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 in Quebec City, Quebec
DISCLOSURES
None
As presented at the CRA ASM
2015 in 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) “endfeel”, contribute to the accuracy of the diagnosis of
regional pain disorders by physical examination.
As presented at the CRA ASM
2015 in 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 in 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 in 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.
2.
Frozen shoulder
Rotator cuff tendinitis
- supraspinatus tendinitis
- infraspinatus tendinitis
- subscapularis tendinitis
- (teres minor tendinitis)
3.
4.
5.
6.
Bicipital tendinitis
AC joint arthropathy/enthesitis
Acute subacromial bursitis
Chronic subacromial bursitis
As presented at the CRA ASM
2015 in 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 in Quebec City, Quebec
Acute subacromial bursitis
Formulating the Physical Examination Data
Differentiating between 6 common shoulder pain disorders
Passive ROM
1
Frozen shoulder
abnormal
Rotator cuff tendinitis
Bicipital tendinitis
Chronic subacromial bursitis
AC joint arthropathy/enthesitis
As presented at the CRA ASM
2015 in Quebec City, Quebec
Acute subacromial bursitis
Formulating the Physical Examination Data
Differentiating between 6 common shoulder pain disorders
Passive ROM
1
Frozen shoulder
abnormal
Rotator cuff tendinitis
Bicipital tendinitis
Chronic subacromial bursitis
AC joint arthropathy/enthesitis
As presented at the CRA ASM
2015 in Quebec City, Quebec
Acute subacromial bursitis
Formulating the Physical Examination Data
Differentiating between 6 common shoulder pain disorders
Passive ROM
1
Frozen shoulder
abnormal
with
normal
isometric muscle testing
Rotator cuff tendinitis
Bicipital tendinitis
Chronic subacromial bursitis
AC joint arthropathy/enthesitis
As presented at the CRA ASM
2015 in Quebec City, Quebec
Acute subacromial bursitis
Formulating the Physical Examination Data
Differentiating between 6 common shoulder pain disorders
Passive ROM
1
Frozen shoulder
abnormal
with
normal
isometric muscle testing
Rotator cuff tendinitis
Isometric Testing
2
abnormal
Bicipital tendinitis
Chronic subacromial bursitis
AC joint arthropathy/enthesitis
As presented at the CRA ASM
2015 in Quebec City, Quebec
Acute subacromial bursitis
Formulating the Physical Examination Data
Differentiating between 6 common shoulder pain disorders
Passive ROM
1
Frozen shoulder
abnormal
with
normal
isometric muscle testing
Rotator cuff tendinitis
Isometric Testing
2
abnormal
Bicipital tendinitis
Chronic subacromial bursitis
AC joint arthropathy/enthesitis
As presented at the CRA ASM
2015 in Quebec City, Quebec
Acute subacromial bursitis
Formulating the Physical Examination Data
Differentiating between 6 common shoulder pain disorders
Passive ROM
1
Frozen shoulder
abnormal
with
normal
isometric muscle testing
Rotator cuff tendinitis
Isometric Testing
2
abnormal
Bicipital tendinitis
Chronic subacromial bursitis
AC joint arthropathy/enthesitis
As presented at the CRA ASM
2015 in Quebec City, Quebec
Acute subacromial bursitis
Formulating the Physical Examination Data
Differentiating between 6 common shoulder pain disorders
Passive ROM
1
Frozen shoulder
abnormal
with
normal
isometric muscle testing
Rotator cuff tendinitis
Isometric Testing
2
abnormal
with
normal
passive ROM testing
Bicipital tendinitis
Chronic subacromial bursitis
AC joint arthropathy/enthesitis
As presented at the CRA ASM
2015 in Quebec City, Quebec
Acute subacromial bursitis
Formulating the Physical Examination Data
