An Examination of Cyriax's Passive Motion Tests

With Patients Having Osteoarthritis of the Knee

Karen W Hayes, Cheryl Petersen and Judith Falconer
PHYS THER. 1994; 74:697-707.

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Research Repofl

An Examination of Cyriax's Passive Motion Tests

With Patients Having Osteoarthritis of the Knee

Background and Purpose. We explored the construct validity and test-retest

reliabilit?,of the passive motion component of the Cyn'm soft tisue diagnosis
system. We compared the hypothesized and actual patterns of restriction, endfeel,
and pai?z/resistancesequence (P/RS) of 79 subjects with osteoarthritis (OA) of the
knee and examined associations among these indicators of dysfunction and related constructs ofjoint motion, pain intensity, and chronicity. Subjects. Subjects
had a mean age of 68.5 years (SD=13.3, range=28-95), knee stzfizess for an
average of 83.6 months (SD=122.4, range= 1-612), knee pain averaging 5.6 cm
(SD=3.1,range=O-10) on a 10-cm visual analogue scale, and at least a 10degree limitation in passive range of motion (ROM) of the knee. Methods. Passive
ROM @oniometry,n = 79))end-jeel (n= 79), and P/RS during endfeel testing
(n=62) were assessed for extension and flexion on three occasions by one of four
experienced physical therapists. Test-retest reliability was estimated for the 2-month
period between the last two occasions. Results. Consistent with hypotheses based
on Cy'm'sassertions about patients with OA, most subjects had capsular endfeeki
for exter~ion;subjects with tissue approximation endfeekifor flexion had more
flexion ROM than did subjects with capsular endfeels, and the P/RS was signficantly correlated with pain intensity (rho=.35,extension; rho =.30,flexion). Contrary to hy~othesesbased on Cyrim's assertions, most subjects had noncapsular
patterns, tissue approximation endfeelsfor flexion, and what Cyriax called pain
synchronous with resistancefor both motions. Pain intensity did not dzfer depending on endfeel. The P/RS was not correlated with chronicity (rho=.03, extension; rho =-.01,flexion). Reliability, as analyzed by intraclass correlation coeficients (I(XJ3,11) and Cohen's kappa coeficients, was acceptable (1.80)or nearly
acceptablefor ROM (KC=. 71-.86, extension;ICC=.95-,9, flexion) but not for
end-jeel ( K =.1 7, extension; K =.48,flexion) and P/RS ( K =.36, extension; K =.34,
jlexion). Conclusion and D2scusston. The use of a quantitative definition of
the capszslar pattern, endfeeki, and P/RS as indicators of knee OA should be reexamined. The validity of the P/RS as representing chronicity and the reliability of
endfeel and the P/RS are questionable. More study of the soft tissue diagnosis
W Petersen C, FalconerJ An examination of Cyrim's
system is indicated. [HayesI
passive motion tests with patients having osteoarthn'tis of the knee. Phys Thm
1994:7 4 . 07-709.1

Karen W Hayes
Cheryl Petersen
Judlth Falconer

Key Wolds: Knee, Osteoarthritis,Pain, Soft tissue syndromes.

The scheme of selective tension testing proposed by Cyriaxl is a clinical

system of diagnosis of painful problems of soft tissues. An anatomical
definition of the lesion is based on
the patient's response to the applica-

tion of force (which Cyriax called

"tension") in different ways. The diagnosis is rendered based on the
patient's report of pain and the
amount and direction of available
movement.l(p43)Physical therapists

have adopted this system to determine

the cause of patient complaints of pain.
The validity of the scheme is grounded
in theory and extensive clinical observation, but it has not been studied
objectively or empirically.

Physical Therapy/Volume 74, Number 8/August 1994

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697 / 9

According to Cyriax,' testing is conducted in four ways: active motion,

passive motion, resisted contractions,
and palpation. The procedures are
usually performed in that order. Active motion is designed to assess the
patient's willingness to move and his
or her range of motion (ROM) and
strength. Passive motion is used to
assess the amount of motion available
and the direction of limitation, if any;
the palpable sensation at the end of
passive motion (end-feel); and the
temporal sequence of pain reported
by the patient and resistance felt by
the examiner during end-feel testing
(paidresistance sequence). Resisted
testing is used to determine the reaction of the muscle, tendon, and bony
attachments to contraction. Palpation
is used last to confirm the involvement of the structure or structures
suggested by the previous portions of
the test. A summary of the passive
motion component of the system is
shown in the Figure, and a full description of the entire system of diagnosis is available in Cyriax's book.'
This report addresses only the passive
motion part of the examination. The
three components of passive motion
testing were designed to be used to
diagnose a condition based on its
pathophysiology. Each of the components is supposed to give additional
information. The amount and direction
of limitation of motion are examined
to determine the presence or absence
of a capsular pattern. A capsular pattern is a joint-specific pattern of restriction that indicates involvement of the
entire joint capsule.l@54)A noncapsular
pattern deviates from the specfic pat-

tern and can indicate the presence of

ligamentous or partial capsular adhesions, extra-articular involvement, or
internal derangements.l@53The type
of end-feel purponedly indicates the
anatomical structures that limit passive
motion (eg, bone, capsule, muscle
contraction, loose bodies in the joint,
other parts of the body) or the patient's unwillingness to complete the
motion.*@53)The paidresistance sequence is assessed to guide the vigor
of treatmentl@54)and is often interpreted as an indicator of the chronicity
of inflammation (active, less active,
none). According to Cyriax, pain before resistance is felt by the examiner
suggests a lesion with active inflammation; pain that he says occurs synchronous with resistance suggests a lesion
with less active inflammation, whereas
pain after resistance suggests a lesion
without inflammation.
The assessment system is designed to
differentiate causes of pain stemming
from inen structures (capsule, ligament, fascia, bursa, nerve root, dura
mater) or contractile structures (muscle, tendon, bony insertions) but is
not sufficient for a definitive diagnosis. Other clinical and radiographic
tests are necessary to diagnose and
discriminate problems arising from
tissues such as bone or cartilage or
neoplastic disease. Cyriaxl claims the
system can be used to identlfy patients having osteoarthritis (OA), even
though the disease primarily involves
articular cartilage. A task force of the
American Rheumatism Association
defined osteoarthritis as a
. . . heterogeneous group of conditions
that lead to joint symptoms and signs

