The Cyriax method of

MSK examination by
“Selective Tissue Tension”
Pre-Workshop Video Podcast SLIDES

Workshop on Physical Examination, Saturday February 7th, 2015

Canadian Rheumatology Association Annual Meeting, Quebec City, Canada
February 4th -7th, 2015
Jean H. Gillies, MCSP, MD, FRCPC
Division of Rheumatology
University of British Columbia
Vancouver, Canada

jeangillies@telus.net

As presented at the CRA ASM

2015. Quebec City, Quebec
DISCLOSURES

None

As presented at the CRA ASM

2015. Quebec City, Quebec
 OBJECTIVES
At the end of this video podcast, the participant will:

1. … understand the concept of Cyriax method of MSK

examination by “selective tissue tension”: active ROM,
passive ROM and isometric muscle testing.

2. … understand the how the concepts of (a) a “capsular”

and a “non-capsular” restriction of ROM and (b) “end-
feel”, contribute to the accuracy of the diagnosis of
regional pain disorders by physical examination.

As presented at the CRA ASM

2015. Quebec City, Quebec
 Cyriax of method of MSK diagnosis by
“Selective Tissue Tension”
Three Concepts
1. active ROM; passive ROM; isometric muscle testing
2. “end-feel”
3. “capsular” or “non-capsular” pattern

Once this information has been documented (both the

positive and negative findings), the provisional diagnosis can
be formulated.

This process can be illustrated by studying six common

causes of shoulder pain.
As presented at the CRA ASM
2015. Quebec City, Quebec
Formulating the Physical Examination Data

Let’s take 6 common problems causing

shoulder pain to illustrate the process.

As presented at the CRA ASM

2015. Quebec City, Quebec
 6 Common Causes of Shoulder Pain
The following common causes of shoulder pain can be
distinguished on physical examination by using the Cyriax
of method of MSK diagnosis by “Selective Tissue Tension”.

1. Frozen shoulder
2. Rotator cuff tendinitis
- supraspinatus tendinitis
- infraspinatus tendinitis
- subscapularis tendinitis
- (teres minor tendinitis)
3. Bicipital tendinitis
4. AC joint arthropathy/enthesitis
5. Acute subacromial bursitis
6. Chronic subacromial bursitis
As presented at the CRA ASM
2015. Quebec City, Quebec
Formulating the Physical Examination Data
Differentiating between 6 common shoulder pain disorders

Frozen shoulder

Rotator cuff tendinitis

Bicipital tendinitis

Chronic subacromial bursitis

AC joint arthropathy/enthesitis

As presented at the CRA ASM

2015. Quebec City, Quebec Acute subacromial bursitis
 Formulating the Physical Examination Data
Differentiating between 6 common shoulder pain disorders

Passive ROM Frozen shoulder

abnormal
1

Rotator cuff tendinitis

Bicipital tendinitis

Chronic subacromial bursitis

AC joint arthropathy/enthesitis

As presented at the CRA ASM

2015. Quebec City, Quebec Acute subacromial bursitis
 Formulating the Physical Examination Data
Differentiating between 6 common shoulder pain disorders

Passive ROM Frozen shoulder

abnormal
1

Rotator cuff tendinitis

Bicipital tendinitis

Chronic subacromial bursitis

AC joint arthropathy/enthesitis

As presented at the CRA ASM

2015. Quebec City, Quebec Acute subacromial bursitis
 Formulating the Physical Examination Data
Differentiating between 6 common shoulder pain disorders

Passive ROM Frozen shoulder

abnormal
1 with
normal
isometric muscle testing

Rotator cuff tendinitis

Bicipital tendinitis

Chronic subacromial bursitis

AC joint arthropathy/enthesitis

As presented at the CRA ASM

2015. Quebec City, Quebec Acute subacromial bursitis
 Formulating the Physical Examination Data
Differentiating between 6 common shoulder pain disorders

Passive ROM Frozen shoulder

abnormal
1 with
normal
isometric muscle testing

Isometric Testing Rotator cuff tendinitis

2 abnormal

Bicipital tendinitis

Chronic subacromial bursitis

AC joint arthropathy/enthesitis

As presented at the CRA ASM

2015. Quebec City, Quebec Acute subacromial bursitis
 Formulating the Physical Examination Data
Differentiating between 6 common shoulder pain disorders

Passive ROM Frozen shoulder

abnormal
1 with
normal
isometric muscle testing

Isometric Testing Rotator cuff tendinitis

2 abnormal

Bicipital tendinitis

Chronic subacromial bursitis

AC joint arthropathy/enthesitis

As presented at the CRA ASM

2015. Quebec City, Quebec Acute subacromial bursitis
 Formulating the Physical Examination Data
Differentiating between 6 common shoulder pain disorders

