The Cyriax method of MSK examination by Selective Tissue Tension
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1 The Cyriax method of MSK examination by Selective Tissue Tension Pre-Workshop Video Podcast SLIDES Workshop on Physical Examination, Saturday February 7 th, 205 Canadian Rheumatology Association Annual Meeting, Quebec City, Canada February 4 th -7 th, 205 Jean H. Gillies, MCSP, MD, FRCPC Division of Rheumatology University of British Columbia Vancouver, Canada jeangillies@telus.net
2 DISCLOSURES None
3 OBJECTIVES At the end of this video podcast, the participant will:. understand the concept of Cyriax method of MSK examination by selective tissue tension : active ROM, passive ROM and. 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.
4 Cyriax of method of MSK diagnosis by Selective Tissue Tension Three Concepts. active ROM; passive ROM; 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.
5 Let s take 6 common problems causing shoulder pain to illustrate the process.
6 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.. Frozen shoulder 2. - supraspinatus tendinitis - infraspinatus tendinitis - subscapularis tendinitis - (teres minor tendinitis) AC joint arthropathy/enthesitis 5. Acute subacromial bursitis 6. Chronic subacromial bursitis
7 Frozen shoulder Chronic subacromial bursitis AC joint arthropathy/enthesitis Acute subacromial bursitis
8 Frozen shoulder Chronic subacromial bursitis AC joint arthropathy/enthesitis Acute subacromial bursitis
9 Frozen shoulder Chronic subacromial bursitis AC joint arthropathy/enthesitis Acute subacromial bursitis
10 Frozen shoulder Chronic subacromial bursitis AC joint arthropathy/enthesitis Acute subacromial bursitis
11 Frozen shoulder 2 Chronic subacromial bursitis AC joint arthropathy/enthesitis Acute subacromial bursitis
12 Frozen shoulder 2 Chronic subacromial bursitis AC joint arthropathy/enthesitis Acute subacromial bursitis
13 Frozen shoulder 2 Chronic subacromial bursitis AC joint arthropathy/enthesitis Acute subacromial bursitis
14 Frozen shoulder 2 passive ROM testing Chronic subacromial bursitis AC joint arthropathy/enthesitis Acute subacromial bursitis
15 Frozen shoulder 2 passive ROM testing 3 AND Chronic subacromial bursitis AC joint arthropathy/enthesitis Acute subacromial bursitis
16 Frozen shoulder 2 passive ROM testing 3 AND Chronic subacromial bursitis AC joint arthropathy/enthesitis Acute subacromial bursitis
17 Frozen shoulder 2 passive ROM testing 3 AND Chronic subacromial bursitis AC joint arthropathy/enthesitis Acute subacromial bursitis
18 Frozen shoulder 2 passive ROM testing 3 AND Chronic subacromial bursitis AC joint arthropathy/enthesitis Acute subacromial bursitis
19 Frozen shoulder 2 passive ROM testing 3 AND Chronic subacromial bursitis AC joint arthropathy/enthesitis Acute subacromial bursitis
20 Frozen shoulder 2 passive ROM testing 3 AND Chronic subacromial bursitis AC joint arthropathy/enthesitis Acute subacromial bursitis
21 A Capsular pattern Frozen shoulder B passive ROM testing C AND Chronic subacromial bursitis AC joint arthropathy/enthesitis Acute subacromial bursitis
22 Capsular pattern Non-capsular pattern Frozen shoulder 2 passive ROM testing 3 AND Chronic subacromial bursitis AC joint arthropathy/enthesitis Acute subacromial bursitis
23 Capsular pattern Non-capsular pattern Frozen shoulder 2 passive ROM testing 3 AND Chronic subacromial bursitis AC joint arthropathy/enthesitis Acute subacromial bursitis
24 Frozen shoulder 2 passive ROM testing Chronic subacromial bursitis 3 AND AC joint arthropathy/enthesitis Acute subacromial bursitis
25 Frozen shoulder 2 passive ROM testing Pain & no weakness Chronic subacromial bursitis 3 AND AC joint arthropathy/enthesitis Acute subacromial bursitis
26 Frozen shoulder 2 passive ROM testing Pain & no weakness Weakness & no pain Chronic subacromial bursitis 3 AND AC joint arthropathy/enthesitis Acute subacromial bursitis