KW Hayes, PhD, PT,is Assistant Professor of Physical Therapy, Northwestern University Medical
School. Address correspondence to Dr Hayes at Programs in Physical Therapy, Northwestern University Medical School, 345 E Superior St, Room 1323, Chicago, IL 60611 (USA).

C Petersen, PT,is Instructor in Physical Therapy, Northwestern University Medical School.

J Falconer, PhD, OTlUL., is Associate Professor of Physical Therapy and Medicine (Arthritis), North-

western University Medical School.

This study was approved by the Institutional Review Board of Northwestern University.
This study was done in collaboration with work supported by the Arthritis Health Professions Association, Arthritis Foundation, National Ofice, and NIH (NIAMS) Multipurpose Arthritis Center Grant
No. AM 30692

which are associated with defective

integrity of the articular cartilage, in
addition to related changes in the underlying bone and at the joint margins.
Although articular cartilage is poorly
innervated and defects in cartilage are
not, in themselves, symptomatic, a
clinical syndrome of symptoms, which
often includes pain, may evolve from
these defects.Z@1039)

According to Cyriax, as the disease

develops and progresses, the capsule
and other structures surrounding the
joint become involved in predictable
ways.1@406)
Cyriax suggested that in knee OA
passive motion is restricted in a capsular pattern, with proportionally
greater restriction in flexion than in
exten~ion.l@5~)
He contended that a 5to 10-degree extension loss corresponds to a 90-degree flexion loss
(extension loss is 6%-11% of flexion
loss).1@56)He suggested that early in
the development of the disease, motions end with involuntary muscle
contraction (spasm end-feel).l@~735~)
As the disease advances, patients develop capsular end-feelsl@52)or hard
and painless end-feels in both extension and flexion, purportedly arising
from bone hitting bone.'@p52.406)If a
loose body were in the joint, a
springy block might be anticipated.
End-feel is related to joint motion or
pain intensity. For example, tissue
approximation is the expected endfeel for knee flexion when the knee
has full ROM. Flexion is expected to
become limited early in OA, and the
flexion end-feel would be expected to
become a capsular end-feel as motion
is lost. Similarly, patients may be
classified as having spasm and empty
end-feels, because these types of endfeels are painful during motion.
Cyriax stated that patients with OA are
often pain-free,l@ll)but pain could
stem from impacted loose bodies in
joints or from subchondral bone after
the cartilage is severely
Because OA is a condition of a poorly
innervated structure and leads to
decreased elasticity of the periarticular structures over an extended pe-

This article was submitted April 22, 1993, and was accepted January 6, 1994.

10 / 698

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Passive Range of

Motion

Wlnful

Sequence of pain
and resirtsnee

Amount ofmotion

End-feel

I
Win

Wln
with
resismee

A m m e n t with
active m d o n
t e t rnults

alter
resismee

Something (bone.
unilape) being
p~nchcd

Not active

Less achve

Same u,

AROM
Ca ulw

possure

~ d i , of
~ ~ , ~E x m d c u l a r
Full sapsular problem ligamenl
a
Icsion (adherent
pan ofulnvlc
musle. swelling.
(directionof
bUrSiU6)
limilationa
rrls1ca D pan
involved)

Inerlslrucbre

Internal
derangement(fmgmenrol
bone a d l a g e ; direction of
limitations relate lo location
of b l a k )

Capvlw

Spaam

Tissue

I
Acute

a ~ u b

Nmal

hthe
logical if
dy
or
where not

acute

ConMtile
8rnbI-e

Springy

blT

Nonnal
demge

,,,
Bonc~bone

Normal

hb

Empty

Implant
diaeaae;
bundtia.

innammation

crpocted
hikqhyte.

Neumpahc

mdunited lrafrure,

vthmpPthY

myasitis oaaifima

Figure. Schematic diagram of the passive motion testing component of the selective
tension .ystem of sofr tissue diagnosis proposed by Cyriax.2(AROM=active range of
motion.)

riod of time, most patients would be

expected to demonstrate either a
painless end-feel or pain developing
after the examiner feels resistance.
Resisted testing would be strong and
painless because muscles are not
involveti in the disease.l@50)Cyriax
claimed that pain could not arise
from articular cartilage compression
resulting from the contraction because articular cartilage is not
inner~ated.~@P~>50)
In addition, compression would relax the ligaments
and capsule rather than stressing
them. Palpation would reveal osteophytes, coarse crepitus or creaking,
and no warrnth.l@p53.4OQ
The primary purpose of our study
was to begin the examination of the
construct validity of the Cyriax system
of soft tissue diagnosis. The process of
construct validation of a measure is,
by definition, theory dependent. The
extent to which a measure performs
within a theoretical framework pro-