Passive ROM Frozen shoulder

abnormal
1 with
normal
isometric muscle testing

Isometric Testing Rotator cuff tendinitis

2 abnormal

Bicipital tendinitis

Chronic subacromial bursitis

AC joint arthropathy/enthesitis

As presented at the CRA ASM

2015. Quebec City, Quebec Acute subacromial bursitis
 Formulating the Physical Examination Data
Differentiating between 6 common shoulder pain disorders

Passive ROM Frozen shoulder

abnormal
1 with
normal
isometric muscle testing

Isometric Testing Rotator cuff tendinitis

2 abnormal
with
normal
passive ROM testing Bicipital tendinitis

Chronic subacromial bursitis

AC joint arthropathy/enthesitis

As presented at the CRA ASM

2015. Quebec City, Quebec Acute subacromial bursitis
 Formulating the Physical Examination Data
Differentiating between 6 common shoulder pain disorders

Passive ROM Frozen shoulder

abnormal
1 with
normal
isometric muscle testing

Isometric Testing Rotator cuff tendinitis

2 abnormal
with
normal
passive ROM testing Bicipital tendinitis

Chronic subacromial bursitis

Passive ROM
abnormal
3 AND AC joint arthropathy/enthesitis
Isometric Testing
As presented at the CRA ASM
abnormal Acute subacromial bursitis
2015. Quebec City, Quebec
 Formulating the Physical Examination Data
Differentiating between 6 common shoulder pain disorders

Passive ROM Frozen shoulder

abnormal
1 with
normal
isometric muscle testing

Isometric Testing Rotator cuff tendinitis

2 abnormal
with
normal
passive ROM testing Bicipital tendinitis

Chronic subacromial bursitis

Passive ROM
abnormal
3 AND AC joint arthropathy/enthesitis
Isometric Testing
As presented at the CRA ASM
abnormal Acute subacromial bursitis
2015. Quebec City, Quebec
 Formulating the Physical Examination Data
Differentiating between 6 common shoulder pain disorders

Passive ROM Frozen shoulder

abnormal
1 with
normal
isometric muscle testing

Isometric Testing Rotator cuff tendinitis

2 abnormal
with
normal
passive ROM testing Bicipital tendinitis

Chronic subacromial bursitis

Passive ROM
abnormal
3 AND AC joint arthropathy/enthesitis
Isometric Testing
As presented at the CRA ASM
abnormal Acute subacromial bursitis
2015. Quebec City, Quebec
 Formulating the Physical Examination Data
Differentiating between 6 common shoulder pain disorders

Passive ROM Frozen shoulder

abnormal
1 with
normal
isometric muscle testing

Isometric Testing Rotator cuff tendinitis

2 abnormal
with
normal
passive ROM testing Bicipital tendinitis

Chronic subacromial bursitis

Passive ROM
abnormal
3 AND AC joint arthropathy/enthesitis
Isometric Testing
As presented at the CRA ASM
abnormal Acute subacromial bursitis
2015. Quebec City, Quebec
 Formulating the Physical Examination Data
Differentiating between 6 common shoulder pain disorders

Passive ROM Frozen shoulder

abnormal
1 with
normal
isometric muscle testing

Isometric Testing Rotator cuff tendinitis

2 abnormal
with
normal
passive ROM testing Bicipital tendinitis

Chronic subacromial bursitis

Passive ROM
abnormal
3 AND AC joint arthropathy/enthesitis
Isometric Testing
As presented at the CRA ASM
abnormal Acute subacromial bursitis
2015. Quebec City, Quebec
 Formulating the Physical Examination Data
Differentiating between 6 common shoulder pain disorders

Passive ROM Frozen shoulder

abnormal
1 with
normal
isometric muscle testing

Isometric Testing Rotator cuff tendinitis

2 abnormal
with
normal
passive ROM testing Bicipital tendinitis

Chronic subacromial bursitis

Passive ROM
abnormal
3 AND AC joint arthropathy/enthesitis
Isometric Testing
As presented at the CRA ASM
abnormal Acute subacromial bursitis
2015. Quebec City, Quebec
 Formulating the Physical Examination Data
Differentiating between 6 common shoulder pain disorders

Passive ROM Capsular pattern Frozen shoulder

abnormal
A with
normal
isometric muscle testing

Isometric Testing Rotator cuff tendinitis

B abnormal
with
normal
passive ROM testing Bicipital tendinitis

Chronic subacromial bursitis

Passive ROM
abnormal
C AND AC joint arthropathy/enthesitis
Isometric Testing
abnormal As presented at the CRA ASM
2015. Quebec City, Quebec Acute subacromial bursitis
 Formulating the Physical Examination Data
Differentiating between 6 common shoulder pain disorders

