Journal of Orthopaedic & Sports Physical Therapy 2OOO;3O (9) :5 12-527

Construct Validity of Cyriax's Selective Tension ~xaminahon: A'ssociation of End-feels With Pain at the Knee and Shoulder Cheryl M. Petersen, P 7; MS Karen W Hayes, P7; PhD

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. ) Orthop Sports Phys Ther 2000;30:5 12-527.

Key Words: manual therapy, orthopedics, physical therapy, tests and measurements

Department of Physical Therapy and Human Movement Sciences, Northwestern University Medical School, Chicago, 111. Study supported by the Foundation for Physical Therapy and approved by the lnstitutional Review Board of Northwestern University, Chicago, 111. Send correspondence to: Cheryl M. Petersen, 645 N. Michigan Avenue, Suite 1100, Chicago, I1 606 1 1. E-mail: c-petersen@nwu.edu

C yriax's system of se- lective tension test- ing, used as part of a patient's physical ex- amination, is de-

signed to identify the specific ana- tomical structure causing the pa- tient's symptoms. Selective tension testing involves using active mo- tion, passive motion, resisted con- tractions, and palpation to identify soft tissue lesions in inert (liga- ment, capsule, bursa, fascia, dura mater, and nerve) or contractile tissues (structures that form part of a muscle) by reproducing the patient's complaint, which is often pain, and demonstrating dysfunc- tion in the soft t i s s ~ e s . ~ ( p p ~ ~ - ~ ~ )

Part of Cyriax's selective tension theory involves the concept of end-feel testing during passive movements. The different sensa- tions that the examiner perceives at the end of each passive move- ment are end-feels. Cyriax suggest- ed that end-feels are important in patient management because they either indicate pathology or guide intervention (ie, a bony end-feel should not be manipulated) .J(p5J)

End-feels can be normal or abnor- mal-pathologic, depending on the movement that they accompany at

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TABLE 1. End-feel classification systems.

CyriaXJW-Yl bl fenbor~~'~~" pa+W-'

Normal 1. Capsular' 1. Soft 1. Soft tissue approximation 2. Bone-to-bone* 2. Firm 2. Muscular 3. Tissue approximation 3. Hard 3. Ligamentous

4. Cartilaginous 5. Capsular

Abnormal-Rthologic 1. Capsular' early in range An end-feel "that occurs at an- 6. Capsular (chronidacute) 2. Bone-to-bone* other place or is of another 7. Adhesions and scarring 4. Spasm quality than is characteristic 8. Bony block 5. Springy block for the joint being tested." 9. Bony grate 6. Empty 10. Springy rebound

11. Rnnus 12. Loose 13. Empty 14. Rinful 15. Muscle

* Capsular and bone-to-bone end-feels can be normal or abnormal-pathologic, depending on the motion and the point in the range at which they occur.

a particular joint or the point in the expected range of motion at which the end-feel occurs. Each joint has a characteristic normal end-feel, which is depen- dent on the anatomy of the joint and the direction of the physiologic movement tested. Other end-feels at each joint would be considered abnormal-patho- logic.

The few studies on end-feel testing have provided little support for the reliability of end-feel testing, or for the theoretical constructs underlying the concept of end-feel, and have provided no strategies to im- prove end-feel testing. Because additional research is needed, this report is part of a study that examined the components of Cyriax's selective tension testing using Cyriax's end-feel classification system. Pain in- formation obtained at the time of end-feel testing al- lowed us to study the magnitude of the subject's pain response for normal versus abnormal-pathologic end- feels.

We hypothesized that abnormal-pathologic end- feels would occur in a pathologically involved joint, and the pain associated with an abnormal-pathologic end-feel would be greater than the pain found with a normal end-feel. The basis for our hypotheses was that pathology at any joint suggests changes in the normal physiology of the tissues (inert or contractile) surrounding the joint complex. Our goal was to de- termine whether pain found during end-feel testing was greater with abnormal-pathologic as compared to normal end-feels. If so, clinicians would then be able to identify joint regions where pathology was present when they found abnormal-pathologic end-feels.

Three different classifications of end-feels are found in the literature. Paris classifies end-feels into groups of 5 normal and 10 abnormal-pathologic end- feel~,'~(p*~) while Cyriax groups end-feels into 6 specific categories with 2 of the end-feels described as being either normal or abnormal-patholog- i ~ . " p p ~ ~ ~ ) Both the Paris and Cyriax classifications are based on the anatomical structure that limits

range of motion. Kaltenborn, in comparison, uses the nature of the resistance "soft," "firm," or "hard" to describe end-feels. He states that "all three types of end-feel have an elastic quality to vary- ing degrees . . . dependent on the anatomy of the joint.""^^*) All 3 systems are summarized in Table 1.

In Cyriax's descriptions of his 6 end-feel categories, he states that bone-to-bone, capsular at the end of nor- mal range, and cissue approximation end-feels occur in healthy joints and are normal for some motions. A cap sular end-feel "consists of the hardish arrest of move- ment, with some give in it, as if two pieces of tough rubber were being squeezed together" such as occurs at the end of shoulder movements. T i e approxima- tion occurs when "the joint cannot be pushed farther because of engagement against another part of the body" as at the end of knee and elbow flexion. A bone-to-bone end-feel "is the abrupt halt to movement when two hard surfaces meet," as when bone engages bone during elbow exten~ion.~(F@-)

Cyriax describes abnormal-pathologic end-feels as capsular, before normal full range is reached (some- times called early capsular), spasm, springy block, and empty. An early capsular end-feel is again the "hardish arrest of movement, with some give in it" occurring at the end of the patient's limited range of motion. The "vibrant twang" of the spasm end-feel, as Cyriax described it, relates to the reflex muscle spasm occurring with inflammation. A springy block end-feel occurs when "a rebound is seen and felt at the extreme of the possible range" in joints in which an inua-articular displacement can occur such as in the knee, sternoclavicular joint, and spine. When the examiner feels no resistance and there is "consider- able pain before the extreme of range is reached," the end-feel is called "empty," and important disease such as acute bursitis, extra-articular abscess, or neo- plasm is s ~ g g e s t e d . ~ ( p p ~ ~ ~ ) We considered a bone-to- bone end-feel abnormal-pathologic when it occurs at a joint in which that end-feel is not normally present.

J Orthop Sports Phys Ther .Volume SO. Number 9 September 2000 513

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TABLE 2. Characteristics of subjects.

Subject characteristic Knee problems (n = 40) Shoulder problems (n = 46)

Age (years) Mean = 31 .8, SD = 9.5, range = 22-60 Mean = 34.3, SD = 12.91, range = 21-75

Sex 18 men, 22 women 21 men, 25 women Side of involvement 20 right, 20 left 33 right, 13 left Highest grade completed in school (years) Mean = 16.0, SD = 1.6, range = 12-1 8 Mean 16.1, SD = 1.9, range = 8-18 Duration of condition (months) Mean = 33.9, SD = 52.1, Mean = 38.9, SD = 49.9,

range = 0.4-234, median = 7.7 range = 0.33-243, median = 17.6 Height (cm) Mean = 173.7, SD = 8.4, Mean = 170.8, SD = 10.3,

range = 157.5-1 88.0 range = 152.Cb193.0 Weight (kg) Mean = 76.1, SD = 16.7, Mean = 72.5, SD = 13.5,

range = 44.3-1 13.3 range = 54.3-1 13.3

Because pain is inherent in the names and defini- tions of 2 of Cyriax's abnormal-pathologic end-feels, spasm and empty, we expected that these end-feels would be painful when present. Theoretically, when an early capsular, a springy block, or bone-to-bone end-feel occur within a joint, pathology exists, and there is reason to believe that these end-feels would be painful as well. According to Cyriax, an early c a p sular end-feel suggests fibrosis of the capsule or liga- ments associated with that joint. A springy block end- feel indicates involvement of a meniscus or disc with- in the joint."pm) A bone-to-bone end-feel indicates degeneration of articular cartilage within the joint. The mechanics of a joint with an early capsular, springy block, or bone-to-bone end-feel would be changed, resulting in probable stress to other tissues of that joint. Pain could be associated with the ab- normal stress.I0 In our experience, patients often re- port pain when abnormal-pathologic end-feels are present. Cyriax stated that pain associated with "ar- thritis" suggests capsular involvement and that early capsular or spasm end-feels could o c c ~ r . ~ ( p p ~ ~ , ~ ~ )