vides evidence for the validity of the

underlying construct that is measured
by the variable. Many methods are
used to examine construct validity of
a measure. For example, evidence for
validity begins to accumulate if data
show that the measure discriminates
among groups with and without the
attribute being measured, correlates
across multiple methods of measuring
the same construct, or supports hypotheses incorporating the construct
being measured.'
In our study, we examined the construct validity of the passive motion
portion of the system of selective
tension testing from two perspectives.
First, we compared the theoretically
expected pattern of restriction, endfeel, and paidresistance sequence
with the actual assessments of patients
with OA of the knee. The hypotheses
were (1) a significant proportion of
subjects with OA will demonstrate a
capsular pattern (H:l), (2) a signifi-

cant proportion of subjects with OA

will have capsular end-feels for both
extension and flexion (H:2), and (3)
significantly more subjects with OA
will have painless end-feels or pain
after resistance than subjects who
have pain with resistance or pain
before resistance (H:3).
Second, we examined relationships
among the components of passive
motion testing and joint motion, pain
intensity, and chronicity. We hypothesized (1) that subjects with tissue
approximation end-feels for knee
flexion will have significantly more
passive ROM than subjects with spasm
and capsular end-feels (H:4), (2) that
subjects with spasm or empty endfeels will have significantly higher
pain intensity than subjects with other
end-feels (H:5), (3) that the pain/
resistance sequence will correlate
positively with pain intensity (H:6),
and (4) that the pain/resistance sequence will correlate positively with
chronicity (H:T).
A second purpose of the study was to
estimate the reliability of the data
generated by each of the components
of the passive motion portion of the
system. The hypotheses for this portion of the study were (1) there will
be no significant differences in passive ROM, end-feel, and paidresistance sequence between sets of measurements (H:8) and (2) test-retest
reliability estimates will exceed .80 for
passive ROM (intraclass correlation
coefficient [ICC]),end-feel assessments (kappa), and paidresistance
sequence (kappa) (H:9).

Method

Subjects for the study were 79 patients with OA of the knee who had
consented to be screened for a study
of the effectiveness of ultrasound on
chronic soft tissue tightness.4 Their
OA was diagnosed by radiography or
clinical examination by physicians.
Among the important criteria for a
clinical diagnosis of OA are the presence of osteophytes, morning stiffness
for less than 30 minutes, crepitus,

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Table 1. Characteristics of Subjects With Osteoarthritis of the Knee (N= 79)

Procedure
SD

Age (Y)
Duration of knee stiffness (mo)

68.5

13.3

83.6

122.4

Range

28.0-95.0
1.0-612.0

Knee pain

5.6

3.1

0.0-10.0

Weight (kg)

81.1

18.6

49.8-124.9

Height (cm)

166.6

9.9

149.9-1 93.0

OPain measured by a 10-cm visual analog scale.

bony enlargement, and age.2 The

characteristics of the 20 male and 59
female patients are shown in Table 1.
The subjects had a mean age of 68.5
years, an average height of 166.6 cm
(65.6 in), and an average weight of
81.1 kg (179.2 lb). Subjects reported
feeling stiffness in their knees from
the disease for an average of 7 years.
On the day previous to screening,
subjects had pain in their knees averaging 5.6 cm on a 10-cm visual analogue scale (VAS). All subjects had at
least a 10-degree limitation in passive
flexion and/or extension ROM.

Examiners
Four examiners participated in the
study. The examiners had practiced
physical therapy for 4 to 18 years. All
examiners were familiar with the
evaluation techniques from their professional and postprofessional education, and they met with each other
and the principal investigator (KWH)
to review the measurement techniques, specific study procedures, and
grading prior to their participation in
the study. Each examiner performed
all measures on the same set of patients at baseline, after treatment, and
after 2 months without active inter-

Table 2. Categories of End-feel Testing and Pain/Resistance Sequence Used in

the
End-feel

Description

Capsular

A hardish arrest of motion, with some give to it, feeling like

leather being stretched or as if two pieces of tough rubber
were being squeezed together

Tissue approximation

Motion ends with a sensation suggesting that motion could

continue if not stopped by one body part contacting another

Springy block

Noticeable rebound is seen andlor felt at end of motion

Bony

An abrupt halt to movement as when two hard surfaces meet

Spasm

A vibrant twang suggesting that muscles have actively or

reflexively acted to end motion

Empty

Pain occurs before the end of motion and patient asks for the
motion to stop; examiner feels no resistance

Painlresistance sequence
1

No pain

Pain occurs after resistance is felt by the examiner

Pain occurs at the same time that resistance is felt by the

examiner

Pain occurs before resistance is felt by the examiner

12 / 700

vention. Evaluators did not have access to previous evaluations.

Passive ROM of the knee was measured with a large universal goniometer with the subjects in the supine
position with the hip flexed to 90
degrees. According to Cyriax, in OA
extension loss is 6% to 11% of flexion
loss.1@56)In our study, therefore, a
capsular pattern was defined as extension loss (with full extension defined
as 0")eing
5 11% of the flexion loss
(with full flexion defined as 150" to
accommodate the maximum flexion
ROM of all subjects and to avoid
negative loss values). Extension
losses greater than 11% of flexion
loss were defined as representing a
noncapsular pattern. End-feel was
assessed at each end of passive ROM
using overpressure and assigned to
one of six categories. The pain/
resistance sequence was also assessed at each end of passive ROM
and graded on a four-point scale.
These scales are shown in Table 2.
The pain/resistance sequence scale
was used in three ways. When it was
studied as an indicator of OA, subjects
with no pain and subjects with pain
after resistance were combined into
one category, and subjects who had
pain with resistance and pain before
resistance were combined into one
category. When the pain/resistance
scale was used as a variable for examining the pain relationships, it was
considered a four-point scale as described. When the pain/resistance
scale was used for analysis of the
concept of chronicity, subjects without
pain on end-feel testing were
dropped from the analysis. Pain in OA
does not correlate with stage of disease activity.5 Patients with early disease may be pain-free, as may patients
with very advanced diseze,5 The
inclusion of a "no pain" category
would abrogate the ordinal nature of
the scale as a measure of chronicity.
Pain intensity was measured by asking
subjects to mark a VAS6 representing
their pain intensity on the previous
day. Chronicity was measured by