Passive ROM Capsular pattern Frozen shoulder

abnormal
1 with
normal Non-capsular pattern
isometric muscle testing

Isometric Testing Rotator cuff tendinitis

2 abnormal
with
normal
passive ROM testing Bicipital tendinitis

Chronic subacromial bursitis

Passive ROM
abnormal
3 AND AC joint arthropathy/enthesitis
Isometric Testing
As presented at the CRA ASM
abnormal 2015. Quebec City, Quebec Acute subacromial bursitis
 Formulating the Physical Examination Data
Differentiating between 6 common shoulder pain disorders

Passive ROM Capsular pattern Frozen shoulder

abnormal
1 with
normal Non-capsular pattern
isometric muscle testing

Isometric Testing Rotator cuff tendinitis

2 abnormal
with
normal
passive ROM testing Bicipital tendinitis

Chronic subacromial bursitis

Passive ROM
abnormal
3 AND AC joint arthropathy/enthesitis
Isometric Testing
As presented at the CRA ASM
abnormal Acute subacromial bursitis
2015. Quebec City, Quebec
 Formulating the Physical Examination Data
Differentiating between 6 common shoulder pain disorders

Passive ROM
abnormal Frozen shoulder
1 with
normal
isometric muscle testing

Isometric Testing Rotator cuff tendinitis

2 abnormal
with
normal
passive ROM testing Bicipital tendinitis

Chronic subacromial bursitis

Passive ROM
abnormal
3 AND AC joint arthropathy/enthesitis
Isometric Testing
As presented at the CRA ASM
abnormal Acute subacromial bursitis
2015. Quebec City, Quebec
 Formulating the Physical Examination Data
Differentiating between 6 common shoulder pain disorders

Passive ROM
abnormal Frozen shoulder
1 with
normal
isometric muscle testing

Pain & no weakness

Isometric Testing Rotator cuff tendinitis
2 abnormal
with
normal
passive ROM testing Bicipital tendinitis

Chronic subacromial bursitis

Passive ROM
abnormal
3 AND AC joint arthropathy/enthesitis
Isometric Testing
As presented at the CRA ASM
abnormal Acute subacromial bursitis
2015. Quebec City, Quebec
 Formulating the Physical Examination Data
Differentiating between 6 common shoulder pain disorders

Passive ROM
abnormal Frozen shoulder
1 with
normal
isometric muscle testing

Pain & no weakness

Isometric Testing Rotator cuff tendinitis
2 abnormal Weakness & no pain
with
normal
passive ROM testing Bicipital tendinitis

Chronic subacromial bursitis

Passive ROM
abnormal
3 AND AC joint arthropathy/enthesitis
Isometric Testing
As presented at the CRA ASM
abnormal Acute subacromial bursitis
2015. Quebec City, Quebec
 Formulating the Physical Examination Data
Differentiating between 6 common shoulder pain disorders

Passive ROM
abnormal Frozen shoulder
1 with
normal
isometric muscle testing

Pain & no weakness

Isometric Testing Rotator cuff tendinitis
2 abnormal Weakness & no pain
with
normal Pain & weakness
passive ROM testing Bicipital tendinitis

Chronic subacromial bursitis

Passive ROM
abnormal
3 AND AC joint arthropathy/enthesitis
Isometric Testing
As presented at the CRA ASM
abnormal Acute subacromial bursitis
2015. Quebec City, Quebec
 Formulating the Physical Examination Data
Differentiating between 6 common shoulder pain disorders

Passive ROM
abnormal Frozen shoulder
1 with
normal
isometric muscle testing

Pain & no weakness

Isometric Testing Rotator cuff tendinitis
2 abnormal Weakness & no pain
with
normal Pain & weakness
passive ROM testing Bicipital tendinitis

Chronic subacromial bursitis

Passive ROM
abnormal
3 AND AC joint arthropathy/enthesitis
Isometric Testing
As presented at the CRA ASM
abnormal Acute subacromial bursitis
2015. Quebec City, Quebec
 Formulating the Physical Examination Data
Differentiating between 6 common shoulder pain disorders

Passive ROM
abnormal Frozen shoulder
1 with
normal
isometric muscle testing

Isometric Testing Rotator cuff tendinitis

2 abnormal
with
normal
passive ROM testing Bicipital tendinitis

Capsular pattern

Non-capsular pattern Chronic subacromial bursitis

Passive ROM
abnormal
3 AND AC joint arthropathy/enthesitis
Isometric Testing
As presented at the CRA ASM
abnormal Acute subacromial bursitis
2015. Quebec City, Quebec
 Formulating the Physical Examination Data
Differentiating between 6 common shoulder pain disorders

Passive ROM
abnormal Frozen shoulder
1 with
normal
isometric muscle testing

Isometric Testing Rotator cuff tendinitis

2 abnormal
with
normal
passive ROM testing Bicipital tendinitis

Capsular pattern

Non-capsular pattern Chronic subacromial bursitis

Passive ROM
abnormal Pain & no weakness
3 AND AC joint arthropathy/enthesitis
Isometric Testing Weakness & no pain
As presented at the CRA ASM
abnormal Pain & weakness Acute subacromial bursitis
2015. Quebec City, Quebec
 Formulating the Physical Examination Data
Differentiating between 6 common shoulder pain disorders

