J.H. Cyriax 1904-1985

Went to University College School Gonville, Caius College Cambridge and St Thomas's Hospital Medical School London
Qualified in Medicine in 1929
Proceeded to MD(Cantab) in 1938; MRCP in 1954; awarded the Heberden Prize in 1943.
From 1949 to 1969 consultant in Orthopaedic Medicine at St. Thomas Hospital London
Honorary Fellow of the Chartered Society of Physiotherapy in 1980
From 1975: Visiting Professor of Orthopaedic Medicine to the University of Rochester, New York

His writings:

Textbook of Orthopaedic Medicine volume I and II (1947, eight edition in 1982)
Osteopathy and Manipulation (1949)
Cervical Spondylosis (1971)
Manipulation Past and Present (1975)
The Slipped Disc (1980)
Illustrated Manual of Orthopaedic Medicine (1983)

Dr, J.H.Cyriax was the first to study thorougly and systematiclly soft tissue lesions of the locomotor system.

Soon after qualifying he became house surgeon in the department of orthopaedic surgery at
St. Thomas's Hospital , an experience that showed him clearly the need for an
equivalent medical department.
He coined the term -orthopaedic medicine," invented the specialty, and became
its first consultant and most famous practitioner.

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 important to the orthopaedic physician,
who has to deal daily with the problem. If the principles of erroneous 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 particular physical rules
and laws, it is easy to correct what is seen (provided the observer knows the correction formula)
and so locate the object accurately.

Examination by Selective Tissue Tension

Cyriax had three principles for examination by Selective Tissue Tension.

Isometric contractions test the function of the contractile tissues.
Passive movements test the function of the inert structures.
Capsular patterns differentiate between joint conditions and other inert structure lesions.

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 could be made to apply tension to themselves by a simple
strong isometric contraction. (the contractile tissues, the muscles with their associated
tendons, nerve and bony insertion)
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 passively.
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 occured 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.