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Table 3. Extension and Flexion Ranges of Passive Motion (in Degrees)

Motion and
Tlme of Measurement

SD

Range

Extensior~
Baselinea

9.77

Posttre,atmentb

7.05

Follow-upb

7.46

Flexion
Baselinea

120.56

Posttreatmentb

124.25

Follow-upb

122.35

"Used for validity analyses.

h ~ s e for
d reliability analyses

subject report of the number of

months they had felt stiffness in their
knees resulting from their disease.
Test-retest reliability of the passive
ROM mc-asurements was estimated
using a :subset of 52 patients in the
ultrasound study who had all three
measurements taken. The data from
the posttreatment and follow-up measurement sessions were used for
analysis. Although the 2-month interval bemeen measurements is long,
subjects received no active intervention during that period. Based on
reports from the subjects, nearly all
had continued to do an assigned
home exercise program during this
period and to be as active as they had
been at the end of treatment. Because
the condition had been present for a
very long time in most of the subjects,
we did not expect that passive ROM,
end-feel, and pairdresistance sequence
would change markedly over 2
months. We acknowledge, however,
that change could have occurred in
these subjects and consider our reliability estimates as containing this
source of error.
The reliability and validity of the VAS
and chronicity data were not tested.
The VAS has been reported to have

test-retest reliability (reported as Pearson correlation coefficients) ranging

from .91 to .977,8and correlations (r)
ranging from .60 to .9OGS8
with other
measures of pain intensity. Chronicity
data were gathered by patient selfreport. Although no reliability and
validity data are available for this
particular measure, the reliability of
patient reports of other variables,
such as activities of daily living, is
acceptable, and patient reports correlate very highly with other methods of
gathering the same information, such
as on-site observation.9Jo

Data Analysis
One-way chi-square analyses were
used to test the first set of hypotheses
pertaining to the proportion of subjects with capsular patterns (H:l),
capsular end-feels for both extension
and flexion (H:2), and painless endfeels o r pain after resistance (H:3) at
baseline. The hypotheses that the
passive ROM of subjects with tissue
approximation end-feels would be
larger than the passive ROM of subjects with spasm o r capsular end-feels
@:4) and that the pain intensity of
subjects with spasm o r empty endfeels would be greater than the pain
intensity of subjects with other end-

*Apple Computer Inc, 20525 Mariani Ave, Cupertino, CA 95104

+SPSS Inc, 444 N Michigan Ave, Chicago, IL 60611.

feels (H:5) were tested with the

Kruskal-Wallis analysis of variance
(ANOVA) with multiple post hoc pairwise comparisons.ll To examine the
relationship between the baseline
measures of pain/resistance sequence
and pain intensity (H:6) o r chronicity
(H:7), Spearman rank correlation
coefficients (rho) were calculated.
The differences between passive extension and flexion ROM measurements on the two occasions and testretest reliability were analyzed
individually for three evaluators (one
evaluator had only five subjects, and
the ICC was unstable) with the
ANOVA for repeated measures and
the ICC (3,1).12 The ICC (3,l) was
chosen to estimate the reliability of
the specific data of each examiner,
assuming a single measurement. The
differences between measurements of
end-feel and pain/resistance sequence
on the two occasions were analyzed
with the Wilcoxon Matched Pairs Test,
and reliability was analyzed with Cohen's kappa coefficients.13 The alpha
level for all analyses was set at .05. AU
analyses were performed on a personal computer* using the SPSS statistical package.+

Results
The descriptive statistics for passive
extension and flexion ROM are displayed in Table 3. At baseline, only 8
subjects displayed a capsular pattern
and 71 subjects displayed a noncapsular pattern. The frequencies of capsular and noncapsular patterns were
significantly different (X'= 50.24,
P<.001), but the hypothesis that a
significant proportion of subjects
would have a capsular pattern (H:l)
was not supported because the results
were in the wrong direction.
The number of subjects demonstrating each type of end-feel is shown in
Table 4. The differences in number of
subjects with each type of end-feel
were significant at baseline for both
extension (X"193.43, P<.001) and
flexion (X'=80.31, P<.001). Most of
the subjects had a capsular end-feel
for extension, accounting for 82.0% of
the chi-square value. In flexion, most

Physical Therapy /Volume 74, Number 8/August 1994

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category that combined pain with

resistance and pain before resistance.