There are few studies examining the reliability or usefulness of end-feel testing. Patla and Paris exam- ined the reliability of end-feel assessments based on Paris' classification system at the elbow for 20 asymp tomatic subjects.I2 Inter-rater reliability for 2 examin- ers, reported as kappa coefficients, was 0.40 for flex- ion and 0.73 for extension. Intra-rater reliability re- ported as percentage of agreement, ranged from 75 to 80%.12 Because asymptomatic subjects were exam- ined in this study, the kappa coefficients may have been inflated due to the examiner's expectation of normal end-feel findings. Hayes et a17 reported intra- rater kappa coefficients of 0.17 for knee extension and 0.48 for knee flexion end-feels based on Cyriax's classification system in subjects with osteoarthritis of the knee. The 2-month time frame between tests in this study could have allowed the symptoms to change, decreasing reliability.

The basic postulates of the Cyriax selective tension system need to be examined because the system of se- lective tension techniques, including end-feel testing, is part of physical therapy musculoskeletal examina-

tions and is taught in many physical therapist educa- tion programs. The reliability and construct validity of either the total system or its parts have only recently been s t~died. '"~J~J~ Part of examining construct va- lidity involves testing hypotheses that should be sup ported if tests perform as predicted from theory.

We theorized that subjects who had early capsular, bone-to bone, spasm, springy block, and empty end- feels at the knee and shoulder would have more pain during end-feel testing than subjects with normal end-feels because these abnormal-pathologic end- feels are purported to suggest some pathologic activi- ty in joint related structures. We have not seen this idea supported or refuted in the applied experimen- tal literature. The purpose of this report is to exam- ine the hypothesis that during passive physiologic motion testing, subjects with abnormal-pathologic end-feels at the knee or shoulder would have greater self-reported pain than subjects with normal end- feels.

METHODS

Subjects

Subjects for the study were recruited from the uni- versity community, comprising primarily students from the professional schools and patients from phy- sician referrals. They all had unilateral knee or shoulder pain.

Subjects with knee pain (18 men and 22 women) had problems equally distributed between the right and left sides. Subjects with shoulder pain (21 men and 25 women) had mostly right-sided problems. The majority of both groups were in their 20's and 30's; many of them were university graduate students. For both groups of subjects, the duration of symp toms was highly variable (Table 2). The median du- ration was nearly 8 months for subjects with knee pain and nearly 18 months for subjects with shoulder pain.

A questionnaire and screening physical examina- tion were used to try to exclude subjects with muscu- loskeletal or neurological conditions that prevented

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active motion at the knee and shoulder or pain aris- ing from the spine and viscera. Subjects were includ- ed if they had voluntary movement of the knee and shoulder and asymptomatic active and passive move- ments with overpressures (additional force applied after resistance to motion is felt) of the cervical or lumbar spine. Exclusion criteria included current or previous spinal problems; fractures or dislocations; genitourinary or lower gastrointestinal problems that could refer pain to the knee; gastric, hepatic, respira- tory or cardiac problems that might refer pain to the shoulder; multiple sclerosis, cerebrovascular accident, peripheral neuropathies, or other neurological con- ditions. Inclusion and exclusion criteria were includ- ed in subject recruitment materials. As part of the screening process, subjects signed an informed con- sent form approved by the Institutional Review Board at Northwestern University and the rights of the subjects were protected through the review board's guidelines. No subjects were excluded from the study after the screening examination.

Evaluators

A research assistant screened all subjects. She had 12 years of experience, 10 of which were in or the paedic practice, and she continued to practice as a physical therapist during the 4year course of the study.

The 2 evaluators, both physical therapists, had studied selective tension testing, and used the system in their practices, but they were not considered ex- perts in Cyriax techniques. The evaluators had 18 and 20 years of experience with at least 10 years of orthopaedic emphasis and continued to practice in orthopaedic physical therapy during the course of the study. The evaluators spent 6 hours with the au- thors as part of the study reviewing data forms, test procedures, and their interpretation. We collected data based on the way typical practitioners had been taught in professional or continuing education pro- grams, and the evaluators did not practice examining patients together.

Passive Tests Performed

Only the passive physiologic motion tests, which are part of a knee or shoulder evaluation recom- mended by Cyriax, were assessed in this study. To test end-feels, the evaluators used standardized stabiliza- tion techniques with overpressures for knee flexion and extension and shoulder full abduction, glenohu- meral abduction, external rotation, internal rotation, and horizontal adduction.

Knee flexion and extension end-feels were evaluat- ed in the supine p o s i t i ~ n . ~ ( p ~ ~ ) Knee flexion was per- formed by passively flexing the subject's hip and the knee with an overpressure at the end of knee flexion

range. Knee extension was produced with the hip in a neutral position with an overpressure at the end of knee extension ra~~ge.'~(pp*~*) The expected end-feel without pathology for knee flexion is tissue approxi- mation, and for knee extension, a normal end-feel is capsular.

All shoulder end-feels were evaluated in the stand- ing position."(ppflWn3) The expected normal end-feel for all shoulder motions is capsular but may also be tissue approximation for shoulder horizontal adduc- tion. During shoulder movements, specific stabiliza- tion of the scapula was used except during full a b duction. During glenohumeral abduction, evaluators stabilized the scapula with their palms over the acro- mion, applying a force in an inferior direction. Cra- dling the subject's upper extremity with the elbow flexed, they performed shoulder abduction in the plane of the scapula. To test full shoulder abduction, evaluators provided no scapular stabilization and moved the shoulder through full passive abduction in the frontal plane. During external rotation, eval- uators stabilized the subject's scapula with their bod- ies and performed external rotation by grasping the subject's flexed forearm, keeping the elbow against the subject's body. During internal rotation, evalua- tors stabilized the scapula in an inferior direction with their fingers over the coracoid process and their palms and forearms over the scapula. They grasped the subject's flexed lower forearm and performed in- ternal rotation. During horizontal adduction, evalua- tors stabilized the lateral border of the scapula with their palm over the scapula and reached in front of the subject to cradle the flexed upper extremity and produce horizontal a d d u c t i ~ n . ' ~ ( ~ ~ ~ - ~ ~ . ~ ~ )

Procedures

The evaluators did not interview the subjects dur- ing the examination. We did not want patient inter- view information to affect the interpretation of the physical examination. The evaluators were told only in which knee or shoulder the pain was located. The subjects were to indicate to the evaluator only if the specific pain complaint was recreated during testing. Evaluators recorded all test results on a data form. Subjects were examined a second time following a lsminute rest period. Subjects were reexamined by the same evaluator (intra-rater condition, n = 23 knee and n = 28 shoulder) or the other evaluator (inter-rater condition, n = 17 knee and n = 18 shoulder). The intra-rater versus inter-rater condi- tions were randomized, and in the inter-rater situa- tion, the order of evaluator was also randomized.

Subjects were instructed to report to the evaluators as soon as they felt the onset of, or an increase in, their pain. Immediately after the evaluator recorded the end-feel, the subject reported the amount of pain he or she experienced. Patients verbally indicat-

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TABLE 3. An example of a contingency table for intra-rater passive knee flexion end-feels. (One evaluator completing repeated assessments on 23 patients.)

Test

Retest Caps E Caps TA SB S E

Caps 5 1 1 E Caps 1 1 1 TA 9 SB 1 S 2 E 1

Kappa value = 0.76, standard error = 0.1 1. Caps indicates capsular; E Caps, early capsular; TA, tissue approximation; SB, springy block; S, spasm; and E, empty.

ed the intensity of their pain from 0 to 10 following each passive physiologic motion end-feel test. On the scale, 0 meant no pain and 10 meant extremely se- vere pain.