Passive ROM
abnormal Frozen shoulder
1 with
normal
isometric muscle testing

Isometric Testing Rotator cuff tendinitis

2 abnormal
with
normal
passive ROM testing Bicipital tendinitis

Capsular pattern

Non-capsular pattern Chronic subacromial bursitis

Passive ROM
abnormal Pain & no weakness
3 AND AC joint arthropathy/enthesitis
Isometric Testing Weakness & no pain
As presented at the CRA ASM
abnormal Pain & weakness Acute subacromial bursitis
2015. Quebec City, Quebec
 Formulating the Physical Examination Data
Differentiating between 6 common shoulder pain disorders

Passive ROM
abnormal Frozen shoulder
1 with
normal
isometric muscle testing

Isometric Testing Rotator cuff tendinitis

2 abnormal
with
normal
passive ROM testing Bicipital tendinitis

Capsular pattern

Non-capsular pattern Chronic subacromial bursitis

Passive ROM
abnormal Pain & no weakness
3 AND AC joint arthropathy/enthesitis
Isometric Testing Weakness & no pain
As presented at the CRA ASM
abnormal Pain & weakness Acute subacromial bursitis
2015. Quebec City, Quebec
 Formulating the Physical Examination Data
Differentiating between 6 common shoulder pain disorders

Passive ROM
abnormal Frozen shoulder
1 with
normal
isometric muscle testing

Isometric Testing Rotator cuff tendinitis

2 abnormal
with
normal
passive ROM testing Bicipital tendinitis

Capsular pattern

Non-capsular pattern Chronic subacromial bursitis

Passive ROM
abnormal Pain & no weakness
3 AND AC joint arthropathy/enthesitis
Isometric Testing Weakness & no pain
As presented at the CRA ASM
abnormal Pain & weakness Acute subacromial bursitis
2015. Quebec City, Quebec
 Formulating the Physical Examination Data
Differentiating between 6 common shoulder pain disorders

Passive ROM
abnormal Frozen shoulder
1 with
normal
isometric muscle testing

Isometric Testing Rotator cuff tendinitis

2 abnormal
with
normal
passive ROM testing Bicipital tendinitis

Capsular pattern

Non-capsular pattern Chronic subacromial bursitis

Passive ROM
abnormal Pain & no weakness
3 AND AC joint arthropathy/enthesitis
Isometric Testing Weakness & no pain
As presented at the CRA ASM
abnormal Pain & weakness Acute subacromial bursitis
2015. Quebec City, Quebec
 Formulating the Physical Examination Data
Differentiating between 6 common shoulder pain disorders

Passive ROM
abnormal Frozen shoulder
1 with
normal
isometric muscle testing

Isometric Testing Rotator cuff tendinitis

2 abnormal
with
normal
passive ROM testing Bicipital tendinitis

Capsular pattern

Non-capsular pattern Chronic subacromial bursitis

Passive ROM
abnormal Pain & no weakness
3 AND AC joint arthropathy/enthesitis
Isometric Testing Weakness & no pain
As presented at the CRA ASM
abnormal Pain & weakness Acute subacromial bursitis
2015. Quebec City, Quebec
 Formulating the Physical Examination Data
Differentiating between 6 common shoulder pain disorders

Passive ROM
abnormal Frozen shoulder
1 with
normal
isometric muscle testing

Isometric Testing Rotator cuff tendinitis

2 abnormal
with
normal
passive ROM testing Bicipital tendinitis

Capsular pattern

Non-capsular pattern Chronic subacromial bursitis

Passive ROM
abnormal Pain & no weakness
3 AND AC joint arthropathy/enthesitis
Isometric Testing Weakness & no pain
As presented at the CRA ASM
abnormal Pain & weakness Acute subacromial bursitis
2015. Quebec City, Quebec
 Formulating the Physical Examination Data
Differentiating between 6 common shoulder pain disorders

Passive ROM
abnormal Frozen shoulder
1 with
normal
isometric muscle testing

Isometric Testing Rotator cuff tendinitis

2 abnormal
with
normal
passive ROM testing Bicipital tendinitis

Capsular pattern

Non-capsular pattern Chronic subacromial bursitis

Passive ROM
abnormal Pain & no weakness
3 AND AC joint arthropathy/enthesitis
Isometric Testing Weakness & no pain
As presented at the CRA ASM
abnormal Pain & weakness Acute subacromial bursitis
2015. Quebec City, Quebec
 Formulating the Physical Examination Data
Differentiating between 6 common shoulder pain disorders