Table 4. Number of Subjects With Each Extension and Flexion End-feel

Capsular

Tissue
Approximation

Springy
Block

Bony

Spasm

Empty

Extension
Baselinea

59

Posttreatmentb

56

Follow-upb

45

0
10

Flexion
Baselinea

17

40

Posttreatmentb

11

38

Follow-upb

11

28

aUsed for validity analyses.

for reliability analyses.

subjects had a tissue approximation

end-feel, accounting for 70.0% of the
chi-square value. The hypothesis that
a significant proportion of subjects
would have capsular end-feels (H:2)
was supported for extension but not
for flexion.
The number of subjects demonstrating each category of paidresistance
sequence is shown in Table 5. Most of
the subjects had no pain, or pain
occurred with resistance. There were
few subjects in whom pain occurred

before or after resistance. The hypothesis that most subjects would have no
pain or pain after resistance (H:3) was
not supported for either extension or
flexion. There was no statistical difference in the number of subjects in the
two categories for extension
(X'=2.32). The number of subjects in
each of the combined categories of
paidresistance sequence differed
from a uniform distribution (50% of
the subjects in each of the two cells)
for flexion (X'=5.23, PC.05), but the
majority of the subjects were in the

Table 5. Number of Subjects With Each Extension and Flexion Sequence of Pain
and Resistance

No Pain

Pain After
Resistance

Pain With
Resistance

Pain Before
Resistance

Baselinea
Posttreatmentb

[I
28

7dl
1

[29
18

edl
1

62
48

Follow-UP"

24

11

42
62

Extension

Flexion
Baselinea

[I 7C

sdl

[29

11

Posttreatmentb

22

17

48

Follow-upb

17

17

41

"Used for validity analyses.

for reliability analyses.

Passive ROM of flexion differed depending on type of end-feel (H:4).

Passive ROM of flexion for subjects
with a tissue approximation end-feel
was greater than passive ROM of
subjects with capsular end-feels
(x2=28.13,PC.001). Pain of these
subjects did not differ depending on
end-feel (X'=4.90 for extension and
x2=3.35 for flexion). The hypothesis
that subjects with spasm and empty
end-feels would have greater pain
(H:5) was not supported.
The Spearman rank correlation coefficient for paidresistance sequence and
pain intensity was .35 (n=62, P=.003)
for extension and .30 (n=62, P = ,009)
for flexion. The correlation between
paidresistance sequence and the
number of months the patient had
stiffness was .03 (n=43, P=not significant) for extension and -.01 (n=45,
P=not significant) for flexion. These
correlations support the hypothesis
that pain/resistance sequence would
be correlated with another variable
representing pain intensity (H:6) but
not that pain/resistance sequence
would be correlated with another
variable representing chronicity (H:7).
The reliability of ROM measurements
ranged from .71 to .86 for knee extension and from .95 to .99 for knee
flexion. Passive extension and flexion
ROM did not differ between test occasions (Tabs. 6 and 7). End-feel also
did not differ between test occasions
for extension (Z=-0.31) or flexion
(Z=-1.25). The kappa coefficients for
extension end-feel and flexion endfeel were .17 and .48, respectively,
indicating slight agreement for extension and moderate agreement for
flexion.14There were no significant
differences between the posttreatment
and follow-up measurements of paid
resistance sequence for either extension (Z=-1.61) or flexion (Z=-0.65).
The kappa coefficients for the pain/
resistance sequence were .36 for
extension and .34 for flexion, indicating only fair agreement.14

'Category dropped for analysis of pain/resistance sequence as an indicator of chronicity.

d~ategoriescombined for analysis of paiwresistance sequence as an indicator of osteoarthritis.

14 / 702

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Table 6. Analysis-of-Variance Results for Passive Knee Extension Range of Motion

Source of Varlation

dl

SS

MS

Examiner 1
Between people

21

1264.91

60.23

Within people

22

229.00

10.41

Between measures
Residual
Total

11.OO

11.OO

21

218 00

10.38

1493.91

34.74

43

5.79

<.01

1.06

NSa

14.62

< .01

ICCb(3,1)=.71
Examiner 2
Between people

369.43

61.57

Within people

29.50

4.21

Between measures

0.07

0.07

Residual

29.43

4.90

13

398.93

30 69

Total

0.01

NS

ICC(3,1)=.85
Examiner 3
Between people

17

1996.25

117.43

Within people

18

156.50

8.69

8.03

8.03

17

148.47

8.73

2152.75

61.51

Between measures
Residual
Total

35

13.51
0.92

< .01
NS

ICC(3,1)=.86
"NS=not significant.
b~~~=intraclass
correlation coeficient

Discussion
Pattern of Restriction, End-feel,
and Pain/Resistance Sequence
as Indicators of Osteoarthritis
Pattern of restriction.A capsular
pattern is supposed to indicate involvement of the entire capsule and is
expected in OA.l(p406j There was a
scarcity of patients with OA who had
a capsular pattern. Perhaps the majority of these patients had not yet developed the capsular pattern. If the capsular pattern did not develop until
very late in the disease, then the system would not be of much assistance
in diagnosing OA. Cyriax stated, however, that the capsular pattern would
exist regardless of whether the patient
is early or late in the course of the
disease. He claimed that only the
end-feel, not the pattern of restriction,
would change with an advancing
condition.I(p53)

loss of e x t e n ~ i o n . ~
Patients
~ J ~ would
be inclined to retain more extension
ROM by using their knees in their
daily activities.

The relative absence of patients with a

capsular pattern is more likely a matter of definition. The method of defining a capsular pattern in this study
depended on the extension loss/
flexion loss percentage defined as the
criterion. Cyriax claimed that the loss
of extension would be about 11% of
the loss of flexi0n.l@5~)
In this study,
the extension loss represented a
larger proportion of the flexion loss
than Cyriax suggested (X=40%,
SD=27, range=&130). We have observed that clinicians tend to interpret
the capsular pattern as flexion loss
greater than extension loss but ignore
the proportional relationship between
the losses. If this definition of the
knee capsular pattern were used, then
76 subjects would have shown a capsular pattern. Most activities of daily
living d o not require full flexion
ROM,I5 SO flexion ROM may be lost
more easily than extension ROM.
Function is affected by only a small

Cyriax used passive motion testing to

indicate the pattern of restriction and
as a provocation test, that is, to determine whether the application of force
reproduces the patient's pain.l@50jWe
did not use passive motion assessment as a provocation test, but we
believe that this omission did not
d e c t the results substantially. Provocation testing is used primarily to
reproduce the patient's symptoms and
not to determine the pattern of
restriction.'