Only the first examination data obtained by each evaluator were used in this report, as would occur in the clinical setting, and all subjects were used in the analysis. Intra-rater and inter-rater reliability was ex- amined. For the knee, intra-rater kappa coefficients (mean = 0.88, SD = 0.17, n = 23) varied from 0.76 to 1.00 with 83 to 100% agreement. An example of a contingency table for intra-rater passive knee flexion is included (Table 3). At the shoulder, intra-rater kappa coefficients (mean = 0.83, SD = 0.16, n = 28) varied from 0.65 to 0.92 with 86 to 96% agree- ment. Inter-rater reliability kappas (knee mean = 0.21, SD = 0.31, n = 17, and shoulder mean = 0.45, SD = 0.16, n = 18) were below 0.47 with between 35 and 89% agreement. Based on the literature on pain scales, we assumed that the pain reports from sub jects were reliable.2.4p8

Data Analysis

Data were analyzed using one-way analysis of vari- ance (ANOVA) using end-feel category as the factor with 6 levels to determine whether the observed dif-

ferences at the knee or the shoulder among the pain means, based on end-feel category, were greater than expected by chance. For knee and shoulder motions in which significant differences were found, post hoc Tukey's Honestly Significant Difference (HSD) tests were used to determine exactly which groups dif- fered. The alpha level was set at 0.05 for all analyses. For one motion, knee flexion, variances were not ho- mogeneous. A Kruskal-Wallis (KW) one-way ANOVA was further used to analyze knee flexion. The ANO- VA for shoulder glenohumeral abduction showed an omnibus difference and Tukey's HSD was not sensi- tive enough to find where there were differences; therefore, the Least Significant Difference (LSD) test was used to analyze (post-hoc) the shoulder glenohu- meral abduction data set."

To check whether reliability of the data affected the results, we analyzed data from all subjects, as well as from only those subjects on whom first and sec- ond evaluations produced the same end-feels.

The analyses were performed using a Power Mac- intosh computer (Apple Computer Inc, Cupertino, Calif), SPSS 6.1.1 statistical software (SPSS Inc, Chi- cago, Ill) and a Claris Works 4.0 spreadsheet (Claris Corporation, Santa Clara, Calif).

RESULTS

The relationship between normal and abnormal- pathologic end-feels was the same at the knee and the shoulder. The magnitude of the mean pain was significantly higher for spasm end-feel than for c a p sular end-feel for knee extension (Table 4 and Fig- ure 1). For knee flexion, early capsular, spasm, springy block, and empty end-feels were more pain- ful than tissue approximation and capsular end-feels (Table 4 and Figure 1). Early capsular and empty end-feels were more painful than the capsular end- feel for shoulder full abduction and for shoulder gle- nohumeral abduction (Table 4 and Figure 2). Early capsular and spasm end-feels were more painful than the capsular end-feel for shoulder external rotation

TABLE 4. Tukey's HSD post hoc significant difference findings in mean (SD) pain comparing pathologic and normal end-feels.

Pathologic Normal

EC S SB E TA C

Knee Extension 3.1 7 (1.60) 7.0 (0)' 4.0 (0) 1.3 1 (1.93) Flexion 4.8 (1.92)* 6.5 (3.54)' 7.0 (0). 8.25 (0.35)' 0.47 (1.06) 1.4 (1.99)

Shoulder Full Abd 4.88 (2.55)' 6.33 (2.31)' 2.67 (2.38) GH Abd 2.5 (2.01)' 3.0 (0) 5.0 (0)' 0.88 (1.63) ER 3.18 (2.71)' 9.0 (0)' 4.0 (0) 1.12 (1.94) IR 4.62 (2.80)' 4.0 (0) 2.0 (2.19) HA 5.06 (2.67)' 4.0 (1.41) 0.60 (1.34) 1.23 (2.25)

Abd indicates abduction; TA, tissue approximation; GH, glenohumeral; C, capsular; ER, external rotation; EC, early capsular; IR, internal rotation; S, spasm; HA, horizontal adduction; SB, springy block; and E, empty.

Indicates a significant difference compared to a normal end-feel (P < .05).

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Flexion Extension 12 * I

TA Cap E Cap SB Spasm Empty Cap E Cap Spasm Empty

FIGURE 1. Knee physiologic motion. Stacked mean pain ratings (black) and standard deviations (white) for each end-feel by motion at the knee. Starred knee physiologic motion pathologic end-feels are more painful than normal (capsular and tissue approximation) end-feels. End-feel categories: TA indicates tissue approximation; Cap, capsular; E Cap, early capsular; SB, springy block.

k i n ratings for pathological end-feels are significantly greater than pain ratings for normal end feels.

(Table 4 and Figure 2). The early capsular end-feel was more painful than the capsular end-feel for shoulder internal rotation, and the early capsular end-feel was more painful than tissue approximation and capsular end-feels for shoulder horizontal adduc- tion (Table 4 and Figure 2). Tissue approximation and capsular end-feels were the only expected nor- mal end-feels found at both the knee and the shoul- der. No bone-to-bone end-feels were found at either joint and would have been considered abnormal- pathologic at these joints. Early capsular end-feels were more painful than capsular normal end-feels for both joints, suggesting pathology.

Knee flexion was the sole motion in which all end- feel categories defined in the study were found (ex- cept bone-to-bone). The pain associated with the a b normal-pathologic end-feels increased in intensity

from early capsular to spasm, springy block, and empty, as seen in Figure 1.

Because of the small sample sizes in some catego- ries, the power of some of the comparisons is low (Figure 3). In other cases, as with shoulder external rotation (Figure 2), a single individual with a high pain level (spasm end-feel) made the comparison sig- nificant (knee extension, one individual with a spasm end-feel; knee flexion, one individual with a springy block end-feel; shoulder glenohumeral abduction, one individual with an empty end-feel; and shoulder external rotation, one individual with a spasm end- feel) (Figures 1 and 2).

Examining results using the data from the reliable subset (subjects with the same end-feel on both eval- uations), the pattern of end-feel responses did not change, and the specific comparisons were almost

Full Cknobumcrd External lntcrnal Horizontal

Abduction Abduction Rotation Rotation Adduction

FIGURE 2. Shoulder physiologic motion. Stacked mean pain ratings (black) and standard deviations (white) for each end-feel by motion at the shoulder. Starred shoulder physiologic motion pathologic end-feels are more painful than normal (capsular and tissue approximation) end-feels. End-feel categories: Cap indicates capsular; E Cap, early capsular; TA, tissue approximation.

Pain ratings for pathological end-feels are significantly greater than pain ratings for normal end feels.

J Orthop Sports Phys Ther *Volume SO. Number 9. September 2000 517

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Physiologic Motions

E l Knee Ext W Knee Flex H Shld FA H Shld CHA HShld ER

Shld IR Shld HA n

TA Cap ECap Spasm SB Empty

FIGURE 3. Number of subjects in each end-feel category by joint motion. End-feel categories: TA indicates tissue approximation; Cap, capsular; E Cap, early capsular; SB, springy block. Physiologic motions: Ext indicates extension; Flex, flexion; Shld, shoulder; FA, full abduction; GHA, glenohumeral abduction; ER, external rotation; IR, internal rotation; HA, horizontal adduction.

identical except for shoulder full abduction and gle- nohumeral abduction (Figures 4 and 5).

