1. Intertester Reliability of the Cyriax Evaluation in
Assessing Patients With Shoulder Pain
Authors: Geraldine L. Pellecchia, MA, PT1 Julie Paolino, PT, ATC2 Jeanne Connell,
PT3
AFFILIATIONS:
1 Assistant Professor, University of Hartford, Physical Therapy Program, 200 Bloomfield
Avenue, West Hartford, CT 06117; Research Coordinator, Physical Therapy and Sports
Medicine Associates, Farmington, CT
2 Site Director, Physical Therapy and Sports Medicine Associates, East Hartford, CT
3 Ms. Connell was Regional Director of Physical Therapy and Sports Medicine
Associates at the time of this study.
Published: Journal of Orthopaedic & Sports Physical Therapy, 1996, Volume: 23
Issue: 1 Pages: 34-38 doi:10.2519/jospt.1996.23.1.34
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 Abstract
James Cyriax's approach to diagnosis and treatment of soft tissue disorders is
frequently used by orthopaedic and sport physical therapists. The reliability of using
Cyriax' s system to determine diagnostic categories, however, has not been
established. The purpose of this study was to examine the intertherapist reliability of
assessments made using Cyriax's shoulder evaluation. Twenty-one cases of painful
shoulder were evaluated independently by two experienced physical therapists.
Therapists used a checklist to indicate their assessment of each case by selecting a
specific shoulder lesion or by indicating that the case did not fit the Cyriax model.
Cohen's kappa statistic was used to measure intertherapist agreement. Therapists
classified 19 of the 21 cases into the same diagnostic category for a percent agreement
of 90.5%. The kappa value was .875, indicating “almost period” agreement. Both
therapists classified the same four cases of painful shoulder as not fitting the Cyriax
model of soft issue examination. The results of this study show that the Cyriax
evaluation can be a highly reliable schema for assessing patients with shoulder pain.
Read More: http://www.jospt.org/doi/abs/10.2519/jospt.1996.23.1.34

2. Diagnosisof ShoulderPain by History and
Selective Tissue Tension: Agreement
Between Assessors
Nigel C. A. Hanchard, MSc1
Tracey E. Howe, PhD2
Meg M. Gilbert, BSc(Hons)3
Study Design: Evaluation of agreement between assessors.
Objective: To evaluate agreement between an expert in selective tissue tension (STT) and 3
other
trained assessors, all using STT in conjunction with a preliminary clinical history, on their
diagnostic labeling of painful shoulders.
Background: Consensus on diagnostic labeling for shoulder pain is poor, hampering
interpretation
of the evidence for interventions. STT, a systematic approach to physical examination and
diagnosis, offers potential for standardization, but its reliability is contentious.
Methods and Measures: Four trained assessors, 1 of whom was considered an expert,
separately
assessed 56 painful shoulders in 53 subjects (32 male [mean ± SD age, 51 ± 13 years], 21
female
[mean ± SD age, 57 ± 12 years]), using STT in conjunction with a preliminary clinical history.
Assessors labeled each painful shoulder as ‘‘rotator cuff lesion,’’ ‘‘bursitis,’’ ‘‘capsulitis,’’ ‘‘other
diagnosis,’’ or ‘‘no diagnosis.’’ Combinations of diagnoses were allowed.
Results: A diagnosis was made in every case, with less than 7% of the diagnoses being
combined.
With the diagnostic categories pooled, agreement (kappa and 95% confidence interval [CI])
between the expert assessor and each of the other assessors was good, ranging from 0.61
(0.44-0.78) to 0.75 (0.60-0.90). For single diagnostic categories, agreement between the expert
and each of the others (dichotomized data) ranged from 0.35 (–0.03-0.73) to 0.58 (0.29-0.87)
for
bursitis; 0.63 (0.40-0.86) to 0.82 (0.65-0.99) for capsulitis; 0.71 (0.49-0.93) to 0.79 (0.61-0.96)
for
rotator cuff lesions; and from 0.69 (0.35-1.00) to 0.78 (0.48-1.00) for other diagnoses.
Conclusions: Overall, STT in conjunction with a preliminary clinical history enables good
agreement between trained assessors. Future work is required to evaluate its criterion validity.
J Orthop Sports Phys Ther 2005;35:147-153.
Key Words: orthopedics, physical therapy, tests