Differentiating between 6 common shoulder pain disorders
Passive ROM
1
Frozen shoulder
abnormal
with
normal
isometric muscle testing
Rotator cuff tendinitis
Isometric Testing
2
abnormal
with
normal
passive ROM testing
Bicipital tendinitis
Chronic subacromial bursitis
Passive ROM
3
abnormal
AC joint arthropathy/enthesitis
AND
Isometric Testing
abnormal
As presented at the CRA ASM
2015 in Quebec City, Quebec
Acute subacromial bursitis
Formulating the Physical Examination Data
Differentiating between 6 common shoulder pain disorders
Passive ROM
1
Frozen shoulder
abnormal
with
normal
isometric muscle testing
Rotator cuff tendinitis
Isometric Testing
2
abnormal
with
normal
passive ROM testing
Bicipital tendinitis
Chronic subacromial bursitis
Passive ROM
3
abnormal
AC joint arthropathy/enthesitis
AND
Isometric Testing
abnormal
As presented at the CRA ASM
2015 in Quebec City, Quebec
Acute subacromial bursitis
Formulating the Physical Examination Data
Differentiating between 6 common shoulder pain disorders
Passive ROM
1
Frozen shoulder
abnormal
with
normal
isometric muscle testing
Rotator cuff tendinitis
Isometric Testing
2
abnormal
with
normal
passive ROM testing
Bicipital tendinitis
Chronic subacromial bursitis
Passive ROM
3
abnormal
AC joint arthropathy/enthesitis
AND
Isometric Testing
abnormal
As presented at the CRA ASM
2015 in Quebec City, Quebec
Acute subacromial bursitis
Formulating the Physical Examination Data
Differentiating between 6 common shoulder pain disorders
Passive ROM
1
Frozen shoulder
abnormal
with
normal
isometric muscle testing
Rotator cuff tendinitis
Isometric Testing
2
abnormal
with
normal
passive ROM testing
Bicipital tendinitis
Chronic subacromial bursitis
Passive ROM
3
abnormal
AC joint arthropathy/enthesitis
AND
Isometric Testing
abnormal
As presented at the CRA ASM
2015 in Quebec City, Quebec
Acute subacromial bursitis
Formulating the Physical Examination Data
Differentiating between 6 common shoulder pain disorders
Passive ROM
1
Frozen shoulder
abnormal
with
normal
isometric muscle testing
Rotator cuff tendinitis
Isometric Testing
2
abnormal
with
normal
passive ROM testing
Bicipital tendinitis
Chronic subacromial bursitis
Passive ROM
3
abnormal
AC joint arthropathy/enthesitis
AND
Isometric Testing
abnormal
As presented at the CRA ASM
2015 in Quebec City, Quebec
Acute subacromial bursitis
Formulating the Physical Examination Data
Differentiating between 6 common shoulder pain disorders
Passive ROM
1
Frozen shoulder
abnormal
with
normal
isometric muscle testing
Rotator cuff tendinitis
Isometric Testing
2
abnormal
with
normal
passive ROM testing
Bicipital tendinitis
Chronic subacromial bursitis
Passive ROM
3
abnormal
AC joint arthropathy/enthesitis
AND
Isometric Testing
abnormal
As presented at the CRA ASM
2015 in Quebec City, Quebec
Acute subacromial bursitis
Formulating the Physical Examination Data
Differentiating between 6 common shoulder pain disorders
Passive ROM
A
abnormal
Capsular pattern
with
normal
isometric muscle testing
Rotator cuff tendinitis
Isometric Testing
B
abnormal
with
normal
passive ROM testing
Bicipital tendinitis
Chronic subacromial bursitis
Passive ROM
C
Frozen shoulder
abnormal
AC joint arthropathy/enthesitis
AND
Isometric Testing
abnormal
As presented at the CRA ASM
2015 in Quebec City, Quebec
Acute subacromial bursitis
Formulating the Physical Examination Data
Differentiating between 6 common shoulder pain disorders
Passive ROM
1
abnormal
with
normal
isometric muscle testing
Capsular pattern
Non-capsular pattern
Rotator cuff tendinitis
Isometric Testing
2