The abnormal-pathologic end-feels were associated with more pain, but were not always painful, and normal end-feels were not always pain-free, as would be expected (Table 5). Across both joints, when a b normal-pathologic end-feels did not produce pain, the end-feels were all early capsular. When normal end-feels produced pain, all but 3 of the end-feels were capsular. The other 3 were tissue approxima- tion end-feels with knee flexion. Both of these results can be explained by pain interpretation variability among individuals. All 3 end-feels (capsular, tissue approximation, and early capsular) can create a stretching or squeezing sensation in tissues that may be felt as painful by some individuals and nonpainful by others. In a clinical situation, practitioners would compare the findings with the opposite extremity. These comparisons were done in this study. In sub- jects who indicated pain but had a normal end-feel, we suspect that they interpreted the stretch of the capsule (capsular) or tissue compression (tissue a p proximation) as painful and that they would report similarly for the uninvolved side. Subjects with an early capsular end-feel without pain may not have in- terpreted the stretch as painful, but would be expect- ed to have a loss in range of motion between the in- volved and uninvolved sides. In this study, 7 of the 11 subjects clearly had range of motion loss in the involved side compared with the uninvolved side, and in the other 4 subjects, the difference in range of motion was so small as to be within measurement error for range of motion. Other findings would add support to whether pathology were present or not, because no examination finding should be interpret- ed in isolation.

These findings support our hypothesis that at the knee and the shoulder, subjects who had early capsu- lar, spasm, springy block, and empty end-feels had

more pain during end-feel testing than subjects with normal end-feels.

DISCUSSION

Subjects

The subjects recruited for this study were recruited mainly from the university's student community. Most fell within the age range of 20-30 years and had a median duration of pain of one year. The knee prob- lems were equally distributed between the right and left sides and the shoulder problems were mostly right-sided. The results from this study may not re- late to other age ranges or to a median duration of symptoms other than one year's time. More right shoulder involvement could be expected because right-hand dominance was more common and, there- fore, more strongly associated with developing pain- ful shoulder problems. These are areas for further research.

End-feels and Pain

Our hypothesis that some abnormal-pathologic end-feels are significantly more painful than normal end-feels was supported for all motions at each joint (Figures 1 and 2). There may also be a pattern of in- creasing intensity of pain responses within the end- feel categories. Early capsular abnormal-pathologic end-feels were more painful than normal capsular end-feels found with knee extension and all shoulder motions and normal tissue approximation end-feels found with knee flexion and shoulder horizontal ad- duction (Figures 1 and 2). Within the abnormal- pathologic end-feels, when all categories were pres- ent except bone-tebone (knee flexion, Figure 1). pain intensity increased from early capsular to spasm, springy block, and empty end-feels. Within this or-

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Flexion Extension

FIGURE 4. Knee physiologic motion. Stacked mean pain ratings (black) and standard deviation (white) for each end-feel by motion at the knee in the reliable subset. Starred knee physiologic motion pathologic end-feels are more painful than normal (capsular and tissue approximation) end-feels in the reliable subset. End-feel categories: TA indicates tissue approximation; Cap, capsular; E Cap, early capsular; SB, springy block.

Pain ratings for pathological end-feels are significantly greater than pain ratings for normal end feels.

dering of increased pain responses with the 4 abnor- mal-pathologic end-feels, we expected that an early capsular end-feel would be the least painful. An early capsular end-feel "when felt in conjunction with a capsular pattern of restriction and in the absence of significant inflammation or effusion . . . indicates capsular fibro~is."'~(*~) As described, stretch should be felt with this end-feel and some people might consider the stretch painful because of the abnormal nature of the tissue being stretched.

In the individual motion analyses, there were no statistical differences in pain intensity among the a b normal-pathologic end-feels, mostly due to small sam- ple size. To increase the sample sizes in the end-feel categories and to explore potential differences in pain intensity among the abnormal-pathologic end-

feels, we pooled the first measure of all the end-feels for both the intra-rater and inter-rater conditions for both motions at the knee and the 5 motions at the shoulder for all subjects (total of 310 end-feels). We believe this aggregation is justified because abnor- mal-pathologic end-feels are the same at each joint. We found significant differences among end-feels F,,, = 26.34. Tukey's HSD showed that all abnor- mal-pathologic end-feels were significantly more pain- ful than normal end-feels and that spasm and empty end-feels were significantly more painful than an ear- ly capsular end-feel. This result reinforces the obser- vation that an early capsular end-feel is less painful than the other abnormal-pathologic end-feels.

Ordering the intensity of the 3 remaining abnor- mal-pathologic end-feels, spasm, springy block, and

Full Glenohumeral External Internal Horizontal Abduction Abduction Rotation Rotation Adduction

FIGURE 5. Shoulder physiologic motion. Stacked mean pain ratings (black) and standard deviations (white) for each end-feel by motion at the shoulder in the reliable subset. Starred shoulder physiologic motion pathologic end-feels are more painful than normal (capsular and tissue approximation) end- feels in the reliable subset. End-feel categories: TA indicates tissue approximation; Cap, capsular; E Cap, early capsular; SB, springy block.

Pain ratings for pathological end-feels are significantly greater than pain ratings for normal end feels.

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TABLE 5. Number of subjects in combined normal versus combined pathologic end-feel categories by joint motion and if pain was present or absent.

Physiologic motion

Knee Shoulder - --

End-feel and pain EXT FLEX FA GHA ER IR HA

Normal EF, no pain 18 21 9 24 17 10 25 Normal EF with pain 14 9 2 1 10 8 14 10 Pathologic EF, no pain 0 0 1 3 5 2 0 Pathologic EF with pain 8 10 15 9 16 20 11

EXT indicates extension; FLEX, flexion; FA, full abduction; CHA, glenohumeral abduction; ER, external rotation; IR, internal rotation; HA, horizontal adduction; and EF, end-feel.

empty is speculative. All 3 end-feels are suggestive of painful pathologies, but to indicate specifically which pathology would be the most painful would be de- pendent on pain behaviors that vary in individuals. A spasm end-feel can occur with capsular restrictions indicating "some degree of synovial inflammation" with "pain felt at the point of restriction."'O(~ A springy block end-feel suggests internal derangement "such as displacements of pieces of torn menisci and ~arti lage"~(@~) or bone loose bodies. Cyriax states "the pain is localized""~~~) with springy block end- feels. Empty end-feels typically are rare. The end-feel is present with acute bursitis at the shoulder and "other painful extraarticular lesions such as neo- plasms."'O(fl) Additional research may reveal a specif- ic ordering of pain within the abnormal-pathologic end-feel categories. We think that our finding that an early capsular end-feel was the least painful of the abnormal-pathologic end-feels does reflect the patho- physiology that is present when an early capsular end-feel is found.

The results of this study were expected because knee or shoulder pathology suggests changes within the normal physiology of one or more tissues (inert or contactile) surrounding the joint complex. When changes in physiology occur, pain is frequently a syrnpt~m.'~ Subjects were chosen for the study be- cause they had symptoms related to knee or shoulder problems suggestive of pathology.

In spite of our efforts to include subjects with a wide variety of problems, some end-feels were rare, leading to low numbers of observations for some comparisons. Coupled with comparisons in which a single subject had extreme pain, these results must be interpreted with caution. We believe, however, that the pattern of results is robust. In general, ab- normal-pathologic end-feels produce more pain than normal end-feels.

Reliability

We believe that reliability of the end-feel data did not affect the results because the pattern of end-feel responses did not change, and the specific compari- sons were almost identical when the reliable subset was used. The only differences were for shoulder full

abduction (the order was the same but none were significant) and glenohumeral abduction (only the empty end-feel category was significant) (Figures 4 and 5). The decrease in the number of significant comparisons was likely due to the decrease in the sample sizes in the reliable subset. More research is needed to confirm these findings with the same and other joints.

In examining the inter-rater reliability, most errors were found between the categories of capsular and early capsular end-feels. Whether these end-feels pro- duce pain may depend on the vigor of the overpres- sure applied. Care must be taken to differentiate stretch from pain and to attend to even slight limita- tions in motion.

End-feel Names

There is no evidence to suggest that the end-feel names are valid representations of the primary tissue that limits movement at a joint. Caution must be used, therefore, in interpreting end-feel names as in- dicators of tissues that are restricting motion at joints. Like Cyriax, Paris specifically categorizes end- feels based on the anatomic structure limiting the range of m o t i ~ n . ~ . ' ~ Kaltenborn, on the other hand, suggests using descriptive labels for end-feels includ- ing soft, firm, or hard but, again, dependent on the anatomy of the joint.g Refinement of definitions is also an area for further research.