Passive ROM
abnormal Frozen shoulder
1 with
normal
isometric muscle testing

Isometric Testing Rotator cuff tendinitis

2 abnormal
with
normal
passive ROM testing Bicipital tendinitis

Capsular pattern

Non-capsular pattern Chronic subacromial bursitis

Passive ROM
abnormal Pain & no weakness
3 AND AC joint arthropathy/enthesitis
Isometric Testing Weakness & no pain
As presented at the CRA ASM
abnormal Pain & weakness Acute subacromial bursitis
2015. Quebec City, Quebec
 Formulating the Physical Examination Data
Differentiating between 6 common shoulder pain disorders

Passive ROM
abnormal Frozen shoulder
1 with
normal
isometric muscle testing

Isometric Testing Rotator cuff tendinitis

2 abnormal
with
normal
passive ROM testing Bicipital tendinitis

Capsular pattern

Non-capsular pattern Chronic subacromial bursitis

Passive ROM
abnormal Pain & no weakness
3 AND AC joint arthropathy/enthesitis
Isometric Testing Weakness & no pain
As presented at the CRA ASM
abnormal Pain & weakness Acute subacromial bursitis
2015. Quebec City, Quebec
 Formulating the Physical Examination Data
Differentiating between 6 common shoulder pain disorders

Passive ROM
abnormal
1 with
normal
isometric muscle testing

Isometric Testing Rotator cuff tendinitis

2 abnormal
with
normal
passive ROM testing Bicipital tendinitis

Passive ROM
abnormal
3 AND
Isometric Testing
As presented at the CRA ASM
abnormal
2015. Quebec City, Quebec
 Formulating the Physical Examination Data
Differentiating between 6 common shoulder pain disorders

Passive ROM
abnormal
1 with
normal
isometric muscle testing

Pain & no weakness

Isometric Testing Rotator cuff tendinitis
2 abnormal Weakness & no pain
with
normal Pain & weakness
passive ROM testing Bicipital tendinitis

Passive ROM
abnormal
3 AND
Isometric Testing
As presented at the CRA ASM
abnormal
2015. Quebec City, Quebec
 Formulating the Physical Examination Data
Differentiating between 6 common shoulder pain disorders

Passive ROM
abnormal
1 with
normal
isometric muscle testing

Pain & no weakness

Isometric Testing Rotator cuff tendinitis
2 abnormal Weakness & no pain
with
normal Pain & weakness
passive ROM testing Bicipital tendinitis

Passive ROM
abnormal
3 AND
Isometric Testing
As presented at the CRA ASM
abnormal
2015. Quebec City, Quebec
 Formulating the Physical Examination Data
Differentiating between 6 common shoulder pain disorders

Passive ROM
abnormal
1 with
normal Rotator cuff tendinitis
isometric muscle testing Supraspinatus tendinitis
pain on resisted abduction
Infraspinatus tendinitis
pain on resisted external rotation
Subscapularis tendinitis
Pain & no weakness pain on resisted internal rotation
Isometric Testing Teres minor tendinitis
pain on resisted internal rotation
2 abnormal Weakness & no pain and adduction
with
normal Pain & weakness
passive ROM testing Bicipital tendinitis

Passive ROM
abnormal
3 AND
Isometric Testing
As presented at the CRA ASM
abnormal
2015. Quebec City, Quebec
 Formulating the Physical Examination Data
Differentiating between 6 common shoulder pain disorders

Passive ROM
abnormal
1 with
normal Rotator cuff tendinitis
isometric muscle testing Supraspinatus tendinitis
pain on resisted abduction
Infraspinatus tendinitis
pain on resisted external rotation
Subscapularis tendinitis
Pain & no weakness pain on resisted internal rotation
Isometric Testing Teres minor tendinitis
pain on resisted internal rotation
2 abnormal Weakness & no pain and adduction
with
normal Pain & weakness
passive ROM testing Bicipital tendinitis
pain on resisted long-lever flexion
pain on resisted horizontal adduction

Passive ROM
abnormal
3 AND
Isometric Testing
As presented at the CRA ASM
abnormal
2015. Quebec City, Quebec
Formulating the Physical Examination Data

We have shown how 6 common causes of shoulder

pain can be distinguished on physical examination
by organizing the data into one of three groups.

Passive ROM
Group 1 abnormal

Isometric Testing
Group 2 abnormal

Passive ROM
abnormal
Group 3 AND
Isometric Testing
abnormal
As presented at the CRA ASM
2015. Quebec City, Quebec
 Formulating the Physical Examination Data
………..
Now for the Differential Diagnosis

Now we will review the differential diagnosis in each

of these three groups.

As presented at the CRA ASM

2015. Quebec City, Quebec
 Differential Diagnosis

Let’s take shoulder pain to illustrate the process.