abnormal
with
normal
passive ROM testing
Bicipital tendinitis
Chronic subacromial bursitis
Passive ROM
3
Frozen shoulder
abnormal
AC joint arthropathy/enthesitis
AND
Isometric Testing
abnormal
As presented at the CRA ASM
2015 in Quebec City, Quebec
Acute subacromial bursitis
Formulating the Physical Examination Data
Differentiating between 6 common shoulder pain disorders
Passive ROM
1
abnormal
with
normal
isometric muscle testing
Capsular pattern
Non-capsular pattern
Rotator cuff tendinitis
Isometric Testing
2
abnormal
with
normal
passive ROM testing
Bicipital tendinitis
Chronic subacromial bursitis
Passive ROM
3
Frozen shoulder
abnormal
AC joint arthropathy/enthesitis
AND
Isometric Testing
abnormal
As presented at the CRA ASM
2015 in Quebec City, Quebec
Acute subacromial bursitis
Formulating the Physical Examination Data
Differentiating between 6 common shoulder pain disorders
Passive ROM
1
Frozen shoulder
abnormal
with
normal
isometric muscle testing
Rotator cuff tendinitis
Isometric Testing
2
abnormal
with
normal
passive ROM testing
Bicipital tendinitis
Chronic subacromial bursitis
Passive ROM
3
abnormal
AC joint arthropathy/enthesitis
AND
Isometric Testing
abnormal
As presented at the CRA ASM
2015 in Quebec City, Quebec
Acute subacromial bursitis
Formulating the Physical Examination Data
Differentiating between 6 common shoulder pain disorders
Passive ROM
1
with
normal
isometric muscle testing
Isometric Testing
2
Frozen shoulder
abnormal
Pain & no weakness
abnormal
with
normal
passive ROM testing
Bicipital tendinitis
Chronic subacromial bursitis
Passive ROM
3
Rotator cuff tendinitis
abnormal
AC joint arthropathy/enthesitis
AND
Isometric Testing
abnormal
As presented at the CRA ASM
2015 in Quebec City, Quebec
Acute subacromial bursitis
Formulating the Physical Examination Data
Differentiating between 6 common shoulder pain disorders
Passive ROM
1
with
normal
isometric muscle testing
Isometric Testing
2
Frozen shoulder
abnormal
abnormal
Pain & no weakness
Weakness & no pain
with
normal
passive ROM testing
Bicipital tendinitis
Chronic subacromial bursitis
Passive ROM
3
Rotator cuff tendinitis
abnormal
AC joint arthropathy/enthesitis
AND
Isometric Testing
abnormal
As presented at the CRA ASM
2015 in Quebec City, Quebec
Acute subacromial bursitis
Formulating the Physical Examination Data
Differentiating between 6 common shoulder pain disorders
Passive ROM
1
with
normal
isometric muscle testing
Isometric Testing
2
Frozen shoulder
abnormal
Pain & no weakness
abnormal
Weakness & no pain
with
normal
passive ROM testing
Pain & weakness
Bicipital tendinitis
Chronic subacromial bursitis
Passive ROM
3
Rotator cuff tendinitis
abnormal
AC joint arthropathy/enthesitis
AND
Isometric Testing
abnormal
As presented at the CRA ASM
2015 in Quebec City, Quebec
Acute subacromial bursitis
Formulating the Physical Examination Data
Differentiating between 6 common shoulder pain disorders
Passive ROM
1
with
normal
isometric muscle testing
Isometric Testing
2
Frozen shoulder
abnormal
Pain & no weakness
abnormal
Weakness & no pain
with
normal
passive ROM testing
Pain & weakness
Bicipital tendinitis
Chronic subacromial bursitis
Passive ROM
3
Rotator cuff tendinitis
abnormal
AC joint arthropathy/enthesitis
AND
Isometric Testing
abnormal
As presented at the CRA ASM
2015 in Quebec City, Quebec
Acute subacromial bursitis
Formulating the Physical Examination Data
Differentiating between 6 common shoulder pain disorders
Passive ROM
1
Frozen shoulder
abnormal
with
normal
isometric muscle testing
Rotator cuff tendinitis
Isometric Testing