Clinicians must consider that musculoskeletal in- volvement may be present if the end-feels defined as abnormal-pathologic by Cyriax are found during pas- sive physiologic movement testing. Early capsular end-feels may be suggestive of ligamentous or capsu- lar fibrosis, but the nature of the relationship be- tween pain and mobility limitations is unclear. Fur- ther research is also needed to determine if similar end-feel findings occur with passive physiologic mo- tion at other joints.

CONCLUSION

These data show that abnormal-pathologic end- feels can be associated with more pain than normal end-feels during passive physiologic motion testing at

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the knee and shoulder. A trend toward an increasing intensity o f pain responses within the end-feel cate- gories was found. These results provide support for the concept o f abnormal-pathologic versus normal end-feels in evaluation o f patients with musculoskele- tal problems. When abnormal-pathologic end-feels are present, dysfunction should be suspected within the tissues surrounding that jo int complex. End-feel testing, part o f passive movement assessment, is an important part o f the physical examination, provid- ing information that may indicate the presence o f tis sue pathology. Further research is necessary to con- tinue to examine end-feels and their relationship to pathology.

ACKNOWLEDGMENTS

We thank our research assistant, evaluators, and the subjects who participated in this study. We also thank Carol Tercyak, PT, MS, for reviewing the manuscript, and Ellen Humphrey, PT, MA, OCS, Yo- landa Aldrete, and Phyllis Koerner for help with manuscript preparation.

REFERENCES 1. Bijl D, Dekker J, van Baar ME, et al. Validity of Cyriax's

concept of capsular pattern for the diagnosis of ostoear- thritis of hip andlor knee. Scand J Rheumatol. 1998;27; 347-351.

2. Boeckstyns MEH, Backer M. Reliability and validity of the evaluation of pain in patients with total knee replace- ment. Pain. 1989;38;29-33.

3. Cyriax J. Textbook of Orthopaedic Medicine Volume I. Diagnosis of Soh Tissue Lesions. 8th ed. London: Bailliere Tindall; 1982.

4. Downie WW, Leatham PA, Rhind VM, Wright V, Branco JA, Anderson JA. Studies with pain rating scales. Ann of Rheum Dis. 1978;37:378-381.

5. Franklin ME, Conner-Kerr T, Chamness M, Chenier TC,

Kelly RR, Hodge T. Assessment of exerciseinduced minor muscle lesions: the accuracy of Cyriax's diagnosis by se- lective tension paradigm. ) Orthop Sports Phys Ther. 1996; 24:122-129.

6. Fritz JM, Delitto A, Erhard RE, Roman M. An examination of the selective tissue tension scheme, with evidence for the concept of a capsular pattern of the knee. Phys Ther. 1998;78:1046-1061.

7. Hayes KW, Petersen C, Falconer J. An examination of Cy- riax's passive motion tests with patients having osteoar- thritis of the knee. Phys Ther. 1994;74:697-707.

8. Jensen MP, Karoly P, Braver S. The measurement of clin- ical pain intensity: a comparison of six methods. Pain. 1986;27:117-126.

9. Kaltenborn FM. Mobilization of the Extremity )oink: Ex- amination and Basic Treatment Techniques. 3rd ed. Oslo: Olaf Norlis Bokhandel; 1980.

10. Kessler RM, Hertling D. Management of Common Mus- culoskeletal Disorders: Physical Therapy Principles and Methods. Philadelphia: Harper & Row; 1 983:44-48, 99- 101.

11. Ombregt L, Bisschop P, ter Veer HJ, Van de Velde T. Clin- ical examination of the shoulder. In: Ombregt L, Bisschop P, ter Veer HI, Van de Velde T. A System of Orthopaedic Medicine. London: WB Saunders Company Ltd; 1995: 21 5-223.

12. Patla CE, Paris SV. Reliability of interpretation of the Paris classification of normal end feel for elbow flexion and extension. lournal of Manual and Manipulative Therapy. 1993;1:60-66.

13. Paris SV, Patla C. E l course notes: Extremity dysfunction & manipulation. Atlanta, Ga: Patris Inc; 1988:86-88.

14. Pellechia GL, Paolina J, Connell J. lntertester reliability of the Cyriax evaluation in assessing patients with shoulder pain. J Orthop Sports Phys Ther. 1996;23:34-38.

15. Petersen C. Active and Passive Movement Testing of the Extremities, Spine, Pelvis and Temporomandibular Joint. Chicago, Ill: Programs in Physical Therapy; 1999:7- lO,l3,87-88.

16. Petty NJ, Moore AP. Neuromuscular Examination and As- sessment: A Handbook for Therapists. Edinburgh: Chur- chill Livingstone; 1998: 6, 8.

17. Portney LG, Watkins MP. Foundations of Clinical Re- search: Applications to Practice. Connecticut: Appleton & Lange; 1993:400-402,429-432.

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Invited Commentary Medicine has long employed palpation and manu-

al exploration of skeletal and visceral structures in order to determine the presence or absence of pa- thology or dysfunction. For example, in individuals with suspected appendicitis, McBurney's point is pal- pated and the pain response is noted. Despite the continual technological explosion in medicine, the patient history and physical examination are under- going a renaissance of sorts and are again being em- phasized in clinical diagnosis.

The study by Petersen and Hayes examined Cy- riax's system of selective tension,' which is a manu- al evaluation method commonly employed by phys- ical therapists. The authors have attempted to pro- vide construct validity to this concept when applied to joint end-feels in subjects with pain at the knee and shoulder. The authors hypothesized that ab- normal-pathologic end-feels would occur in a path- ologically involved joint, and the pain associated with an abnormal-pathologic end-feel would be greater than the pain found with a normal end- feel.

The authors reported that the 5 shoulder posi- tions and knee flexion resulted in increased pain when an early capsular pattern was present. The authors also attempted to draw inferences from other categorical comparisons, but these may be in- valid. In particular, a major limitation in this study was the extremely low (1-3) number of cases in 3 of 6 end-feel categories (spasm, springy block, and empty end-feel). In addition, the low number in several of the end-feel categories had a significant effect on statistical power for between group com- parisons. At the outset, there was no mention of what a clinically meaningful difference in pain be- tween end-feel categories should be, and the num- ber of subjects per category needed to detect this difference, if it exists. Furthermore, the authors state "because of the small sample sizes in some categories, the power of some of the comparisons is lo~."~(p"') However, the authors never provide the reader with a value for that "low" statistical power. More concerning is the multiple between category comparisons. For instance, the authors state "In other cases, as with shoulder external ro- tation, a single individual with a high pain level (spasm end-feel) made the comparison signifi- cant. . . "2(p"7) In fact, they describe 5 of these cases in which there is only one individual in the category; however, the comparisons were signifi- cant. Some of these findings are likely spurious,

particularly in light of the fact that multiple com- parisons (21 in Table 4) were made with no at- tempt to adjust the alpha level in order to prevent a Type I error; some of these findings are just as likely due to chance."t is questionable whether or not post-hoc tests performed with only one subject and, therefore, with no variance is a reasonable a p proach. Any discussion of the spasm, springy block, and empty end-feel, therefore, should be viewed with extreme caution.

A potentially more meaningful analysis would be to know whether or not the subjects with end-feel categories with low prevalence (spasm, springy block, and empty end-feel) had diagnoses that differed from those subjects with early capsular patterns and if their eventual treatment outcomes were grossly dif- ferent. This would provide support for the concept that even though the prevalence of these categories is low, the classification of patients into these catego- ries either assists with identifying "red flag" diagno- ses (ie, tumor, infection, etc) or results in a distinctly different treatment approach. If not, then do we need all these categories, or is normal and abnormal enough?

