1994; 74:697-707. PHYS THER.

Karen W Hayes, Cheryl Petersen and Judith Falconer

With Patients Having Osteoarthritis of the Knee
An Examination of Cyriax's Passive Motion Tests
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Research Repofl
An Examination of Cyriax's Passive Motion Tests
With Patients Having Osteoarthritis of the Knee
Key Wolds: Knee, Osteoarthritis, Pain, Soft tissue syndromes.
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/resistance sequence (P/RS) of 79 subjects with osteoarthritis (OA) of the
The scheme of selective tension test- tion of force (which Cyriax called have adopted this system to determine
ing proposed by Cyriaxl is a clinical "tension") in different ways. The diag- the cause of patient complaints of pain.
system of diagnosis of painful prob- nosis is rendered based on the The validity of the scheme is grounded
lems of soft tissues. An anatomical patient's report of pain and the in theory and extensive clinical obser-
definition of the lesion is based on amount and direction of available vation, but it has not been studied
the patient's response to the applica- movement.l(p43) Physical therapists objectively or empirically.
Karen W Hayes
Cheryl Petersen
Judlth Falconer
Physical Therapy/Volume 74, Number 8/August 1994 697 / 9
knee and examined associations among these indicators of dysfunction and re-
lated 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 10-
degree 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' s assertions about patients with OA, most subjects had capsular endfeeki
for exter~ion; subjects with tissue approximation endfeeki for flexion had more
flexion ROM than did subjects with capsular endfeels, and the P/RS was signfi-
cantly correlated with pain intensity (rho =.35, extension; rho =.30, flexion). Con-
trary to hy~otheses based on Cyrim's assertions, most subjects had noncapsular
patterns, tissue approximation endfeels for flexion, and what Cyriax called pain
synchronous with resistance for both motions. Pain intensity did not dzfer de-
pending on endfeel. The P/RS was not correlated with chronicity (rho=.03, exten-
sion; rho =-.01, flexion). Reliability, as analyzed by intraclass correlation coefi-
cients (I(XJ3, 11) and Cohen's kappa coeficients, was acceptable (1.80) or nearly
acceptable for 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 reex-
amined. 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
system is indicated. [Hayes IW Petersen C, FalconerJ An examination of Cyrim's
passive motion tests with patients having osteoarthn'tis of the knee. Phys Thm
1994: 7 4 . 0 7-709.1
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According to Cyriax,' testing is con-
ducted in four ways: active motion,
passive motion, resisted contractions,
and palpation. The procedures are
usually performed in that order. Ac-
tive 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 reac-
tion of the muscle, tendon, and bony
attachments to contraction. Palpation
is used last to confirm the involve-
ment 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 de-
scription of the entire system of diag-
nosis 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 compo-
nents 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 pat-
tern is a joint-specific pattern of restric-
tion 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 adhe-
sions, extra-articular involvement, or
internal derangements.l@53 The 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 pa-
tient's unwillingness to complete the
motion.*@53) The paidresistance se-
quence is assessed to guide the vigor
of treatmentl@54) and is often inter-
preted as an indicator of the chronicity
of inflammation (active, less active,
none). According to Cyriax, pain be-
fore resistance is felt by the examiner
suggests a lesion with active inflamma-
tion; pain that he says occurs synchro-
nous 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, liga-
ment, fascia, bursa, nerve root, dura
mater) or contractile structures (mus-
cle, tendon, bony insertions) but is
not sufficient for a definitive diagno-
sis. 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 pa-
tients 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 Uni-
versity 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 Asso-
ciation, Arthritis Foundation, National Ofice, and NIH (NIAMS) Multipurpose Arthritis Center Grant
No. AM 30692
This article was submitted April 22, 1993, and was accepted January 6, 1994.
which are associated with defective
integrity of the articular cartilage, in
addition to related changes in the un-
derlying 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 cap-
sular pattern, with proportionally
greater restriction in flexion than in
exten~ion.l@5~) He contended that a 5-
to 10-degree extension loss corre-
sponds 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, mo-
tions end with involuntary muscle
contraction (spasm end-feel).l@~735~)
As the disease advances, patients de-
velop capsular end-feelsl@52) or hard
and painless end-feels in both exten-
sion 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 end-
feel 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 end-
feels 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 periarticu-
lar structures over an extended pe-
10 / 698 Physical The] rapy /Volume 74, Number 8IAugust 1994
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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.)
Passive 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 be-
cause articular cartilage is not
inner~ated.~@P~>50) In addition, com-
pression would relax the ligaments
and capsule rather than stressing
them. Palpation would reveal osteo-
phytes, coarse crepitus or creaking,
and no warrnth.l@p53.4OQ
Sequence of pain End-feel
Amount of motion and resirtsnee
I
Wln Win
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-
Wlnful
Something (bone.
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 hy-
potheses incorporating the construct
being measured.'
In our study, we examined the con-
struct 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, end-
feel, 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-
with alter
resismee resismee
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).
Amment with unilape) being
active mdon p~nchcd
Second, we examined relationships
among the components of passive
motion testing and joint motion, pain
intensity, and chronicity. We hypothe-
sized (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 end-
feels 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 se-
quence 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 por-
tion of the study were (1) there will
be no significant differences in pas-
sive ROM, end-feel, and paidresis-
tance sequence between sets of mea-
surements (H:8) and (2) test-retest
reliability estimates will exceed .80 for
passive ROM (intraclass correlation
coefficient [ICC]), end-feel assess-
ments (kappa), and paidresistance
sequence (kappa) (H:9).