2
abnormal
with
normal
passive ROM testing
Bicipital tendinitis
Capsular pattern
Passive ROM
3
Non-capsular pattern
abnormal
Chronic subacromial bursitis
AC joint arthropathy/enthesitis
AND
Isometric Testing
abnormal
As presented at the CRA ASM
2015 in Quebec City, Quebec
Acute subacromial bursitis
Formulating the Physical Examination Data
Differentiating between 6 common shoulder pain disorders
Passive ROM
1
Frozen shoulder
abnormal
with
normal
isometric muscle testing
Rotator cuff tendinitis
Isometric Testing
2
abnormal
with
normal
passive ROM testing
Bicipital tendinitis
Capsular pattern
3
Passive ROM
Non-capsular pattern
abnormal
Pain & no weakness
AND
Isometric Testing
abnormal
Weakness & no pain
As presented at the CRA ASM
Pain
2015&inweakness
Quebec City, Quebec
Chronic subacromial bursitis
AC joint arthropathy/enthesitis
Acute subacromial bursitis
Formulating the Physical Examination Data
Differentiating between 6 common shoulder pain disorders
Passive ROM
1
Frozen shoulder
abnormal
with
normal
isometric muscle testing
Rotator cuff tendinitis
Isometric Testing
2
abnormal
with
normal
passive ROM testing
Bicipital tendinitis
Capsular pattern
3
Passive ROM
Non-capsular pattern
abnormal
Pain & no weakness
AND
Isometric Testing
abnormal
Weakness & no pain
As presented at the CRA ASM
Pain
2015&inweakness
Quebec City, Quebec
Chronic subacromial bursitis
AC joint arthropathy/enthesitis
Acute subacromial bursitis
Formulating the Physical Examination Data
Differentiating between 6 common shoulder pain disorders
Passive ROM
1
Frozen shoulder
abnormal
with
normal
isometric muscle testing
Rotator cuff tendinitis
Isometric Testing
2
abnormal
with
normal
passive ROM testing
Bicipital tendinitis
Capsular pattern
3
Passive ROM
Non-capsular pattern
abnormal
Pain & no weakness
AND
Isometric Testing
abnormal
Weakness & no pain
As presented at the CRA ASM
Pain
2015&inweakness
Quebec City, Quebec
Chronic subacromial bursitis
AC joint arthropathy/enthesitis
Acute subacromial bursitis
Formulating the Physical Examination Data
Differentiating between 6 common shoulder pain disorders
Passive ROM
1
Frozen shoulder
abnormal
with
normal
isometric muscle testing
Rotator cuff tendinitis
Isometric Testing
2
abnormal
with
normal
passive ROM testing
Bicipital tendinitis
Capsular pattern
3
Passive ROM
Non-capsular pattern
abnormal
Pain & no weakness
AND
Isometric Testing
abnormal
Weakness & no pain
As presented at the CRA ASM
Pain
2015&inweakness
Quebec City, Quebec
Chronic subacromial bursitis
AC joint arthropathy/enthesitis
Acute subacromial bursitis
Formulating the Physical Examination Data
Differentiating between 6 common shoulder pain disorders
Passive ROM
1
Frozen shoulder
abnormal
with
normal
isometric muscle testing
Rotator cuff tendinitis
Isometric Testing
2
abnormal
with
normal
passive ROM testing
Bicipital tendinitis
Capsular pattern
3
Passive ROM
Non-capsular pattern
abnormal
Pain & no weakness
AND
Isometric Testing
abnormal
Weakness & no pain
As presented at the CRA ASM
Pain
2015&inweakness
Quebec City, Quebec
Chronic subacromial bursitis
AC joint arthropathy/enthesitis
Acute subacromial bursitis
Formulating the Physical Examination Data
Differentiating between 6 common shoulder pain disorders
Passive ROM
1
Frozen shoulder
abnormal
with
normal
isometric muscle testing
Rotator cuff tendinitis
Isometric Testing
2
abnormal
with
normal
passive ROM testing
Bicipital tendinitis
Capsular pattern
3
Passive ROM
Non-capsular pattern
abnormal
Pain & no weakness
AND
Isometric Testing
abnormal
Weakness & no pain
As presented at the CRA ASM