The purpose of a diagnostic or classification system is to identify subgroups of patients who are more likely to respond to a particular intervention. The se- lective tension scheme is designed to systematically stress various joint-related structures. The interpreta- tion of the examination then theoretically guides the therapist's treatment decisions. However, the deter- mination of the "end-feel" by the therapist is a mul- tifactor decision that accounts for both the patient's response and the therapist's interpretation of the end-range feel; in clinical practice, this is likely influ- enced by knowledge of the patient's present symp toms and other historical factors. In this study, the therapists recorded the end-feel and the subjects re- ported the amount of pain they felt. The therapist had no knowledge of the patient's history or present symptoms. This was purposeful in order to minimize bias from the history, which may influence the thera- pist's end-feel decision. It does limit the generaliza- bility of the results.

The process of appraising the elements of a pa- tient's history and physical examination, both part of the orthopaedic physical therapy practice, is critical to our professional growth. Research can provide evi- dence that either validates or refutes examination systems; however, it is difficult to interpret if the present paper provides proof or disproof for the se-

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lective tension concept. At best, I believe we are with the idea that the selective tension concepts have some merit.

Timothy W. Flynn, PT, PhD, OCS, FAAOMPT Associate Professor and Research Director U.S. Army-Baylor Graduate Program in Physical

Therapy 3151 Scott Road Fort Sam Houston, TX 78234-6138

left

may REFERENCES 1. Cyriax J. Textbook of Orthopaedic Medicine, Volume 1:

Diagnosis of Soft k u e Lesions. 8th ed. London, England: Bailleire Tindall; 1982.

2. Petersen CM, Hayes KW. Construct validity of Cyriax's se- lective tension examination: association of end-feels with pain at the knee and shoulder. ] Orthop Sports Phys Ther. 2OOO;3O:Sl2-521.

3. Portney LG, Watkins MP. Foundations of Clinical Research. Applications to Practice. Norwalk, Conn: Appleton & Lange; 1993.

Invited Commentary The paper "Construct Validity of Cyriax's Selective

Tension Examination: Association of End-feels With Pain at the Knee and Shoulder" by Cheryl Petersen, PT, MS, and Karen Hayes, PT, PhD, examines the concept of end-feel and relates the normal to the ab- normal-pathogenic using pain experienced by sub- jects as an indication of pathology. The knee and shoulder are investigated within this preliminary study. The methodology and discussion consider oth- er interpretations of end-feel, but are rooted in the classification expounded upon by Dr James Cyriax, FRCP, which is notably relevant to the assessment procedures used in orthopaedic medicine. Cheryl Pe- tersen and Karen Hayes' attempt to substantiate Dr Cyriax's theories should be applauded.

Dr Cyriax's claim that "all pain arises from a le- sion, all treatment must reach the lesion, and all treatment must exert a beneficial effect on the le- sionW4(pJ) has been handed down through his teach- ing years, as has his assertion that it was for his as- sessment procedures that he wanted to be known and remembered. His pragmatic and logical a p proach towards establishing the "source" of the symptoms led him to state that normal tissue should function painlessly, whilst traumatised or inflamed tis- sue would It followed then, that if appropriate tension could be applied to specific tissues, then the outcome, in terms of pain production, would be able to incriminate or eliminate the structure from the clinical "inquiry." The study by Petersen and Hayes supports the theories underpinning the use of selec- tive tension as a diagnostic tool, but some discussion is required to clarify the clinical significance of its conclusions.

Dr Cyriax classified the soft tissues into inert and contractile structures; inert implying joint capsules, ligaments, fascia, bursae, etc, and contractile as mus- cle, tendon, and attachments to bone.5 The term se- bctive tension denoted that appropriate tension should be applied to tissues, with passive movements

being applied to test inert structures and resisted tests to stress contractile structures.

The application of passive movements reveals a specific sensation through the operator's hands when the end of available range has been reached. Dr Cy- riax termed this sensation the "end-feel." Petersen and Hayes use classifications of end-feels according to Cyriax, Paris, and Kaltenborn, but the Cyriax clas- sification, and the subsequent terminology adopted within the paper, have been developed in the cur- rent teaching of orthopaedic medicine and may be confusing to those who have studied the specialism more recently. As mentioned in the paper, Cyriax classified normal end-feels as "bone-to-bone," "tissue approximation," and "~apsular,"~ and the authors' explanations are an accurate representation of when they exist. Current orthopaedic medicine teaching, however, tends to describe normal end-feels as hard (bone-to-bone) , soft (tissue approximation), and elas- tic (capsular), describing the elastic resistance pro- duced in the inert tissues at the end of range,' and which, in the norm, could include tendon or liga- ment rather then confining itself to capsular resis- tance only.

In the abnormal end-feels that Cyriax referred to as "capsular," "spasm," "springy," and "empty,""t is the abnormal "capsular" end-feel that I believe needs further discussion. Cyriax noted that each indi- vidual joint develops a pattern of pain and limitation within its movements when the capsule is irritated. This pattern was demonstrated by limitation of move- men& in a fixed proportion, which he described as the capsular pattern, and he propounded that each joint has its own specific pattern. The significance of the capsular pattern is that it denotes that an "arthri- tis" is present, using the term as a generic for any cause of inflammation of the joint capsule, be it de- generative, traumatic, or inflammatory disease.

At the knee, the capsular pattern is represented by proportionally more limitation of flexion than of ex-

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tension. The capsular pattern of the shoulder is de- scribed as proportionally more limitation of glenohu- meral external rotation, less of abduction, and least of medial rotation. The concept of the capsular pat- tern is important in context of the study by Petersen and Hayes and helps to explain several of the obser- vations.

Revisiting the notion that an end-feel is a specific sensation imparted through the operator's hands, the abnormal-pathologic capsular end-feel will tend to feel "harder" when compared with the asympto- matic side, even at an early stage in the pathological process. This is attributed to the intervention of in- voluntary muscle spasm that protects the capsule from being stretched, long before capsular contrac- ture has had a chance to deve l~p .~ Capsular contrac- ture and fibrosis provide the next stage in contribut- ing to the abnormal end-feel? and the "hard" end- feel becomes more apparent, again compounded by protective muscle spasm. I doubt though, that within the age group studied by Petersen and Hayes, true capsular changes have developed. Only in the most advanced stages of osteoarthrosis would degenerative changes within the articular cartilage or bone with osteophyte formation be likely to present a true bone-to-bone end-feeL3 The point that should be em- phasised is that it is essential to compare with the asymptomatic side in order to fully exploit the rele- vance of the test and its clinical usefulness.

Cyriax linked the relationship of pain and capsular limitation as a guide for treatment techniques that in- volved the use of passive stretching to increase range and to reduce pain."F) The presence of pain before capsular resistance is experienced indicates that an ac- tive or irritable lesion is present that renders the joint unsuitable for stretching. Hyperirritability may be demonstrated by the presence of the "empty"' end- feel referred to earlier, but I would suggest that this may demand further investigation. Pain synchronous with limitation and with some preserved elasticity in the end-feel indicates that the joint is suitable for stretching. However, in the presence of the "hard" end-feel of muscle protection, the advice would be to employ other treatment modalities before introducing stronger stretching mobilisations. Capsular limitation before the onset of pain acts as a guide that the joint will tolerate strong passive stretches, particularly effec- tive in treating the less irritable, lower grade "arthri- tis" in the shoulder and hip.

As mentioned above, even in the earliest stage of capsulitis, a "hard" capsular end-feel may exist due to the involuntary muscle activity that acts to prevent the inflamed tissues being stretched as a response to the pain felt on specific passive movements. In prep aration for our own text,7 our literature search re- vealed the theory of Eyring and Murray,%hich stat- ed that the development of the capsular pattern could be associated with joint effusion, causing the

joint to assume an antalgic position of ease, with movements out of this position causing pain and pro- tective spasm. Eyring and MurrayG noted a possible relationship between intra-articular pressure and pain, and conducted a series of experiments to de- termine the position of minimum pressure in various joints. It was observed that symptomatic joints with effusion spontaneously assume a position of mini- mum pressure, which coincides with that of mini- mum pain. This provides a possible explanation for the specific capsular patterns and accounts for the development of a "hard" end-feel associated with pain on specific movements, even in the early capsu- l i t i ~ . ~ In protecting the painful, inflamed joint, the painful movements are comparatively underused and the limitation in the capsular pattern is further com- pounded by the ensuing capsular contracture and fi- brosis, as attributed by Petersen and Hayes to Cy- riax,3 and as supported by B ~ n k e r . ~

Petersen and Hayes note the affective aspects of pain experienced and observe that this could explain why subjects with an early capsular pattern at the shoulder do not complain of pain at the end of range of motion on external rotation at the shoul- der, whilst subjects with apparent asymptomatic shoulders may resent the capsular stretch and com- plain of pain at end of normal range of motion. Pe- tersen and Hayes propose that the evaluators' skills in applying overpressure might be a factor in this, but their findings broadly support the intrarater and interrater reliability of the study for the shoulder.