End-feel. According to the examiners

in this study, most subjects had the
expected capsular end-feel for extension. The end-feel for passive extension in healthy knees is supposed to
be capsular. The end of motion might
occur earlier in the range when a
subject has OA, but the qualitative
sensation felt by the examiner would
be unchanged. A large number of
subjects had tissue approximation
end-feels for flexion, which was not
expected and may be an overestimate.
One likely reason for this result was
the obesity of many of the subjects.
Because their extremities were large,
they could have tissue approximation
end-feels along with limitations in
passive ROM.
The examiners characterized some
subjects as having each of the other
end-feels. Each type of end-feel might
be expected in OA under specific
circumstances, but none of the others
would be expected to be common.
Spasm end-feels are expected early in
the disease as muscles act to protect
the joint from motion. Bony end-feels
are expected after the joint has deteriorated to the point that osteophyte
formation prevents motion. Springy
block end-feels might be expected if
the patient has an intra-articular derangement, such as an impacted loose
body. The small number of patients
with bony end-feels for either extension or flexion may have resulted
from selection bias; some referring
physicians may have screened poten-

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Table 7. Analysis-ojvariance Results for Passiz.re Knee Flexion Range of Motion

dl

SS

MS

Between people

21

28219.73

1343.80

52.51

Within people

22

563.00

25.59

29.45

29.45

21

533.55

25.41

43

28782.73

669.37

Source of Variation

Exam~ner1

Between measures
Residual
Total

1.16

NSa

98.66

<.01

ICCb(3,1)=.96
Examiner 2
Between people

4735.43

789.24

Within people

56.00

8.00

23.14

23.14

Between measures
Residual
Total

32.86

5.48

13

4791.43

368.57

4.23

NS

ICC(3,1)=.99
Examiner 3
Between people

17

14440.25

Within people

18

468.50

26.03

66.69

66.69

17

401.81

23.64

Between measures
Residual

849.43

32.63
2.82

<.01

NS

Total

"NS=not significant.
h ~ ~ ~ = i n t r a c lcorrelation
ass
coefficient.

tial subjects having radiographic evidence of bony blockage.

The accuracy of the number of subjects in each end-feel category is affected by the poor estimates of the
reliability of the end-feel data. Because several categories have rather
abrupt termination of motion, these
categories are difficult to distinguish
from each other. Some subjects,
therefore, may have been categorized
incorrectly. For both motions, most
subjects were classified as having
end-feels associated with healthy
knees. If these classifications were
incorrect, using end-feel as a diagnostic indicator would likely lead to frequent underdiagnosis of the
condition.
The assumptions underlying the categories of end-feel proposed by Cyriax
have not been studied. For example,
when the end-feel feels like leather

16 / 704

being stretched, Cyriax claimed that

capsule or ligament is stopping movement, and when motion ceases
abruptly, he assumed that bone is
hitting bone.l@53)There is no evidence, however, that structures identified in the end-feel category labels
are actually the structures that stop
motion. Other practitioners have
suggested changing end-feel category
labels to more descriptive ones such
as "soft", "firm," and "hard."l"l9 Riddle20 proposed operational definitions
for descriptive end-feels. He suggested that a soft end-feel demonstrates a gradual increase in resistance
to movement at end-range; a firm
end-feel is an abrupt increase in endrange resistance, and a hard end-feel
entails an immediate cessation of
movement at end-range. This nomenclature avoids the problem of assuming what structure stops motion, but
the classification still must be studied
to determine whether such assess-

ment appropriately guides diagnosis

or treatment selection.

Pain/resistance sequence. The

number of subjects with no pain on
overpressure supports Cyriax's contention that passive motion is often
painless in OA.l(pl1)The poor reliability for the pain/resistance sequence
data makes it difficult to draw conclusions about the use of the paidresistance sequence as an indicator of OA.
The small number of subjects with
pain after resistance would suggest
that the pain/resistance sequence is
not a good indicator of OA. Because
the OA of these subjects was longstanding, more of them were expected to demonstrate pain after resistance. The paidresistance sequence
measure may have misclasslfied subjects as having a moderately acute
condition. Alternatively, perhaps some
of these subjects had experienced an
event, such as an acute flare o r unusual activity, that triggered an acute
response in their joints.
Cyriax might disagree with the diagnosis of the majority of these subiects,
and in some cases, he would probably be correct. In this study, medical
diagnosis of OA was used as the "gold
standard" for comparison Although
the combination of radiographic evidence and clinical signs can have very
good sensitivity and specificity,' clinical diagnosis is not flawless. Nonetheless, we advise against intrepreting the
variables examined in our study, especially a proportional definition of
the pattern of restriction, as sensitive
indicators of OA for treatment purposes. According to our data, if the
capsular pattern were incorrectly
assumed to be highly sensitive and
specific for OA, such an assumption
would cause many false negative
results. As a consequence, patients
might be treated as if they had a remediable. local problem, rather than
a chronic, degenerative condition.
Short-term treatment might be similar
to that for OA, but the long-term
management might differ in important
ways. Patients would not be directed
toward self-management, joint protection, and appropriate modifications in
activities and lifestyle.

