec_major_sternal": 4.0
}
}
]
},
{
"id": "pw_coracobrachialis_biceps",
"pair": [
"coracobrachialis",
"biceps"
],
"text": "Tiebreaker — Coracobrachialis vs Biceps Brachii",
"question": "Is this pain residual after surrounding muscles have been treated, AND does it extend to the POSTERIOR arm or dorsal hand; OR is this a first presentation with pain primarily in the biceps region?",
"answers": [
{
"id": "residual_posterior_extension",
"label": "Residual after other treatment, with posterior arm or dorsal hand extension",
"lr": {
"coracobrachialis": 5.0,
"biceps": 0.2
}
},
{
"id": "first_presentation_biceps",
"label": "First presentation with pain in the biceps region — no posterior arm extension",
"lr": {
"coracobrachialis": 0.2,
"biceps": 5.0
}
}
]
},
{
"id": "pw_pec_minor_scalene",
"pair": [
"pec_minor",
"scalene"
],
"text": "Tiebreaker — Pectoralis Minor vs Scalene",
"question": "Do symptoms worsen with the arm abducted and laterally rotated (Wright position), OR does nocturnal arm hanging dominate?",
"answers": [
{
"id": "wright_positive",
"label": "Wright position (arm raised and rotated out) worsens symptoms",
"lr": {
"pec_minor": 4.0,
"scalene": 0.3
}
},
{
"id": "nocturnal_dominant",
"label": "Nocturnal arm aching requiring bed-hanging is the dominant feature",
"lr": {
"pec_minor": 0.3,
"scalene": 4.0
}
}
]
}
],
"treatment_dag": {
"edges": [
{
"from": "infraspinatus",
"to": "deltoid_anterior",
"type": "key_satellite",
"label": "Infraspinatus is the most important key TrP driving anterior deltoid satellite TrPs"
},
{
"from": "infraspinatus",
"to": "biceps",
"type": "key_satellite",
"label": "Infraspinatus TrPs drive biceps brachii satellite TrPs — treat infraspinatus first"
},
{
"from": "infraspinatus",
"to": "supraspinatus",
"type": "functional_unit",
"label": "Infraspinatus-supraspinatus team — almost always active together; treat in the same session"
},
{
"from": "scalene",
"to": "pec_major_sternal",
"type": "key_satellite",
"label": "Scalene TrPs refer pain to the pectoral region and drive pectoral satellite TrPs"
},
{
"from": "scalene",
"to": "pec_minor",
"type": "key_satellite",
"label": "Scalene TrPs drive pectoralis minor satellite TrPs"
},
{
"from": "pec_major_sternal",
"to": "pec_minor",
"type": "functional_unit",
"label": "Pectoralis major and minor are almost always active together — inactivate pec major first; pec minor often resolves without direct treatment"
},
{
"from": "pec_major_clavicular",
"to": "subclavius",
"type": "functional_unit",
"label": "Clavicular pec major and subclavius almost always coexist — treat in the same session"
},
{
"from": "pec_major_sternal",
"to": "sternalis",
"type": "key_satellite",
"label": "Pectoralis major TrPs are almost always active alongside sternalis TrPs — inactivate pec major first"
},
{
"from": "biceps",
"to": "coracobrachialis",
"type": "key_satellite",
"label": "Biceps brachii (short head) TrPs are a key driver of coracobrachialis satellite TrPs — treat biceps first"
},
{
"from": "supraspinatus",
"to": "deltoid_anterior",
"type": "key_satellite",
"label": "Supraspinatus TrPs drive anterior and middle deltoid satellite TrPs"
},
{
"from": "pec_major_sternal",
"to": "latissimus",
"type": "secondary_load",
"label": "Latissimus dorsi develops secondary TrPs as part of the pectoral-driven pseudothoracic outlet quadrad"
},
{
"from": "infraspinatus",
"to": "pec_major_sternal",
"type": "antagonist_risk",
"label": "⚠ Infraspinatus release may reactively activate pectoralis major (unaccustomed shortening) — spray pectoralis after infraspinatus release"
}
],
"edge_type_labels": {
"key_satellite": "Treat first — key TrP driving satellites",
"functional_unit": "Treat concurrently in same session",
"secondary_load": "Treat after primary resolves",
"antagonist_risk": "⚠ Treat in alternating cycles — reactive activation risk"
}
}
}