An overview on The Cyriax Approach to Orthopaedic Manual Physical Therapy for undergraduate physiotherapy students

1. The Cyriax Approach
to
Orthopaedic Manual Physical Therapy
Dr Sreeraj S R, Ph.D.

2. Sreeraj S R
History
• Dr James H Cyriax (1904-1985), an orthopaedic surgeon in
London, was the first to approach the study of soft tissue
injuries in a systemic way.
• He laid out the foundation of a method of logical, clinically
reasoned, differential diagnosis, which he called “selective
tissue tension testing”.

3. Sreeraj S R
Principles
• The Principles of Cyriax concept are;
1. All pain arises from a lesion.
2. All treatment must reach the affected site.
3. All treatment must exert a beneficial effect on the affected
site.

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Core Concept
1. A good understanding of the phenomenon "referred pain“
2. Examination by Selective Tissue Tension Test
• Cyriax had three principles for examination by Selective Tissue
Tension Test.
1. Passive movements test the function of the inert structures.
2. Capsular patterns differentiate between joint conditions and other
inert structure lesions.
3. Isometric contractions test the function of the contractile tissues.

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Contractile and Non-contractile Tissues
• Contractile Structure
• It includes muscles and its attachment.
• Pain may be elicited by active contraction as well as passive stretching
in opposite directions.
• Non-contractile
• These tissues posses no inherent capacity to contract and relax.
• Extreme range of active movements will stretch the structures causing
pain.
• Testing a muscle in its neutral position eliminates the pain of
impingement and instability.

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Capsular Pattern
• A distinctive feature of the Cyriax method is the capsular
pattern.
• Each joint has its own distinctive capsular pattern associated
with injury.
• This capsular pattern denotes inflammation due to injuries.
• A non-capsular pattern implies that the capsule is not involved,
and that intra - or extra - articular tissue is the source of pain
due to inflamation or injury.

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Selective
Tissue
Tension
Testing (STT)
Wise CH (2015)

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Treatment
• Treatment depends largely on the existing type of disorder and
can be categorized as: Traumatic, inflammatory, degenerative,
internal derangement, functional disorders, psychogenic pain.
• The types of treatment options are:
1. Deep friction
2. Passive movements
3. Active movements and proprioceptive training
4. Injection and infiltration techniques

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Deep Friction Massage
• There are two forms of treatment.
1. The longitudinal in which the application of force runs parallel to
fibers of the soft tissue structures.
2. The transverse friction massage in which the force is applied
perpendicular to the fibers, separate each fiber, assisting in
alignment of newly-formed collagen during healing.
• Friction;
• Should be applied with sufficient sweep to reach all the affected tissue
and
• Should produce movement between the individual connective tissue
fibers of the affected structure.

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Deep Friction Massage
1. No movement between finger and skin is allowed
2. The main goal of friction is to move fibres in relation to each other and adjacent structures,
called Sweep.
3. Amount of pressure: The amount of pressure applied depends on three elements:
1. The depth of the lesion: increased pressure must be applied to deeper structures.
2. The ‘age’ of the lesion: recent sprains and injuries require only preventive friction because
crosslinks or adhesions have not had time to form. In long-standing cases more pressure is
needed to get rid of these.
3. The tenderness of the lesion: Pain can be avoided by starting with a minimal amount of
pressure – just enough to reach the lesion – and progressively increasing the force as
treatment proceeds.
4. Duration and frequency:
1. usually given for about 10–20 minutes and on every second day.
2. Massage immediately after an injury should be of very low intensity and short duration.
3. Treatment is stopped once the patient is pain-free during daily activities and functional tests
are totally negative.

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Deep Friction Massage
• Effects
• Increased blood supply relieves pain.
• By moving the painful structure to and fro, helps to free it from
adhesion.
• The structures moved in the limitation of normal behavior but not
stretched.
• It increases tissue perfusion at damaged area and stimulates
mechanoreceptor cells.
• Friction itself is a painful technique.

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Deep Friction Massage
• Position of the Patient
• The patient's position must be
comfortable, and the lesion must be
within finger's reach,
• Full relaxation is necessary for a
muscle belly to access a deeply
seated lesion.
• Tendons with a sheath must be kept
taut.
• Position of the Therapist and the
Hands
• The therapist should avoid flexed
positions.
• Movement is generated in the
shoulder and conducted via elbow
and forearm to the digits.
Friction to the
supraspinatus tendon:
counterpressure is by
the thumb.
Friction to the
infraspinatus
tendon:
counterpressure
is by the fingers.