Cyriax2 noted that "pain is not always an essential component of limited movement in arthritis." Using the hip as an example, he observed that radiological- ly confirmed arthritis, with considerable restriction of range of motion in the capsular pattern, may coexist with complete absence of pain when the capsule is stretched quite hard.3(p55) This may also act as an ex- ample of the resistance before the experience of pain (as referred to earlier). The comparison with the contralateral side would satisfactorily provide a check on the clinical significance of these findings, but it is not clear from Petersen and Hayes that this was always performed.

I question the specific movements selected at each joint studied as being representative. At the shoulder, external rotation, internal rotation, and the end of passive elevation through flexion would conceivably stress the capsule to provide a capsular end-feel. So- called glenohumeral abduction is used more as a measure of range of movement at the glenohumeral joint, observing the commencement of scapular movement, and does not provide a true end-feel.' Horizontal adduction is taught by the Society of Or- thopaedic Medicine as an accessory test for impinge- ment of, for example, the upper fibres of subscapu- laris or the subdeltoid bursa, or compression of the acromioclavicular joint. I accept, however, that pain

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may produce a protective muscle spasm, which may produce an abnormal "hard" capsular end-feel. On applying passive extension to the knee, an initial ov- erpressure is usually applied to test for range of movement, whilst a small crisp drop or "bounce home" into extension applied to a normal knee should produce a harder, normal bone-to-bone end- feel,' similar to that encountered as the normal end- feel of passive elbow extension.

The concept of the "capsular" pattern is a valu- able tool in clinical diagnosis and the end-feel feed- back provides an effective guide for treatment selec- tion. I note the suggestion of Sims: based on the findings of Bijl et all with reference to the hip, that little evidence was found to support the classically de- scribed capsular pattern as presented by Cyria~.~5 However, my personal clinical experience of 26 years is thoroughly supportive of the classical capsular pat- tern at the hip, the knee, and shoulder specified in the study by Petersen and Hayes, and as given for other for diagnosis and treatment. A bal- ance should be found between finding evidence to support our clinical efficacy and establishing evi- dence to refute its benefit, and I fear that the em- phasis is more often on the latter. Petersen and Hayes' demonstration that abnormal-pathologic end- feels produce more pain than normal end-feels has provided a valid endorsement for the link between abnormal-pathologic end-feels and regional dysfunc- tion. They acknowledge that further research is needed to examine end-feels and their relationship to pathology, and, in context of the complete Cyriax assessment, the specific tissue affected.

Petersen and Hayes' introduction explains that "part of ' Cyriax's selective tension theory involves the concept of end-feel testing during passive move- ments. The study, however, is ultimately focusing on capsular considerations where the end-feel is particu- larly important in diagnosis and treatment. Later, Pe- tersen and Hayes state that "other findings" would add support to whether pathology were present or not, because no examination finding should be taken in isolation. Other inert tissues such as liga- ment or bursa, and even tendonitis, may produce pain on passive testing, but do not usually present with an abnormal-pathologic end-feel. Points from the patient's history and analysis of other tests lead to confirmation of clinical diagnosis. In relation to the shoulder, Pellecchia et al,R in looking at the in-

tertester reliability of the Cyriax evaluation as a whole, found it to be highly reliable in the assess- ment of patients with shoulder pain, facilitating the identification of diagnostic categories.

I urge those therapists who may have come to the approach through the original work of Dr Cyriax to reacquaint themselves with its tenets in light of the developments that are continuing in orthopaedic medicine and the continued expansion of its evi- dence base through studies such as this. The paucity of quality research to provide support for much of our work as physical therapists is a frustration to all in our profession. The Society of Orthopaedic Medi- cine has funds available that are intended to support projects that set out to increase the evidence base of musculoskeletal therapy, and welcomes applications. On behalf of the Society, I am pleased to have had the opportunity to provide a commentary on this pa- per, and I thank Dr Di Fabio for his invitation.

Elaine Atkins, MA, Grad Dip Phys, MCSP SRP Course Principal, Society of Orthopaedic Medicine 154 High Road Woodford Green Essex, England IG8 9EF

Society of Orthopaedic Medicine www.soc~rthemed.org

REFERENCES 1. Bijl et al. Validity of Cyriax' concept of capsular pattern for

the diagnosis of osteoarthritis of hip andlor knee. Scand) Rheumatol. 1998;27:347-35 1.

2. Bunker TD. Frozen shoulder: unravelling the enigma. Ann R Coll Surg Engl. 1997;79:21 G213.

3. Cyriax J. Textbook of Orthopaedic Medicine Volume 1 . Di- agnosis of Soft Tissue Lesions. 8th ed. London: Bailliere Tindall; 1982.

4. Cyriax J. Textbook of Orthopaedic Medicine. Volume 2. Treatment by Manipulation, Massage and Injection. 1 1 th ed. London: Bailliere Tindall; 1984.

5. Cyriax JH, Cyriax PJ. Illustrated Manual of Orthopaedic Medicine. Oxford: Butterworths; 1 983.

6. Eyring EJ, Murray WR. The effect of joint position on the pressure of intra-articular effusion. ) Boneloint Surg. 1964; 46-A:l235-1241.

7. Kesson M, Atkins E. Orthopaedic Medicine--A Practical Approach. Oxford: Butterworth Heinemann; 1998.

8. Pellecchia GL, Paolina J, Connell J. lntertester reliability of the Cyriax evaluation in assessing patients with shoulder pain. ) Orthop Sports Phys Ther. 1 996;23:43-48.

9. Sims K. Assessment and treatment of hip osteoarthritis. Manual Therapy. 1999;4:136-144.

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Author Response We thank Ms Atkins and Dr Elynn for a dialogue

that provides incentive to continue researching selec- tive tension testing and other physical therapy exami- nation and treatment interventions. We note that both commentators appear to believe that research is performed to "prove," "substantiate," or justify our practice. To the contrary, the purpose of research is a quest for truth, and all outcomes, both positive and negative, can serve to inform decision making. The results of individual research studies may s u p port or refute specific hypotheses and contribute to research and a larger body of knowledge, but no sin- gle study can be used as proof that the intervention or assessment is effective.

We believe that evidence from a systematic collec- tion of data is more meaningful than clinical obser- vation or experience. Elaine Atkins, for example, seems to believe that our study "substantiates" Cy- riax's approach to selective tension testing, but dis- misses Bijl's study,' which questions the capsular pat- tern at the hip, by stating that her clinical observa- tions are superior to their data. Clinical observation is a good source of testable hypotheses, but research is needed to make datadriven decisions regarding the best examination techniques and treatment inter- ventions used to treat orthopaedic problems.

Cyriax was logical and very insightful, but we must continue to examine his and other pioneer work in or- thopaedic medicine. Ms Atkins demonstrates an evolu- tionary process of changing an existing system. When clinicians change the principles or interpretations of a system such as that promoted by Cyriax, as Ms Atkins does, it suggests that their experience with the system causes them to question some of the premises. This process is entirely appropriate, but those changes should not be attributed to the originator of the sys tem. Because so many clinicians cite Cyriax for their practices, we decided to return to the basic tenets of Cyriax's work, without changing his examination scheme.