Pain
2015&inweakness
Quebec City, Quebec
Chronic subacromial bursitis
AC joint arthropathy/enthesitis
Acute subacromial bursitis
Formulating the Physical Examination Data
Differentiating between 6 common shoulder pain disorders
Passive ROM
1
Frozen shoulder
abnormal
with
normal
isometric muscle testing
Rotator cuff tendinitis
Isometric Testing
2
abnormal
with
normal
passive ROM testing
Bicipital tendinitis
Capsular pattern
3
Passive ROM
Non-capsular pattern
abnormal
Pain & no weakness
AND
Isometric Testing
abnormal
Weakness & no pain
As presented at the CRA ASM
Pain
2015&inweakness
Quebec City, Quebec
Chronic subacromial bursitis
AC joint arthropathy/enthesitis
Acute subacromial bursitis
Formulating the Physical Examination Data
Differentiating between 6 common shoulder pain disorders
Passive ROM
1
Frozen shoulder
abnormal
with
normal
isometric muscle testing
Rotator cuff tendinitis
Isometric Testing
2
abnormal
with
normal
passive ROM testing
Bicipital tendinitis
Capsular pattern
3
Passive ROM
Non-capsular pattern
abnormal
Pain & no weakness
AND
Isometric Testing
abnormal
Weakness & no pain
As presented at the CRA ASM
Pain
2015&inweakness
Quebec City, Quebec
Chronic subacromial bursitis
AC joint arthropathy/enthesitis
Acute subacromial bursitis
Formulating the Physical Examination Data
Differentiating between 6 common shoulder pain disorders
Passive ROM
1
Frozen shoulder
abnormal
with
normal
isometric muscle testing
Rotator cuff tendinitis
Isometric Testing
2
abnormal
with
normal
passive ROM testing
Bicipital tendinitis
Capsular pattern
3
Passive ROM
Non-capsular pattern
abnormal
Pain & no weakness
AND
Isometric Testing
abnormal
Weakness & no pain
As presented at the CRA ASM
Pain
2015&inweakness
Quebec City, Quebec
Chronic subacromial bursitis
AC joint arthropathy/enthesitis
Acute subacromial bursitis
Formulating the Physical Examination Data
Differentiating between 6 common shoulder pain disorders
Passive ROM
1
Frozen shoulder
abnormal
with
normal
isometric muscle testing
Rotator cuff tendinitis
Isometric Testing
2
abnormal
with
normal
passive ROM testing
Bicipital tendinitis
Capsular pattern
3
Passive ROM
Non-capsular pattern
abnormal
Pain & no weakness
AND
Isometric Testing
abnormal
Weakness & no pain
As presented at the CRA ASM
Pain
2015&inweakness
Quebec City, Quebec
Chronic subacromial bursitis
AC joint arthropathy/enthesitis
Acute subacromial bursitis
Formulating the Physical Examination Data
Differentiating between 6 common shoulder pain disorders
Passive ROM
1
abnormal
with
normal
isometric muscle testing
Rotator cuff tendinitis
Isometric Testing
2
abnormal
with
normal
passive ROM testing
Bicipital tendinitis
Passive ROM
3
abnormal
AND
Isometric Testing
abnormal
As presented at the CRA ASM
2015 in Quebec City, Quebec
Formulating the Physical Examination Data
Differentiating between 6 common shoulder pain disorders
Passive ROM
1
abnormal
with
normal
isometric muscle testing
Isometric Testing
2
Pain & no weakness
abnormal
Weakness & no pain
with
normal
passive ROM testing
Pain & weakness
Passive ROM
3
abnormal
AND
Isometric Testing
abnormal
As presented at the CRA ASM
2015 in Quebec City, Quebec
Rotator cuff tendinitis
Bicipital tendinitis
Formulating the Physical Examination Data
Differentiating between 6 common shoulder pain disorders
Passive ROM
1
abnormal
with
normal
isometric muscle testing
Isometric Testing
2
Pain & no weakness
abnormal
Weakness & no pain
with
normal
passive ROM testing
Pain & weakness
Passive ROM
3
abnormal
AND
Isometric Testing
abnormal
As presented at the CRA ASM