As presented at the CRA ASM

2015. Quebec City, Quebec
 Formulating the Physical Examination Data
Differentiating between 6 common shoulder pain disorders

Passive ROM Capsular pattern Frozen shoulder

abnormal
1 with
normal Non-capsular pattern
isometric muscle testing

Isometric Testing Rotator cuff tendinitis

2 abnormal
with
normal
passive ROM testing Bicipital tendinitis

Chronic subacromial bursitis

Passive ROM
abnormal
3 AND AC joint arthropathy/enthesitis
Isometric Testing
As presented at the CRA ASM
abnormal Acute subacromial bursitis
2015. Quebec City, Quebec
 Shoulder Pain: Differential Diagnosis
Inflammatory arthritis
(e.g., RA, PsA, SpA, AS, gout, CPPD,
Passive ROM Capsular pattern
hydroxyapatite crystal disease, septic
arthritis with normal motor power),
abnormal OA, Frozen shoulder
1 with
normal Non-capsular pattern
isometric muscle testing

Isometric Testing
2 abnormal
and
passive ROM normal

Passive ROM
3 abnormal
AND
Isometric Testing
As presented at the CRA ASM
abnormal
2015. Quebec City, Quebec
 Shoulder Pain: Differential Diagnosis
inflammatory arthritis
(e.g., RA, PsA, SpA, AS, gout, CPPD,
Passive ROM Capsular pattern
hydroxyapatite crystal disease, septic
arthritis with normal motor power),
abnormal OA, frozen shoulder
1 with
normal Non-capsular pattern Ligamentous laxity
isometric muscle testing (e.g., hypermobility syndrome,
sequella of previous dislocation )

Isometric Testing
2 abnormal
and
passive ROM normal

Passive ROM
3 abnormal
AND
Isometric Testing
As presented at the CRA ASM
abnormal
2015. Quebec City, Quebec
 Shoulder Pain: Differential Diagnosis

Passive ROM
abnormal
1 with
normal
isometric muscle testing

Pain & no weakness

Isometric Testing
B abnormal Weakness & no pain
and
passive ROM normal Pain & weakness

Passive ROM
C abnormal
AND
Isometric Testing
As presented at the CRA ASM
abnormal
2015. Quebec City, Quebec
 Shoulder Pain: Differential Diagnosis

Passive ROM
abnormal
1 with
normal
isometric muscle testing

Tendinitis, Bursitis,
Pain & no weakness Hematoma in muscle
Isometric Testing
B abnormal Weakness & no pain
and
passive ROM normal Pain & weakness

Passive ROM
C abnormal
AND
Isometric Testing
As presented at the CRA ASM
abnormal
2015. Quebec City, Quebec
 Shoulder Pain: Differential Diagnosis

Passive ROM
abnormal
1 with
normal
isometric muscle testing

Tendinitis, Bursitis,
Pain & no weakness Hematoma in muscle
Isometric Testing
Tendon rupture,
B abnormal Weakness & no pain Abnormal nerve conduction
and (e.g., proximal muscle weakness)
passive ROM normal Pain & weakness

Passive ROM
C abnormal
AND
Isometric Testing
As presented at the CRA ASM
abnormal
2015. Quebec City, Quebec
 Shoulder Pain: Differential Diagnosis

Passive ROM
abnormal
1 with
normal
isometric muscle testing

Tendinitis, bursitis,
Pain & no weakness hematoma in muscle
Isometric Testing
tendon rupture,
B abnormal Weakness & no pain abnormal nerve conduction
and (e.g., proximal muscle weakness)
passive ROM normal Pain & weakness

Passive ROM
C abnormal
AND
Isometric Testing
As presented at the CRA ASM
abnormal
2015. Quebec City, Quebec
 Shoulder Pain: Differential Diagnosis

Passive ROM
abnormal
with
A normal
isometric muscle testing

Isometric Testing
B abnormal
and
passive ROM normal

Capsular pattern

Passive ROM Non-capsular pattern

C abnormal
Pain & no weakness
AND
Isometric Testing Weakness & no pain
As presented at the CRA ASM
abnormal
2015.
Pain Quebec City, Quebec
& weakness
 Shoulder Pain: Differential Diagnosis

Passive ROM
abnormal
with
A normal
isometric muscle testing

Isometric Testing
B abnormal
and
passive ROM normal
Inflammatory arthritis
(and global Grade 4/5 weakness)
Capsular pattern

Passive ROM Non-capsular pattern

C abnormal
Pain & no weakness
AND
Isometric Testing Weakness & no pain
As presented at the CRA ASM
abnormal
2015.
Pain Quebec City, Quebec
& weakness
 Shoulder Pain: Differential Diagnosis

Passive ROM
abnormal
with
A normal
isometric muscle testing

Isometric Testing
B abnormal
and
passive ROM normal

Capsular pattern
Acute gout, Acute septic joint
Passive ROM Non-capsular pattern
C abnormal
Pain & no weakness
AND
Isometric Testing Weakness & no pain
As presented at the CRA ASM
abnormal
2015.
Pain Quebec City, Quebec
& weakness
 Shoulder Pain: Differential Diagnosis