27 Frozen shoulder 2 passive ROM testing Pain & no weakness Weakness & no pain Pain & weakness Chronic subacromial bursitis 3 AND AC joint arthropathy/enthesitis Acute subacromial bursitis
28 Frozen shoulder 2 passive ROM testing Pain & no weakness Weakness & no pain Pain & weakness Chronic subacromial bursitis 3 AND AC joint arthropathy/enthesitis Acute subacromial bursitis
29 Frozen shoulder 2 passive ROM testing Capsular pattern 3 AND Non-capsular pattern Chronic subacromial bursitis AC joint arthropathy/enthesitis Acute subacromial bursitis
30 Frozen shoulder 2 passive ROM testing Capsular pattern 3 AND Non-capsular pattern Pain & no weakness Weakness & no pain Pain 205. & weakness Quebec City, Quebec Chronic subacromial bursitis AC joint arthropathy/enthesitis Acute subacromial bursitis
31 Frozen shoulder 2 passive ROM testing Capsular pattern Non-capsular pattern Chronic subacromial bursitis Pain & no weakness 3 AND AC joint arthropathy/enthesitis Weakness & no pain Pain 205. & weakness Quebec City, Quebec Acute subacromial bursitis
32 Frozen shoulder 2 passive ROM testing Capsular pattern Non-capsular pattern Chronic subacromial bursitis Pain & no weakness 3 AND AC joint arthropathy/enthesitis Weakness & no pain Pain 205. & weakness Quebec City, Quebec Acute subacromial bursitis
33 Frozen shoulder 2 passive ROM testing Capsular pattern Non-capsular pattern Chronic subacromial bursitis Pain & no weakness 3 AND AC joint arthropathy/enthesitis Weakness & no pain Pain 205. & weakness Quebec City, Quebec Acute subacromial bursitis
34 Frozen shoulder 2 passive ROM testing Capsular pattern Non-capsular pattern Chronic subacromial bursitis Pain & no weakness 3 AND AC joint arthropathy/enthesitis Weakness & no pain Pain 205. & weakness Quebec City, Quebec Acute subacromial bursitis
35 Frozen shoulder 2 passive ROM testing Capsular pattern 3 AND Non-capsular pattern Pain & no weakness Weakness & no pain Pain 205. & weakness Quebec City, Quebec Chronic subacromial bursitis AC joint arthropathy/enthesitis Acute subacromial bursitis
36 Frozen shoulder 2 passive ROM testing Capsular pattern 3 AND Non-capsular pattern Pain & no weakness Weakness & no pain Pain 205. & weakness Quebec City, Quebec Chronic subacromial bursitis AC joint arthropathy/enthesitis Acute subacromial bursitis
37 Frozen shoulder 2 passive ROM testing Capsular pattern Non-capsular pattern Chronic subacromial bursitis Pain & no weakness 3 AND AC joint arthropathy/enthesitis Weakness & no pain Pain 205. & weakness Quebec City, Quebec Acute subacromial bursitis
38 Frozen shoulder 2 passive ROM testing Capsular pattern Non-capsular pattern Chronic subacromial bursitis Pain & no weakness 3 AND AC joint arthropathy/enthesitis Weakness & no pain Pain 205. & weakness Quebec City, Quebec Acute subacromial bursitis
39 Frozen shoulder 2 passive ROM testing Capsular pattern Non-capsular pattern Chronic subacromial bursitis Pain & no weakness 3 AND AC joint arthropathy/enthesitis Weakness & no pain Pain 205. & weakness Quebec City, Quebec Acute subacromial bursitis
40 2 passive ROM testing 3 AND
41 2 passive ROM testing Pain & no weakness Weakness & no pain Pain & weakness 3 AND
42 2 passive ROM testing Pain & no weakness Weakness & no pain Pain & weakness 3 AND
43 2 passive ROM testing Pain & no weakness Weakness & no pain Pain & weakness 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 3 AND
44 2 passive ROM testing Pain & no weakness Weakness & no pain Pain & weakness 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 pain on resisted long-lever flexion pain on resisted horizontal adduction 3 AND
45 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 Group 2 Group 3 AND
46 .. Now for the Differential Diagnosis Now we will review the differential diagnosis in each of these three groups.