3. Reliability of Classifications Derived From Cyriax's Resisted Testing in Subjects
With Painful Shoulders and Knees
Authors: Karen W. Hayes , PT, PhD1 Cheryl M. Petersen , PT, MS2
AFFILIATIONS:
1Associate Professor, Physical Therapy and Human Movement Sciences, Director, Professional
Education, Department of Physical Therapy and Human Movement Sciences, Feinberg School of
Medicine, Northwestern University, Chicago, IL.
2Assistant Professor, Department of Physical Therapy, Concordia University Wisconsin, Mequon, WI.
Please send correspondence to Karen W. Hayes, 645 N. Michigan Avenue, Suite 1100, Chicago, IL
60611. E-mail: k-hayes@northwestern.edu
Published: Journal of Orthopaedic & Sports Physical Therapy, 2003, Volume: 33
Issue: 5 Pages: 235-246 doi:10.2519/jospt.2003.33.5.235
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 Abstract
Study Design Intrarater and interrater reliability.
Objectives Examine intrarater and interrater reliability of the resisted-testing component
of Cyriax's selective tension testing for patients with painful shoulders and knees.
Background Clinicians make diagnostic and intervention decisions about lesions in
contractile tissues based on resisted testing. Diagnostic and intervention decisions
require reliable data gathering, especially when more than 1 physical therapist manages
a patient. No studies have examined agreement of the results of the resisted tests used
in selective tension testing, either within or between physical therapists, in subjects
having pathology.
Methods and Measures Subjects with pain in 1 knee (18 male, 22 female; mean age ±
SD = 31.8 ± 9.5 years) or shoulder (21 male, 25 female; mean age ± SD = 34.3 ± 12.9
years) were examined twice. Referring diagnoses included ligament injuries, overuse
syndromes, joint instability, and postsurgical symptoms, with some subjects seeking
initial diagnosis. Two physical therapists used standardized positions to evaluate 2 knee
motions or 6 shoulder and elbow motions. Evaluators applied maximal isometric manual
resistance and rated the contraction as strong or weak while subjects identified the
presence or absence of pain during the contraction. Evaluators did not interview the
subjects and were masked to previous test results. Analyses included percentage of
agreement, kappa coefficients, confidence intervals, and maximum kappa coefficients.
Results Intrarater kappa coefficients ranged from 0.44 to 0.82 and interrater coefficients
ranged from 0.00 to 0.46. The small number of subjects who were classified as weak
affected the kappa coefficients. In the intrarater condition, evaluators averaged 91% of
maximum kappa for the knee and 66.5% for the shoulder. In the interrater condition,
they averaged 60.4% of the maximum kappa for both the knee and the shoulder.

4. Conclusions Based on 2 physical therapist evaluators with previous education in the
selective tension system and an additional 6 hours of formal training on the methods,
intrarater reliability of resisted tests was generally acceptable for the knee but not for the
shoulder. Interrater reliability of these tests, however, was generally not acceptable.
Results were limited by subjects who were younger and had mostly chronic conditions
that were mildly to moderately severe and by the small subject samples in the analyses.
Reliability might be improved by more intensive training of the evaluators and by
standardizing the magnitude of the applied resistance and stabilization of the subjects.
Read More: http://www.jospt.org/doi/abs/10.2519/jospt.2003.33.5.235

5. Article about END-FEEL
Construct Validity of Cyriax's Selective Tension Examination: Association of End-
Feels With Pain at the Knee and Shoulder
Authors: Cheryl M. Petersen, PT, MS1Karen W. Hayes, PT, PhD1
AFFILIATION:
1 Department of Physical Therapy and Human Movement Sciences, Northwestern University Medical
School, Chicago, Ill.
Send correspondence to: Cheryl M. Petersen, 645 N. Michigan Avenue, Suite 1100, Chicago, IL 60611.
E-mail: c-petersen@nwu.edu
Published: Journal of Orthopaedic & Sports Physical Therapy, 2000, Volume: 30 Issue: 9
Pages: 512-527 doi:10.2519/jospt.2000.30.9.512
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 Abstract
Study Design Descriptive.
Objectives To examine the relationship between pain and normal and abnormal-pathologic end-
feels during passive physiologic motion assessment at the knee and shoulder. We theorized
that abnormal-pathologic end-feels would be more painful than normal end-feels.
Background End-feel testing and pain intensity information are part of physical therapy
musculoskeletal patient examinations. End-feels are categorized as normal or abnormal-
pathologic. No previous studies have examined the relationship between pain during end-feel
testing and the type of end-feel.
Methods and Measures Two physical therapists examined subjects with unilateral knee or
shoulder pain. Each subject was examined twice. Passive physiologic motions, 2 at the knee
and 5 at the shoulder, were tested by applying an overpressure at the end of range of motion
using standardized positions. Subjects reported the amount of pain (0–10) immediately after the
evaluator recorded the end-feel. Analyses included one-way ANOVAs and post-hoc Tukey's
Honestly Significant Difference tests.
Results Some abnormal-pathologic end-feels were significantly more painful than the normal
end-feels at both the knee and the shoulder for all physiologic motions. Among the abnormal-
pathologic end-feel categories there were no statistical differences in pain intensity, although
small samples in some categories may be responsible for this finding.
Conclusion Abnormal-pathologic end-feels are associated with more pain than normal end-feels
during passive physiologic motion testing at the knee or shoulder. Dysfunction should be
suspected when abnormal-pathologic end-feels are present. J Orthop Sports Phys Ther
2000;30:512–527.
Read More: http://www.jospt.org/doi/abs/10.2519/jospt.2000.30.9.512