Passive ROM
abnormal
with
A normal
isometric muscle testing

Isometric Testing
B abnormal
and
passive ROM normal

Capsular pattern

Passive ROM Non-capsular pattern

Chronic bursitis, AC joint
C abnormal
Pain & no weakness arthropathy/enthesitis, Labral tear
AND
Isometric Testing Weakness & no pain
As presented at the CRA ASM
abnormal
2015.
Pain Quebec City, Quebec
& weakness
 Shoulder Pain: Differential Diagnosis

Passive ROM
abnormal
with
A normal
isometric muscle testing

Isometric Testing
B abnormal
and
passive ROM normal Pain & weakness

Capsular pattern

Passive ROM Non-capsular pattern

C abnormal
Pain & no weakness
AND
Isometric Testing Weakness & no pain Acute bursitis
As presented at the CRA ASM
abnormal OMINOUS
2015.
Pain Quebec City, Quebec
& weakness Fracture, Metastasis
 Shoulder Pain: Differential Diagnosis
Inflammatory arthritis
(e.g., RA, PsA, SpA, AS, gout, CPPD,
Passive ROM Capsular pattern
hydroxyapatite crystal disease, septic
arthritis with normal motor power),
abnormal OA, Frozen shoulder
with
A normal Non-capsular pattern Ligamentous laxity
isometric muscle testing (e.g., hypermobility syndrome, sequella of
previous dislocation )

Tendinitis, Bursitis,
Pain & no weakness Hematoma in muscle
Isometric Testing
Tendon rupture,
B abnormal Weakness & no pain Abnormal nerve conduction
and (e.g., proximal muscle weakness)
passive ROM normal Pain & weakness

Inflammatory arthritis
(and global Grade 4/5 weakness)
Capsular pattern
Acute gout, Acute septic joint
Passive ROM Non-capsular pattern
Chronic bursitis, AC joint
C abnormal
Pain & no weakness arthropathy/enthesitis, Labral tear
AND
Isometric Testing Weakness & no pain Acute bursitis
As presented at the CRA ASM OMINOUS
abnormal
2015.
Pain Quebec City, Quebec
& weakness Fracture, Metastasis
 Concept 1

Active ROM
Passive ROM
Isometric Muscle Testing

As presented at the CRA ASM

2015. Quebec City, Quebec
 Cyriax method of MSK examination by
“Selective Tissue Tension”

• Active ROM
Tests the willingness of patient to
move limb or trunk
• Passive ROM
Tests the “inert structures”
• Isometric Resisted Muscle Testing
Tests the “contractile structures”

As presented at the CRA ASM

2015. Quebec City, Quebec
 Cyriax method of MSK examination by
“Selective Tissue Tension”

• Active ROM
non-contributory to the diagnosis

• Passive ROM
tests the “inert structures”
capsule, ligaments, fascia, cartilage (disc,
meniscus, labrum), dura mater, dural sheaths,
nerve roots,(± bursa)

• Isometric Resisted Testing—

tests the “contractile structures”
muscle, tendon, (± bursa)
As presented at the CRA ASM
2015. Quebec City, Quebec
 Concept 2

Capsular Pattern
Non-Capsular Pattern

As presented at the CRA ASM

2015. Quebec City, Quebec
 Passive ROM Testing

Capsular Pattern
Limitation of ROM in a fixed proportion
[specific to each joint]

Non-Capsular Pattern
Any other pattern

Very difficult concept to grasp.

As presented at the CRA ASM
2015. Quebec City, Quebec
 Passive ROM Testing

Capsular Pattern
RA, PsA, AS, SpA, OA, gout, CPPD, hydroxyapatite
crystal disease, traumatic arthritis, septic arthritis, frozen
shoulder

Non-Capsular Pattern
Ligament [sprain]
Tendon [tendinitis, tenosynovitis]
Internal derangement [disc, meniscus, labrum]
Extra-articular limitation [bursitis, hematoma]
Bone [fracture, bone metastasis, avascular necrosis]
As presented at the CRA ASM
2015. Quebec City, Quebec
 Decreased pROM: Capsular Pattern

Glenohumeral Joint
external rotation* ↓↓↓ > abduction** ↓↓ > internal rotation*↓
*measured @ 0º abduction;
* *glenohumeral abduction [e.g., no scapular movement]