2015 in Quebec City, Quebec
Rotator cuff tendinitis
Bicipital tendinitis
Formulating the Physical Examination Data
Differentiating between 6 common shoulder pain disorders
Passive ROM
1
abnormal
with
normal
isometric muscle testing
Isometric Testing
2
Rotator cuff tendinitis
Pain & no weakness
abnormal
Weakness & no pain
with
normal
passive ROM testing
Pain & weakness
Passive ROM
3
abnormal
AND
Isometric Testing
abnormal
As presented at the CRA ASM
2015 in Quebec City, Quebec
Supraspinatus tendinitis
pain on resisted abduction
Infraspinatus tendinitis
pain on resisted external rotation
Subscapularis tendinitis
pain on resisted internal rotation
Teres minor tendinitis
pain on resisted internal rotation
and adduction
Bicipital tendinitis
Formulating the Physical Examination Data
Differentiating between 6 common shoulder pain disorders
Passive ROM
1
abnormal
with
normal
isometric muscle testing
Isometric Testing
2
Rotator cuff tendinitis
Pain & no weakness
abnormal
Weakness & no pain
with
normal
passive ROM testing
Pain & weakness
abnormal
AND
Isometric Testing
abnormal
Bicipital tendinitis
pain on resisted long-lever flexion
pain on resisted horizontal adduction
Passive ROM
3
Supraspinatus tendinitis
pain on resisted abduction
Infraspinatus tendinitis
pain on resisted external rotation
Subscapularis tendinitis
pain on resisted internal rotation
Teres minor tendinitis
pain on resisted internal rotation
and adduction
As presented at the CRA ASM
2015 in 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.
Group 1
Group 2
Passive ROM
abnormal
Isometric Testing
abnormal
Passive ROM
Group 3
abnormal
AND
Isometric Testing
abnormal
As presented at the CRA ASM
2015 in 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 in Quebec City, Quebec
Differential Diagnosis
Let’s take shoulder pain to illustrate the process.
As presented at the CRA ASM
2015 in Quebec City, Quebec
Formulating the Physical Examination Data
Differentiating between 6 common shoulder pain disorders
Passive ROM
1
abnormal
with
normal
isometric muscle testing
Capsular pattern
Non-capsular pattern
Rotator cuff tendinitis
Isometric Testing
2
abnormal
with
normal
passive ROM testing
Bicipital tendinitis
Chronic subacromial bursitis
Passive ROM
3
Frozen shoulder
abnormal
AC joint arthropathy/enthesitis
AND
Isometric Testing
abnormal
As presented at the CRA ASM
2015 in Quebec City, Quebec
Acute subacromial bursitis
Shoulder Pain: Differential Diagnosis
Inflammatory arthritis
Passive ROM
1
abnormal
with
normal
isometric muscle testing
Capsular pattern
Non-capsular pattern
Isometric Testing
abnormal
2
and
passive ROM normal
Passive ROM
3
abnormal
AND
Isometric Testing
abnormal
As presented at the CRA ASM
2015 in Quebec City, Quebec
(e.g., RA, PsA, SpA, AS, gout, CPPD,
hydroxyapatite crystal disease, septic
arthritis with normal motor power),
OA, Frozen shoulder
Shoulder Pain: Differential Diagnosis
inflammatory arthritis
Passive ROM
1
abnormal
with
normal
isometric muscle testing
Capsular pattern
Non-capsular pattern
Isometric Testing
abnormal
2
and
passive ROM normal
Passive ROM
3
abnormal
AND
Isometric Testing
abnormal
As presented at the CRA ASM
2015 in Quebec City, Quebec
(e.g., RA, PsA, SpA, AS, gout, CPPD,
hydroxyapatite crystal disease, septic
arthritis with normal motor power),
OA, frozen shoulder
Ligamentous laxity
(e.g., hypermobility syndrome,
sequella of previous dislocation )
Shoulder Pain: Differential Diagnosis
Passive ROM
1
abnormal
with
normal
isometric muscle testing
Pain & no weakness
Isometric Testing
abnormal
B
and
passive ROM normal