47 Differential Diagnosis Let s take shoulder pain to illustrate the process.
48 Capsular pattern Non-capsular pattern Frozen shoulder 2 passive ROM testing 3 AND Chronic subacromial bursitis AC joint arthropathy/enthesitis Acute subacromial bursitis
49 Shoulder Pain: Differential Diagnosis Capsular pattern Non-capsular pattern Inflammatory arthritis (e.g., RA, PsA, SpA, AS, gout, CPPD, hydroxyapatite crystal disease, septic arthritis motor power), OA, Frozen shoulder 2 and passive ROM 3 AND
50 Shoulder Pain: Differential Diagnosis Capsular pattern Non-capsular pattern inflammatory arthritis (e.g., RA, PsA, SpA, AS, gout, CPPD, hydroxyapatite crystal disease, septic arthritis motor power), OA, frozen shoulder Ligamentous laxity (e.g., hypermobility syndrome, sequella of previous dislocation ) 2 and passive ROM 3 AND
51 Shoulder Pain: Differential Diagnosis B and passive ROM Pain & no weakness Weakness & no pain Pain & weakness C AND
52 Shoulder Pain: Differential Diagnosis B and passive ROM Pain & no weakness Weakness & no pain Pain & weakness Tendinitis, Bursitis, Hematoma in muscle C AND
53 Shoulder Pain: Differential Diagnosis B and passive ROM Pain & no weakness Weakness & no pain Pain & weakness Tendinitis, Bursitis, Hematoma in muscle Tendon rupture, Ab nerve conduction (e.g., proximal muscle weakness) C AND
54 Shoulder Pain: Differential Diagnosis B and passive ROM Pain & no weakness Weakness & no pain Pain & weakness Tendinitis, bursitis, hematoma in muscle tendon rupture, nerve conduction (e.g., proximal muscle weakness) C AND
55 Shoulder Pain: Differential Diagnosis A B and passive ROM C AND Capsular pattern Non-capsular pattern Pain & no weakness Weakness & no pain Pain 205. & weakness Quebec City, Quebec
56 Shoulder Pain: Differential Diagnosis A B C and passive ROM AND Capsular pattern Non-capsular pattern Pain & no weakness Weakness & no pain Pain 205. & weakness Quebec City, Quebec Inflammatory arthritis (and global Grade 4/5 weakness)
57 Shoulder Pain: Differential Diagnosis A B and passive ROM Capsular pattern C AND Non-capsular pattern Pain & no weakness Weakness & no pain Pain 205. & weakness Quebec City, Quebec Acute gout, Acute septic joint
58 Shoulder Pain: Differential Diagnosis A B and passive ROM Capsular pattern C AND Non-capsular pattern Pain & no weakness Weakness & no pain Pain 205. & weakness Quebec City, Quebec Chronic bursitis, AC joint arthropathy/enthesitis, Labral tear
59 Shoulder Pain: Differential Diagnosis A B and passive ROM Pain & weakness Capsular pattern C AND Non-capsular pattern Pain & no weakness Weakness & no pain Pain 205. & weakness Quebec City, Quebec Acute bursitis OMINOUS Fracture, Metastasis
60 Shoulder Pain: Differential Diagnosis A Capsular pattern Non-capsular pattern Inflammatory arthritis (e.g., RA, PsA, SpA, AS, gout, CPPD, hydroxyapatite crystal disease, septic arthritis motor power), OA, Frozen shoulder Ligamentous laxity (e.g., hypermobility syndrome, sequella of previous dislocation ) B and passive ROM Pain & no weakness Weakness & no pain Pain & weakness Tendinitis, Bursitis, Hematoma in muscle Tendon rupture, Ab nerve conduction (e.g., proximal muscle weakness) Capsular pattern Inflammatory arthritis (and global Grade 4/5 weakness) C AND Non-capsular pattern Pain & no weakness Weakness & no pain Pain 205. & weakness Quebec City, Quebec Acute gout, Acute septic joint Chronic bursitis, AC joint arthropathy/enthesitis, Labral tear Acute bursitis OMINOUS Fracture, Metastasis
61 Concept Active ROM Isometric Muscle Testing
62 Cyriax method of MSK examination by Selective Tissue Tension Active ROM Tests the willingness of patient to move limb or trunk Tests the inert structures Isometric Resisted Muscle Testing Tests the contractile structures
63 Cyriax method of MSK examination by Selective Tissue Tension Active ROM non-contributory to the diagnosis 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)
64 Concept 2 Capsular Pattern Non-Capsular Pattern
65 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.