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Relationshlps Among Pattern of

Restriction, End-feel, and
Pain/Resistance Sequence and
Related Constructs Underlying
Joint Motion, Pain intensity,
and Chronicity

is nonredundant, contributing a
unique bit of information beyond
pain averaged over daily activity.
The correlation between pain/resistance sequence and the number of
months of stiffness was extremely low,
suggesting that the paidresistance
sequence is not a measure of chronicity. Even when corrected for unreliability, assuming that the number of
months of stiffness was measured
without error, the correlation coefficients were still low (rho=.O7 for
extension and -.02 for flexion). If the
paidresistance sequence represented
the concept of chronicity, then pain
after resistance would represent a
chronic state; pain with resistance
would indicate a subacute state, and
pain before resistance would indicate
an acute state. The low corrected
correlation coefficients suggest that
this pattern is not present in these
data.

Subjects with tissue approximation

end-feels had more ROM than subjects with capsular end-feels, supporting a relationship between end-feel
and the underlying basis, or construct,
for joint motion. Subjects with tissue
approxirr~ationend-feels were expected to have more ROM than subjects with spasm end-feels, but they
did not. In addition, subjects with
spasm or empty end-feels were expected to have more pain than subjects with other types of end-feel, and
they did not report more pain. Bearing in mind the poor reliability for
the end-feel data, these results tentatively support Cyriax's claim that as
the disease progresses, the flexion
end-feel changes from tissue approxi5 ~refute
~ ~ ~ ~ ) In this study, the measure of chronicmation to c a p ~ u l a r , ~ @ pbut
his idea that pain causes muscles to
ity was the length of time the patient
felt joint stiffness. In discussing the
act to limit motion.
paidresistance sequence, Cyriax referred to the activity of the
Pain intensity on the previous day is a
lesi0n.l@5~)
Although the two concomposite of pain experienced during
cepts are related, months of stiffness
rest and activity, both weight bearing
may not reflect the chronicity of the
and non-weight bearing, and may not
tissue reaction. Nonetheless, the lack
be related to the level of pain experiof correlation between paidresistance
enced during end-feel testing. The
sequence and months of stiffness
relationship might be stronger if pain
diminishes the validity of using the
intensity had been assessed at the
paidresistance sequence to indicate
time of end-feel testing, as is comthe chronicity of the lesion.
monly done clinically.
The correlation between pain/resistance sequence and pain measured
with the VAS was low but significant.
The correlation may have been low
because of the questionable reliability
of measurement of the paidresistance
sequence. To estimate the potential
magnitude of the correlations, we
corrected them for attenuation due to
~nreliability.~~
Because no reliability
data were available for the pain measure, it was assumed to have been
measured without error. The corrected Spearman rank correlation
coefficients were .58 for extension
and .52 for flexion. This outcome
suggests that the paidresistance sequence is related to pain intensity but

Based on these data, the validity of

some of the assumptions of selective
tension testing is questionable. More
investigation of the validity of passive
motion and the other components of
the system is necessary. The diagnostic accuracy of the system must be
examined in prospective studies of a
wide variety of conditions in differing
patient populations. Because results
from the knee should not be generalized to other joints, similar studies
should examine different joints, particularly their capsular patterns.

Reliability
The reliability estimates for measurements of extension and flexion ROM
do not differ markedly from those of
other reliability studies of goniometric
measurements of knee ROM in which
intrarater reliability values of .85 to
.98 for extension and .95 to .99 for
flexion were found.22-24 AS in these
previous studies, reliability was better
for flexion than for extension. The
lower reliability for knee extension
could reflect the dficulty therapists
have aligning the goniometer in extension and the inability of a goniometer to account for the rotation of the
tibia that occurs as the knee comThis lower reliabilpletes e~tension.~5
ity may also be a result of the smaller
variability in knee extension ROM
among subjects compared with the
variability of knee flexion.
The reliability estimates of end-feel
and paidresistance sequence assessments may have been low because
there was limited variability in the
group on both variables. Consequently, chance agreement would be
high, decreasing the kappa coeffi~ i e n tKappa
. ~ ~ changes with the probabilities of each of the possible categories and is best when the
probabilities are approximately equal.
The maximum possible kappa coefficient can be calculated for a given set
of marginal probabilities.13 Given the
distributions in this study, the maximum kappa coefficient would be .78
for extension end-feel, .78 for flexion
end-feel, .75 for paidresistance sequence in extension, and .88 for paid
resistance in flexion. For both variables, the reliability estimates are
considerably below these values. The
reliability of the paidresistance sequence assessments may be low because the time interval between the
onset of pain and the onset of resistance may be too short to determine
clinically through manual palpation.
The low reliability estimates could
represent actual patient change over
the 2-month period; however, there
were no statistical differences in
grades between measurements, and
passive ROM reliability estimates were
acceptable or nearly acceptable over

Physical Therapy /Volume 74, Number

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the same time period. We believe that

actual changes in end-feel and p a i d
resistance sequence are unlikely. The
reliability of both end-feel and p a i d
resistance sequence assessments is
probably unacceptable, but should be
studied again with less time between
measurements and greater variability
in the sample.
The low reliability estimates of the
end-feel and pain/resistance sequence
assessments are similar to those
found by other investigators examining tests that rely on physical therapists' judgment of very small motion
such as Lachman's Test,z7 tibiofemoral
abduction,28 and tests of sacroiliac
mobility.29 Patla and Paris3O found the
percentage of intrarater agreement of
end-feel testing of the elbow to be
75% to 80%, but there was little variability in their sample. Chance agreement, therefore, would be high but
was not reported.30 The results of this
study underscore the dependence of
validity on reliability. It must be possible to classlfy patients consistently in
the same category of end-feel o r p a i d
resistance sequence to have confidence in relationships cited as evidence for o r against the validity of
Cyriax's system or to make diagnostic
and treatment decisions using the
system.