Weakness & no pain
Pain & weakness
Passive ROM
C
abnormal
AND
Isometric Testing
abnormal
As presented at the CRA ASM
2015 in Quebec City, Quebec
Shoulder Pain: Differential Diagnosis
Passive ROM
1
abnormal
with
normal
isometric muscle testing
Pain & no weakness
Isometric Testing
abnormal
B
and
passive ROM normal
Weakness & no pain
Pain & weakness
Passive ROM
C
abnormal
AND
Isometric Testing
abnormal
As presented at the CRA ASM
2015 in Quebec City, Quebec
Tendinitis, Bursitis,
Hematoma in muscle
Shoulder Pain: Differential Diagnosis
Passive ROM
1
abnormal
with
normal
isometric muscle testing
Pain & no weakness
Isometric Testing
abnormal
B
and
passive ROM normal
Weakness & no pain
Pain & weakness
Passive ROM
C
abnormal
AND
Isometric Testing
abnormal
As presented at the CRA ASM
2015 in Quebec City, Quebec
Tendinitis, Bursitis,
Hematoma in muscle
Tendon rupture,
Abnormal nerve conduction
(e.g., proximal muscle weakness)
Shoulder Pain: Differential Diagnosis
Passive ROM
1
abnormal
with
normal
isometric muscle testing
Pain & no weakness
Isometric Testing
abnormal
B
and
passive ROM normal
Weakness & no pain
Pain & weakness
Passive ROM
C
abnormal
AND
Isometric Testing
abnormal
As presented at the CRA ASM
2015 in Quebec City, Quebec
Tendinitis, bursitis,
hematoma in muscle
tendon rupture,
abnormal nerve conduction
(e.g., proximal muscle weakness)
Shoulder Pain: Differential Diagnosis
Passive ROM
abnormal
A
with
normal
isometric muscle testing
Isometric Testing
abnormal
B
and
passive ROM normal
Capsular pattern
Passive ROM
C
abnormal
AND
Isometric Testing
abnormal
Non-capsular pattern
Pain & no weakness
Weakness & no pain
As presented at the CRA ASM
2015
Quebec City, Quebec
Pain
& in
weakness
Shoulder Pain: Differential Diagnosis
Passive ROM
abnormal
A
with
normal
isometric muscle testing
Isometric Testing
abnormal
B
and
passive ROM normal
Capsular pattern
Passive ROM
C
abnormal
AND
Isometric Testing
abnormal
Non-capsular pattern
Pain & no weakness
Weakness & no pain
As presented at the CRA ASM
2015
Quebec City, Quebec
Pain
& in
weakness
Inflammatory arthritis
(and global Grade 4/5 weakness)
Shoulder Pain: Differential Diagnosis
Passive ROM
abnormal
A
with
normal
isometric muscle testing
Isometric Testing
abnormal
B
and
passive ROM normal
Capsular pattern
Passive ROM
C
abnormal
AND
Isometric Testing
abnormal
Acute gout, Acute septic joint
Non-capsular pattern
Pain & no weakness
Weakness & no pain
As presented at the CRA ASM
2015
Quebec City, Quebec
Pain
& in
weakness
Shoulder Pain: Differential Diagnosis
Passive ROM
abnormal
A
with
normal
isometric muscle testing
Isometric Testing
abnormal
B
and
passive ROM normal
Capsular pattern
Passive ROM
C
abnormal
AND
Isometric Testing
abnormal
Non-capsular pattern
Pain & no weakness
Weakness & no pain
As presented at the CRA ASM
2015
Quebec City, Quebec
Pain
& in
weakness
Chronic bursitis, AC joint
arthropathy/enthesitis, Labral tear
Shoulder Pain: Differential Diagnosis
Passive ROM
abnormal
A
with
normal
isometric muscle testing
Isometric Testing
abnormal
B
and
passive ROM normal
Pain & weakness
Capsular pattern
Passive ROM
C
abnormal
AND
Isometric Testing
abnormal
Non-capsular pattern
Pain & no weakness
Weakness & no pain
As presented at the CRA ASM
2015
Quebec City, Quebec
Pain
& in
weakness
Acute bursitis
OMINOUS
Fracture, Metastasis
Shoulder Pain: Differential Diagnosis
Inflammatory arthritis
Passive ROM
abnormal
A
with
normal
isometric muscle testing
Capsular pattern
(e.g., RA, PsA, SpA, AS, gout, CPPD,
hydroxyapatite crystal disease, septic
arthritis with normal motor power),