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Deep Friction Massage
• Three main techniques can be distinguished.
1. To-and-fro Movements
2. Pronation-supination
3. Pinch Grip

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Deep Friction Massage
• To-and-fro movements
• These are used in the treatment
of dense, round or flat
collagenous bundles (tendons or
ligaments) and in the treatment
of tenosynovitis.
• Movement is with the arm;
friction is given by use of the
pulpy part of the finger
• Counterpressure is usually
provided to enable a good
sweep.
Friction to the
supraspinatus
tendon:
counterpressure
is by the thumb.

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Deep Friction Massage
• Pronation-supination
• Used where the lesion is
difficult to reach
• For Example: the anterior
aspect of the Achilles tendon
• Is performed with the pulpy
part of the third finger
reinforced by the index finger.
• No counterpressure is given.
Active phase of pronation–supination
friction technique to the anterior aspect of
the Achilles tendon.
a. starting position;
b. end of supination.
a b

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Deep Friction Massage
• Pinch grip
• Normal technique for a muscle
belly which is fully relaxed.
• The pinch is between the thumb
and the other fingers
• By drawing the fingers upwards
over the affected area, the
therapist feels the muscle fibres
escape from the grip until only
skin and subcutaneous tissue
remain.
Pinch grip friction
to the Achilles
tendon

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Passive movements
• Treatment by passive movement is otherwise known as
mobilization.
• Depending on its velocity and the range of movement, it can be
graded as:
1. Grade A
2. Grade B
3. Grade C

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Passive movements
• Grade A mobilization is a passive movement performed within the pain-free range.
• Indications
1. To promote healing of injured connective tissue: Grade A mobilizations are applied
early in the treatment of sprained ligaments to promote orientation of the regenerating
fibres.
2. Distractions at the shoulder: Gentle and rhythmical grade A movements stretch the
arthritic joint capsule fibres longitudinally, stimulate the mechanosensor mechanisms in
the joint and so inhibiting somatosympathetic reflexes that are co-responsible for the
vasoconstriction, muscle spasm, pain and increased inflammation of the joint.
3. Reduction of an intra-articular displacement in a peripheral joint: elements of traction
combined with joint rotations/movements in the less painful direction and repeated
several times with progressively increasing force.

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Passive movements
• Grade B mobilizations are passive movements performed to the end of the possible range
indicated by an end-feel. All stretching and traction techniques are grade B mobilizations.
• Indications
1. To maintain a normal range at the joint: Passive Movements with gentle stretching of
the capsule, starting as soon as possible after the onset of paralysis, injury or surgery
to prevent loss of capsular elasticity.
2. To stretch the capsule of a joint: Useful in all ‘non-irritable’ capsulitis where the
condition is characterized by capsular pattern with hard-elastic end-feel. Stretching
aims at restoring mobility and function by breaking micro-adhesions and stretching of
shortened capsule.
3. To stretch a muscle: Children with short calf muscles can be helped by sustained
stretching followed by full relaxation and active contraction of the muscle.
4. Traction: Traction is used to separate articular surfaces from each other. Can be used
for reducing a displaced fragment by increasing joint space, pain reduction, relax of
the muscle.

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Passive movements
• Grade C mobilization is a minimal thrust with a high velocity and over a small
amplitude performed at the end of the possible range OR end-feel. Another word for
grade C mobilization is manipulation.
• Indications
• Rupture of ligamentous adhesions: Small ligamentous adhesions from immobilizations
can be ruptured by a high-velocity, small-amplitude thrust manipulation, along with
intensive deep transverse friction. The joint is stretched as far as possible in the
limited direction and manipulated with a single firm thrust, during which a typical
‘snap’ is often heard.
• Rupture of tenoperiosteal adhesions: Aadherent and disorganized scar tissue which
causes a self-perpetuating inflammation in conditions like Tendinitis (e.g. Tennis
Elbow) can be ruptured to produce a permanent elongation of the tendon. .
• To reduce a bony subluxation: A subluxation of one of the carpal bones or of the
cuboid bone can easily be reduced by digital pressure combined with translatory
movement during traction.

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Contraindications to forced movements
• Capsular inflammation
• Muscle spasm: Grade C mobilizations is absolute
Contraindication. Grade B mobilizations may be used.
• Severe osteoporosis: Grade B and C mobilizations should
always be carried out with caution for fear of avulsion
fracturing.
• Joints and ligaments not under voluntary tension
control: This is the case for the acromioclavicular, the
sternoclavicular and the sacroiliac joints and the sacrococcygeal
ligament.