Ms Atkins questioned the movements that we test- ed at the knee and the shoulder, the definitions of the end-feels, and whether a true end-feel was as- sessed for glenohumeral abduction. We used the mo- tions suggested by Cyriax for the knee and shoulder, and we used his 6 categories of end-feels. The end- feel testing that was performed for the 5 shoulder and 2 knee physiologic motions was based on his testing scheme. End-feel testing was completed for glenohumeral abduction using the principles of sta- bilization and overpressure.

According to Cyriax, end-feels are based on the anatomy of the joint ~ o m p l e x * ( p p ~ ~ ~ ) and, contrary to Ms Atkin's suggestion that knee and elbow exten- sion end-feels are the same, the end-feel for knee ex- tension may be slightly different than elbow exten- sion due to the presence of the meniscii at the knee.

The diierent definitions of end-feels that Ms Atkins documents reflect current orthopaedic medicine teach- ing that varies from Cyriax's original work. Based on research and clinical observation, change is construc- tive and inevitable, but these altered definitions cannot be attributed to Cyriax. Ms Atkins stated that there are still 3 normal end-feels, but she uses diierent nomen- clature: hard (bone-to-bone) , soft (tissue approxima- tion), and elastic (capsular). Three abnormal-patholog- ic end-feels remain unchanged from Cyriax's defini- tions of spasm, springy block, and empty end-feels. Ms Atkins' description and explanations of her fourth a b normal-pathologic end-feel, "hard," seem to be based on Cyriax's concept of the capsular pattern and end- feels found during the stages of arthritis, but they dif- fer from those of Cyriax. Ms Atkins does not use the terms "spasm" and "capsular" as abnormalpathologic end-feels with arthritis. She uses "hard" end-feel to de- scribe the muscle spasm that occurs during acute or subacute arthritis, the capsular changes that occur with progression of arthritis and the end stage changes of articular cartilage degeneration and osteophyte forma- tion. Our concern with Ms Atkins' use of only one type of end-feel (hard) to describe the entire progression of pathologic arthritic changes is that it fails to guide in- tervention. We believe that a spasm end-feel with acute or subacute problems must be treated differently than a hard end-feel (Cyriax's capsular end-feel, early in the range of motion), and, in particular, a hard bone-to- bone end-feel. The original Cyriax abnormal-pathologic end-feel categories provided important and necessary information relative to intervention.

Ms Atkins also expressed concern that the nature of the end-feel cannot be determined without comparison with the contralateral side. In our study, end-feels were determined in relation to the contralateral side, which is reflected by the inclusion criterion of unilateral symptoms and is directly stated in our manuscript (first paragraph of the Methods section, Subjects). Normality for each subject was referenced to the uninvolved side during all examination procedures.

Ms Atkins focuses much of her commentary on the capsular pattern and pain resistance sequence as defined by Cyriax. The intent of our study was to ex- plore Cyriax's concept of end-feels by examining

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whether or not self-reported pain was greater for ab- normal-pathologic versus normal end-feels. The study was not intended to investigate Cyriax's concept of a capsular pattern or to investigate pain coincident with resistance as a measure of chronicity or related to interventions.

We disagree with Ms Atkins' assertion that inert tis- sues other than the capsule and contractile structures may produce pain without an abnormal end-feel. She offers no data to support this assertion, and in making it, she disagrees with Cyriax and other orthopaedic practitioners. For example, Cyriax indicates that muscle spasm will occur with a gastrocnemius b rea~h .~ (p~~) With acute subdeltoid bursitis, Cyriax states that muscle spasm is not felt but that patients have an empty end- feel.'(^'^^) The elicitation of muscle spasm is document- ed by Petty and Moore7(p4*) "as a result of nerve irrita- tion or secondary to injury of underlying structures, such as bone, joint or muscle." Kessler and Her- tling9(pp41wm.4*7) indicate that practitioners should note the presence of protective muscle guarding, suggestive of a spasm end-feel, during joint play movement test- ing at the knee, including varus-valgus and internalex- ternal rotation tests, which are considered ligamentous stress tests. Meadows5(W) reports a hard capsular end- feel (what we called early capsular end-feel) with "peri- capsular tissue hypomobility caused by arthrosis, adhe- sions, or scarring" suggestive of ligamentous involve- ment, and an early spasm end-feel "caused by arthritis, grade 2 muscle tear, fracture near a muscle insertion, dural sleeve, or other meningeal compression and/or inflammation." While most of these statements are based on observation and require systematic data col- lection to test their validity, Ms Atkins appears to stand outside the mainstream on this issue.

Regarding our statistical analysis, we appreciate Dr Flynn's comments. He is correct in urging caution when interpreting the comparisons among groups with small sample sizes. We indicated that such com- parisons had low statistical power, but did not report the actual power. Computation of power analyses with sample sizes less than 10 can be ina~curate.~ To exemplify the low power, we provide, as an example, the comparison between the early capsular ( n = 3) and empty (n = 2) end-feels for shoulder horizontal adduction. Even with an effect size of 2.5, usually considered to be quite large, the comparison was nonsignificant at an alpha level of .05. The power of this analysis was less than Effect sizes cannot be computed with single subjects because of the lack of variance, and results representing single subjects can certainly be spurious. We concur with Dr Flynn and reiterate our own caution that these results must be interpreted with caution. Much larger samples are needed to corroborate our results.

Regarding the multiple comparisons without an ad- justment in the alpha level, we thought that this proce- dure would not be necessary in the presence of the

very small probability values for the omnibus ANOVAs. Although we chose to report that the probabilities of the significant omnibus analyses were < .05, the actual probabilities were all substantially smaller, ranging from .O1 to < .0001. To address Dr Flynn's concern, we reanalyzed the data using Bonferroni post hoc multiple comparisons, which adjust the alpha level for the num- ber of comparison^.^ In all analyses, except the analysis for glenohumeral abduction, the results were exactly the same. There were no differences among end-feels for glenohumeral abduction using an adjusted alpha level for the post hoc tests.

We support Dr Flynn's suggestions regarding an analysis of the relationship between low prevalence abnormal-pathologic end-feel categories and their re- lated diagnoses, and an analysis of whether interven- tion outcomes would differ among the various diag- noses. These questions were not part of the original purpose of our study and, consequently, the diagno- sis and intervention outcome data are either incom- plete or were not collected. These questions would be the basis for excellent future research projects.

Dr Flynn is concerned about the omission of the in- terview as part of the patient examination. We acknowl- edge the importance of the patient interview, which, in most circumstances, generates the hypotheses related to the probable pathologies that are further tested dur- ing the patient examination. Those hypotheses, howev- er, create expectations of the results of portions of the patient examination. Our omission of the interview was intentional to allow assessment of the end-feel without that expectation bias.

We thank the commentators, and we urge all or- thopaedic practitioners to take every opportunity to collect data about their practices to inform future decision making.

Cheryl M. Petersen, PT, MS Karen W. Hayes, PT, PhD

REFERENCES Bijl D, Dekker J, van Baar ME, et al. Validity of Cyriax's concept of capsular pattern for the diagnosis of hip andlor knee. Scand) Rheumatol. 1998;27:347-351. Cyriax J. Textbook of Orthopaedic Medicine Volume I. Di- agnosis of Soft Tissue Lesions. 8th ed. London: Bailliere Endall; 1982. Kessler RM, Hertling D. Management of Common Mus- culoskeletal Disorders: Physical Therapy Principles and Methods. Philadelphia, Pa: Harper & Rowe; 1983. Kraemer HC, Thiemann S. How Many Subjects? Statistical Power Analysis in Research. Newbury Park, Calif: Sage Publications; 1987. Meadows TS. Orthopedic Differential Diagnosis in Physical Therapy: A Case Study Approach. New York, NY: McGraw- Hill; 1999. Norusis MJ. SPSS 6.7 Base System User's Guide, Pdrt 2. Chicago, Ill: SPSS, Inc; 1994. Petty NJ, Moore AP. Neuromusculoskeletal Examination and Assessment: A Handbook for Therapists. Edinburgh: Churchill Livingstone; 1998.

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