66 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]
67 Decreased prom: Capsular Pattern Glenohumeral Joint external rotation* > abduction** > internal rotation* 0º abduction; * *glenohumeral abduction [e.g., no scapular movement] Elbow Joint flexion > extension Wrist Joint flexion = extension
68 Decreased prom: Capsular Pattern 0º position of joints: The Neutral Zero Method of describing joint ROM First described in 936 (taking the anatomical position as the 0º starting position) Cave EF, Roberts SM. A method of measuring and recording joint function. JBJS; 936; 8:2: e.g. ROM knee flexion Prior to 936: 0º 35º or 80º 45º or 95º 45º Since 972: 0º 35º e.g. ROM knee hyperextension Prior to 936: 0º 5º or 80º 95º or 95º 45º or -5º Since 972: 0º 5º
69 Capsular Pattern: Proportional limitation of prom Knee Joint: Capsular Pattern Flexion: 0 35 [] Flexion: 0 20 [capsular pattern slight decreased ROM] Flexion: 0 85 [capsular pattern moderate decreased ROM] Flexion: 5 70 [capsular pattern marked decreased ROM] [inflammatory=00 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: 0 30 [non-capsular pattern moderate decreased ROM] [e.g., symptomatic loose body, symptomatic meniscal tear]
70 Concept 3 End-feel
71 Cyriax method of MSK examination by Selective Tissue Tension END-FEEL Normal Physiological end-feel Ab Pathological end-feel
72 Cyriax method of MSK examination by Selective Tissue Tension END-FEEL. 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 e.g., knee meniscal tear, hip labral tear 5. Muscle spasm Always e.g., fracture 6. Empty feel Always e.g., metastasis
73 . 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 The hands have to be each side of the joint being tested.
74 SUMMARY
75 Cyriax of method of MSK diagnosis by selective tissue tension Summary: Three Concepts. Examine: active ROM passive ROM. 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.
76 Shoulder Pain: Differential Diagnosis A Capsular pattern Non-capsular pattern Inflammatory arthritis (e.g., RA, PsA, SpA, AS, gout, CPPD, hydroxyapatite crystal disease, septic arthritis motor power), OA, Frozen shoulder Ligamentous laxity (e.g., hypermobility syndrome, sequella of previous dislocation ) B and passive ROM Pain & no weakness Weakness & no pain Pain & weakness Tendinitis, Bursitis, Hematoma in muscle Tendon rupture, Ab nerve conduction (e.g., proximal muscle weakness) Capsular pattern Inflammatory arthritis (and global Grade 4/5 weakness) C AND Non-capsular pattern Pain & no weakness Weakness & no pain Pain 205. & weakness Quebec City, Quebec Acute gout, Acute septic joint Chronic bursitis, AC joint arthropathy/enthesitis, Labral tear Acute bursitis OMINOUS Fracture, Metastasis
77 Frozen shoulder 2 passive ROM testing 3 AND Chronic subacromial bursitis AC joint arthropathy/enthesitis Acute subacromial bursitis
78 The End
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