Elbow Joint
flexion ↓↓ > extension ↓

Wrist Joint
flexion ↓ = extension ↓

As presented at the CRA ASM

2015. Quebec City, Quebec
 Decreased pROM: Capsular Pattern

0º position of joints:
The “Neutral Zero Method” of describing joint ROM

First described in 1936 (taking the anatomical position as the 0º starting position)
Cave EF, Roberts SM. A method of measuring and recording joint function.
JBJS; 1936; 18:2:455-466

e.g. ROM knee flexion

Prior to 1936: 0º→135º or 180º→45º or 195º→45º
Since 1972: 0º→135º

e.g. ROM knee hyperextension

Prior to 1936: 0º→15º or 180º→195º or 195º→45º or -15º

Since 1972: 0º→15º
As presented at the CRA ASM
2015. Quebec City, Quebec
 Capsular Pattern:
Proportional limitation of pROM
Knee Joint: Capsular Pattern
Flexion: 0°→135°[normal]
Flexion: 0°→120°[capsular pattern – slight decreased ROM]
Flexion: 10°→85°[capsular pattern – moderate decreased ROM]
Flexion: 15°→70°[capsular pattern – marked decreased ROM]
[inflammatory=100 cc fluid e.g., gout, septic arthritis, etc]

Knee Joint: Non-Capsular Pattern

Flexion: 0°→40°[non-capsular pattern – marked decreased ROM]
[e.g., pre-patellar bursitis]

Flexion: 10°→130°[non-capsular pattern – moderate decreased ROM]

[e.g., symptomatic loose body, symptomatic meniscal tear]

As presented at the CRA ASM

2015. Quebec City, Quebec
 Concept 3

End-feel

As presented at the CRA ASM

2015. Quebec City, Quebec
Cyriax method of MSK examination by
“Selective Tissue Tension”

END-FEEL

Normal
• Physiological end-feel

Abnormal
• Pathological end-feel

As presented at the CRA ASM

2015. Quebec City, Quebec
 Cyriax method of MSK examination by
“Selective Tissue Tension”
END-FEEL
1. Bone-on-Bone
Normal: elbow extension, knee extension
2. Soft tissue approximation
Normal: elbow flexion, knee flexion
3. Capsular feel
Normal: shoulder external rotation, hip internal rotation
4. Springy block
Always abnormal e.g., knee meniscal tear, hip labral tear
5. Muscle spasm
Always abnormal e.g., fracture
6. Empty feel
Always abnormal e.g., metastasis
As presented at the CRA ASM
2015. Quebec City, Quebec
 END FEEL
.

CORRECT

Accurate hand position results in

detection of:-
a. Pathological end-feel
b. Very slight decrease in pROM. HAND POSITION
• very important
• essential !

HAND POSITION
The hands have to be each
INCORRECT
side of the joint being tested.
As presented at the CRA ASM
2015. Quebec City, Quebec
SUMMARY

As presented at the CRA ASM

2015. Quebec City, Quebec
Cyriax of method of MSK diagnosis by “selective tissue tension”
Summary: Three Concepts

1. Examine:
active ROM
passive ROM
isometric muscle testing.
2. At the end of the range when testing the pROM -
determine the “end-feel”.
3. If there is a decreased pROM –
decide if the limitation is in a “capsular” or a
“non-capsular” pattern.

As presented at the CRA ASM

2015. Quebec City, Quebec
 Shoulder Pain: Differential Diagnosis
Inflammatory arthritis
(e.g., RA, PsA, SpA, AS, gout, CPPD,
Passive ROM Capsular pattern
hydroxyapatite crystal disease, septic
arthritis with normal motor power),
abnormal OA, Frozen shoulder
with
A normal Non-capsular pattern Ligamentous laxity
isometric muscle testing (e.g., hypermobility syndrome, sequella of
previous dislocation )

Tendinitis, Bursitis,
Pain & no weakness Hematoma in muscle
Isometric Testing
Tendon rupture,
B abnormal Weakness & no pain Abnormal nerve conduction
and (e.g., proximal muscle weakness)
passive ROM normal Pain & weakness

Inflammatory arthritis
(and global Grade 4/5 weakness)
Capsular pattern
Acute gout, Acute septic joint
Passive ROM Non-capsular pattern
Chronic bursitis, AC joint
C abnormal
Pain & no weakness arthropathy/enthesitis, Labral tear
AND
Isometric Testing Weakness & no pain Acute bursitis
As presented at the CRA ASM OMINOUS
abnormal
2015.
Pain Quebec City, Quebec
& weakness Fracture, Metastasis
 Formulating the Physical Examination Data
Differentiating between 6 common shoulder pain disorders

Passive ROM Frozen shoulder

abnormal
1 with
normal
isometric muscle testing

Isometric Testing Rotator cuff tendinitis

2 abnormal
with
normal
passive ROM testing Bicipital tendinitis

Chronic subacromial bursitis

Passive ROM
abnormal
3 AND AC joint arthropathy/enthesitis
Isometric Testing
As presented at the CRA ASM
abnormal Acute subacromial bursitis
2015. Quebec City, Quebec
 The End

As presented at the CRA ASM

2015. Quebec City, Quebec