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Active movements
• Physical activity is also the primary stimulus for the repair of
musculoskeletal tissues especially during immobilization on
skeletal muscle, tendon, ligament, joint capsule and articular
cartilage.
• These are in the form of;
1. Simple active movements to gain or preserve normal range in a joint
2. Isometric contractions
3. Isotonic contractions
4. Coordination exercises
5. Electrical contractions

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Active movements
• Simple active movements to gain or preserve normal
range in a joint
• Immobilization can lead to;
• Capsular and ligamentous tightness or adhesion
• Muscle shortening and wasting
• Development of arthritis
• Moving the joint early in injured as well as noninjured direction
helps to maintain tissue integrity.

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Active movements
• Isometric contractions
• Isometric contraction is the development of tension within a
muscle without significant change in its fibre length, joint
motion or work.
• They are mainly performed to strengthen/stabilizing muscle
groups early in injury.
• Example is in treatment of shoulder instability: in order to
provide a firm foundation for the scapula, the muscles of the
shoulder girdle (trapezius, serratus anterior, rhomboids and
pectoralis minor) are strengthened by isometric training.

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Active movements
• Isotonic contractions
• Isotonic exercise is classically defined as the movement of a
load at constant resistance through an arc of motion.
• They are performed in the following situations:
• In minor muscular tears after the lesion has been prepared by gentle
transverse friction
• To strengthen weakened muscles as in arthritis or after local or
generalized immobilization.
• To strengthen muscles so they can protect joints or inert structures
from being painfully overstretched.

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Active movements
• Coordination exercises
• A better coordination exercises of muscle groups should be included in the
rehabilitation programe to deal with the problems of instability (e.g., in shoulder,
knee and ankle).
• The ability to control the position of a joint during active motions (proprioception)
and to produce a voluntary muscular contraction to stabilize the joint and/or to alter
the joint position to prevent excessive joint displacements is referred to as reactive
neuromuscular control.
• Most functional training techniques used to re-establish the proprioceptive skills make
use of eccentric training in which the muscle–tendon unit is lengthened while active.
Small weights and multiple repetitions of the movements are used.
• PNF techniques may be used as a method promoting or hastening the neuromuscular
mechanism through stimulation of the proprioceptors.

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Active movements
• Electrical contractions
• In circumstances where a strong voluntary muscle contraction
is not possible due to paralysis, paresis or severe injury daily
application of electrical stimulation (ES) may retard the loss of
muscle strength or even improve it in already weakened
musculature.
• The gains are not long-lasting, however, and electrical
stimulations should only be used temporarily while awaiting
neurological recovery.

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Injection and infiltration techniques
• In orthopaedic medicine three types of product are used:
1. Local anesthetics: Commonly used are procaine bupivacaine and lidocaine/lignocaine
2. Corticosteroids: The ability to suppress inflammation has made the glucocorticoids very
useful but also potentially harmful.
3. Sclerosing agents: Chemical agents such as phenol and dextrose are infiltrated into
weakened ligaments and tendons in order to create the formation of strong, thickened
fibrous tissue. Because of its proliferative effect on connective tissue, the technique is called
prolotherapy or sclerotherapy.
• In Injection the tip of the needle is placed in exactly the right place and all the product is
deposited at one single push, as is done in an ordinary intramuscular injection. This technique is
mainly used for intra-articular and caudal epidural injections.
• In Infiltration a drug is locally administered into a structure, as in bursitis, tendinitis,
tenosynovitis, tenovaginitis, lesions of a muscle belly and also in ligamentous problems.

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Reference
1. Ludwig O. Chapter 5. Principles of Treatment. A System of
Orthopaedic Medicine, 3rd Ed. London, Elsevier, 2013, pp. 83–
115.
2. Yadav A. Chapter-05, Cyriax Mobilization Techniques. In:
Advanced Techniques In Physiotherapy And Occupational
Therapy. 1st ed. S.L.: Jaypee Brothers Medical P; 2019. p. 24–
32.
3. Woodman R. Chapter 5, The Cyriax Approach. In:
Orthopaedic manual physical therapy : from art to evidence
by Wise CH. 1st ed. Philadelphia, Pa: F.A. Davis Company;
2015. p. 110–29.

30. Thank You