The value of studying the validity and

reliability of any measurement system
is to obtain data that allow refinement
of measurements that are potentially
informative and to seek new systems
if existing systems are inadequate.
This study examined the passive motion components of the soft tissue
diagnosis system proposed by Cyriax.
We examined validity by studying
whether the three passive motion
components were indicators of subjects with OA of the knee. We also
examined relationships among the
three indicators of dysfunction and
related constructs underlying joint
motion, pain intensity, and chronicity.
Iast, we estimated the test-retest reliability of measurements of each of the
three components.

The results of this study provide evidence of the need to question and
further examine selective tension
testing as a diagnostic system. Testretest reliability estimates were acceptable for passive ROM measurements but not for end-feel and paid
resistance sequence classification.
Very few subject. exhibited a capsular
pattern by Cyriax's quantitative definition. A proportional definition of a
capsular pattern should be abandoned, but the concept of a pattern of
ROM loss may be useful. When corrected for unreliability, paidresistance
sequence is an indicator of pain intensity but not chronicity. Poor reliability estimates limit our ability to
interpret additional findings. For example, more subjects retained tissue
approximation end-feels than predicted; fewer subjects had painless
end-feels o r pain after resistance during end-feel testing than predicted,
and end-feel was related to joint motion but not to pain intensity. More
investigation of selective tension testing is needed to improve the reliability and examine other facets of validity, particularly the use of the system
to guide treatment decisions.
Acknowledgments

We thank the Biostatistical and Data

Management Core of the Northwestern University Multipurpose Arthritis
Center for their assistance in data
processing and data management,
especially Ahn Chung and Delilah
Jones. We also thank Katie Sirianni,
PT, Linda Tieman Roherty, PT, and
Babette Sanders, PT, for serving as
evaluators in this study and Russell M
Woodman, PT, FSOM, OCS, for consulting with us.
References
1 Cyriax J. Textbook of Orrhopaedic Medicine,
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3 Ghiselli EE, Campbell JP, Zedeck S. Measurement Theoryfor the Behavioral Sciences.
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4 Falconer J, Hayes KW, Chang RW. Effect of

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Invited Commentary

James Cyriax's views on many aspects

of diagnosis and treatment still remain important within the areas of
manual therapy and orthopedic physical therapy. His position within physical medicine, his appointment at St
Thomas' Hospital in London, his formidable and determined personality,
and the certainty with which he put
forward his views and hypotheses had
enormous influence at the time, and
his influence pervades much of the
literature to this day. There is no
doubt that he made a major contribution toward the development of orthopedic physical therapy, promoted
active physical therapy among his
medical colleagues, and added substantially to theory on the topic. At the
same time, it also seems certain that
this very dominance was counterproductive in a number of important
ways.
Cyriax was primarily a gifted clinician,
but many of his observations on pathology, on a consideration of what
he presumed occurred in tissues and
structures during the sequence of
examination and physical testing, and
on the effects that various physical
maneuvers may have on pathology
were not necessarily based on a thorough understanding of the basic morphology and subsequent pathological
change of the structures he so authoritatively described. For these reasons,
it is very timely that Hayes and colleagues should objectively consider
Cyriax's passive motion tests for patients with osteoarthritis (OA) of the
knee.

It is extremely important for physical

therapists to critically review aspects
of current treatment dogma and subject them to objective testing. In this
instance, Cyriax's views on passive
motion testing for patients having OA
of the knee are based on clinical
observation and grounded in his
personal theory. The hypotheses
(guesswork) associated with this theory development quickly became
established dogma, and were accepted with little questioning by at
least a generation of physical therapists and orthopedists. It is salutary to
note how often clinical observation
and a dominant personality have
combined to produce a medical belief
system, reinforced through careful
training and effectively limiting the
vision of large numbers of followers.'
The introduction to the article properly sets the scene and allows the
reader to become quite familiar with
Cyriax's views on passive motion
testing of the knee and on the pain
and "end-feel" patterns that he described as being characteristic of
various manifestations of OA. The
information provided is clear, concise,
and informative and properly documents Cyriax's viewpoint. The authors
then carefully show how they set out
to review and examine both the construct validity and reliability of this
particular view of the reality of 0.4 in
the knee.
The subjects studied were in the main
elderly, relatively short, obese, and
predominantly female. This subject
selection is necessarily limiting in its

scope, something the authors readily

accept. The subjects were also part of
a study of the effects of ultrasound on
chronic soft tissue tightness, presumably of the knee, although this is not
stated. It would have been useful to
have had a better understanding of
the ultrasound study to help answer
two questions:
1. Were all of the 79 patients examined for the current study prior to
receiving the ultrasound?
2. What ultrasound treatment did the
52 patients who were subsequently
retested 2 months later for range
of motion receive?

This information is of importance to

the reader as it has the potential to
considerably alter the state of the
tissues examined and adds an additional confounding variable to the
equation under consideration.
It is also puzzling to note that the
four examiners involved were selected on the basis of their knowledge of the techniques in question
and had "met" with each other to
review the procedures and tests to be
used in the study. I am surprised that
a greater effort was not made to ensure that the examiners were carefully
trained and were shown to be able to
measure the same variables in the
same way. The intertester reliability
does not appear to have been gauged
in this study, a surprising omission
given the careful nature of the rest of
the investigation. This is a considerable drawback to the study, as it raises

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An Examination of Cyriax's Passive Motion Tests

With Patients Having Osteoarthritis of the Knee
Karen W Hayes, Cheryl Petersen and Judith Falconer
PHYS THER. 1994; 74:697-707.

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