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"The Shoulder" Demo
Dr. J.H. Cyriax
Father of Orthopaedic Medicine
Dr, J.H.Cyriax was the first to study thorougly and systematiclly soft tissue lesions of
the locomotor system.
Cyriax decided to devote his life to this problem and started by rejecting all the old "non-system" of
examination. He relegated palpation to a merely confirmatory role once the correct tissue had been
incriminated, and set to work to develop a system of examination based on testing the function of all the
components of the soft-tissue moving parts.
The pillars of his system are:
- A good understanding of the phenomenon "referred pain"
The chief obstacle to correct diagnosis in painful conditions is the fact that the symptom is often felt at a distance from
its source. The diagnosis will often turn on the assessment of the site and nature of the pain
and the manner in which it is projected and elicited.
The concept of referred pain is extremely impor-
tant to the orthopaedic physician, who has to deal
daily with the problem. If the principles of erro-
neous localization by the cortex are clearly understood, the examiner can turn a misleading
phenomenon to diagnostic advantage.
In the Cyriax concept, referred pain obeys certain rules. The inadequacy in the sensory cortex is structural and
therefore can easily be accommodated. To a certain degree, referred pain can be compared with the
refraction of light when it falls on a water surface.
The observer does not see objects under the water
surface at their exact localization. However, since
the error of perception is structural and obeys parti-
cular physical rules and laws, it is easy to correct
what is seen (provided the observer knows the cor-
rection formula) and so locate the object accurately.
- Examination by Selective Tissue Tension
Cyriax had to begin somewhere, so he started with the
simple assumption that if a damaged tissue was
pulled it would hurt ... tension on the structure would
give rise to pain, wherever that pain might be felt. If
each structure acting on or around a joint could be
put under tension independently and in turn, then the
structure at fault could be identified. This simple
postulate turned out to be extremely effective.
He worked out that some tissues (the contractile
tissues, the muscles with their associated tendons,
nerve and bony insertion) could be made to apply
tension to themselves by a simple strong isometric
The inert structures (joint capsule, ligaments, bursae) would not
have been moved during this contraction, but could,
by contrast, be put under tension by being stretched
A logical system of Examination was developing, and would become known as "Examination by
Selective Tissue Tension".
Accurate clinical observation next showed him that
when inflammation of a joint was present (synovitis
or capsulitis), not only would passive stretching of the
capsule be painful but limitation of range was always
in a specific pattern; this pattern was always similar
for that particular joint, although each joint has a
different and instantly recognisable capsular pattern.
Cyriax had three principles for examination by
Selective Tissue Tension.
1.Isometric contractions test the function of the
2.Passive movements test the function of the inert
3.Capsular patterns differentiate between joint
conditions and other inert structure lesions.