OA, Frozen shoulder
Non-capsular pattern
Ligamentous laxity
(e.g., hypermobility syndrome, sequella of
previous dislocation )
Pain & no weakness
Isometric Testing
abnormal
B
and
passive ROM normal
Weakness & no pain
Pain & weakness
Capsular pattern
Passive ROM
C
abnormal
AND
Isometric Testing
abnormal
Tendinitis, Bursitis,
Hematoma in muscle
Tendon rupture,
Abnormal nerve conduction
(e.g., proximal muscle weakness)
Inflammatory arthritis
(and global Grade 4/5 weakness)
Acute gout, Acute septic joint
Non-capsular pattern
Pain & no weakness
Weakness & no pain
As presented at the CRA ASM
2015
Quebec City, Quebec
Pain
& in
weakness
Chronic bursitis, AC joint
arthropathy/enthesitis, Labral tear
Acute bursitis
OMINOUS
Fracture, Metastasis
Concept 1
Active ROM
Passive ROM
Isometric Muscle Testing
As presented at the CRA ASM
2015 in 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 in 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 in Quebec City, Quebec
Concept 2
Capsular Pattern
Non-Capsular Pattern
As presented at the CRA ASM
2015 in 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 in 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 in 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 in 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
Since 1972: 0º→135º
or
180º→45º
or
195º→45º
or
195º→45º
e.g. ROM knee hyperextension
Prior to 1936: 0º→15º
Since 1972: 0º→15º
or
180º→195º
As presented at the CRA ASM
2015 in Quebec City, Quebec
or
-15º
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 in Quebec City, Quebec
Concept 3
End-feel
As presented at the CRA ASM
2015 in 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 in 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 in 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
INCORRECT
As presented at the CRA ASM
2015 in Quebec City, Quebec
The hands have to be each
side of the joint being tested.
SUMMARY
As presented at the CRA ASM
2015 in 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 in Quebec City, Quebec
Shoulder Pain: Differential Diagnosis
Inflammatory arthritis
Passive ROM
abnormal
A
with
normal
isometric muscle testing
Capsular pattern
(e.g., RA, PsA, SpA, AS, gout, CPPD,
hydroxyapatite crystal disease, septic
arthritis with normal motor power),
OA, Frozen shoulder
Non-capsular pattern
Ligamentous laxity
(e.g., hypermobility syndrome, sequella of
previous dislocation )
Pain & no weakness
Isometric Testing
abnormal
B
and
passive ROM normal
Weakness & no pain
Pain & weakness
Capsular pattern
Passive ROM
C
abnormal
AND
Isometric Testing
abnormal
Tendinitis, Bursitis,
Hematoma in muscle
Tendon rupture,
Abnormal nerve conduction
(e.g., proximal muscle weakness)
Inflammatory arthritis
(and global Grade 4/5 weakness)
Acute gout, Acute septic joint
Non-capsular pattern
Pain & no weakness
Weakness & no pain
As presented at the CRA ASM
2015
Quebec City, Quebec
Pain
& in
weakness
Chronic bursitis, AC joint
arthropathy/enthesitis, Labral tear
Acute bursitis
OMINOUS
Fracture, Metastasis
Formulating the Physical Examination Data
Differentiating between 6 common shoulder pain disorders
Passive ROM
1
Frozen shoulder
abnormal
with
normal
isometric muscle testing
Rotator cuff tendinitis
Isometric Testing
2
abnormal
with
normal
passive ROM testing
Bicipital tendinitis
Chronic subacromial bursitis
Passive ROM
3
abnormal
AC joint arthropathy/enthesitis
AND
Isometric Testing
abnormal
As presented at the CRA ASM
2015 in Quebec City, Quebec
Acute subacromial bursitis
The End
As presented at the CRA ASM
2015 in Quebec City, Quebec