I
t et rnults
Less achve Not active
Same u,
r I I
AROM
Ca ulw
1
possure
Inerlslrucbre
~ d i , ~ ~ , ~ of Exmdcul ar Internal
Full sapsular problem ligamenl a Icsion (adherent derangement (fmgmenrol
panofulnvlc musle. swelling. bonea d l a g e ; direction of
Method
(directionof bUrSiU6) limitations relate lo location
limilationa of bl ak)
rrls1ca D pan
involved)
Subjects for the study were 79 pa-
tients 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 pres-
ence of osteophytes, morning stiffness
for less than 30 minutes, crepitus,
ConMtile
8rnbI-e
Physical Therapy /Volume 74, Number 8/August 1994
Capvlw Spaam Tissue Springy Bonc~bone Empty
I blT
, , ,
Acute Nonnal
a ~ u b
I
I mpl ant
diaeaae;
N ma l h t h e acute
demge Normal hb bundtia.
logical if innam-
dy or mation
where not
crpocted
hikqhyte. Neumpahc
mdunited lrafrure, vthmpPthY
myasitis oaaifima
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-
Table 1. Characteristics of Subjects With Osteoarthritis of the Knee (N= 79)
vention. Evaluators did not have ac-
cess to previous evaluations.
Procedure
X SD Range
Passive ROM of the knee was mea-
Age (Y)
68.5 13.3 28.0-95.0
Duration of knee stiffness (mo) 83.6 122.4 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 aver-
aging 5.6 cm on a 10-cm visual ana-
logue 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 pro-
fessional and postprofessional educa-
tion, and they met with each other
and the principal investigator (KWH)
to review the measurement tech-
niques, specific study procedures, and
grading prior to their participation in
the study. Each examiner performed
all measures on the same set of pa-
tients at baseline, after treatment, and
after 2 months without active inter-
sured with a large universal goniome-
ter 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 exten-
sion 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 as-
sessed 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
Table 2. Categories of End-feel Testing and Pain/Resistance Sequence Used in
one category, and subjects who had
the
pain with resistance and pain before
resistance were combined into one
category. When the pain/resistance
End-feel Description
scale was used as a variable for exam-
ining the pain relationships, it was
Capsular A hardish arrest of motion, with some give to it, feeling like considered a four-point scale as de-
leather being stretched or as if two pieces of tough rubber
scribed. When the pain/resistance
were being squeezed together
scale was used for analysis of the
Tissue approximation Motion ends with a sensation suggesting that motion could
concept of chronicity, subjects without
continue if not stopped by one body part contacting another
pain on end-feel testing were
Springy block Noticeable rebound is seen andlor felt at end of motion
dropped from the analysis. Pain in OA
Bony An abrupt halt to movement as when two hard surfaces meet
does not correlate with stage of dis-
Spasm A vibrant twang suggesting that muscles have actively or
ease activity.5 Patients with early dis-
reflexively acted to end motion
ease may be pain-free, as may patients
Empty
Pain occurs before the end of motion and patient asks for the
with very advanced diseze,5 The
motion to stop; examiner feels no resistance
inclusion of a "no pain" category
Painlresistance sequence
would abrogate the ordinal nature of
1 No pain the scale as a measure of chronicity.
2 Pain occurs after resistance is felt by the examiner
3 Pain occurs at the same time that resistance is felt by the Pain intensity was measured by asking
examiner
subjects to mark a VAS6 representing
4 Pain occurs before resistance is felt by the examiner
their pain intensity on the previous
day. Chronicity was measured by
12 / 700 Physical Therapy /Volume 74, Number 8/August 1994
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Table 3. Extension and Flexion Ranges of Passive Motion (in Degrees)
Motion and
-
Tlme of Measurement X SD Range n
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 d for 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 mea-
surement sessions were used for
analysis. Although the 2-month inter-
val bemeen measurements is long,
subjects received no active interven-
tion 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 reli-
ability 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 Pear-
son correlation coefficients) ranging
from .91 to .977,8 and correlations (r)
ranging from .60 to .9OGS8 with other
measures of pain intensity. Chronicity
data were gathered by patient self-
report. 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 corre-
late 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 sub-
jects with capsular patterns (H:l),
capsular end-feels for both extension
and flexion (H:2), and painless end-
feels or 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 sub-
jects with spasm or capsular end-feels
@:4) and that the pain intensity of
subjects with spasm or empty end-
feels 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 pair-
wise comparisons.ll To examine the
relationship between the baseline
measures of pain/resistance sequence
and pain intensity (H:6) or chronicity
( H: 7) , Spearman rank correlation
coefficients (rho) were calculated.
The differences between passive ex-
tension and flexion ROM measure-
ments on the two occasions and test-
retest 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 Co-
hen's kappa coefficients.13 The alpha
level for all analyses was set at .05. AU
analyses were performed on a per-
sonal computer* using the SPSS statis-
tical package.+
Results
The descriptive statistics for passive
extension and flexion ROM are dis-
played in Table 3. At baseline, only 8
subjects displayed a capsular pattern
and 71 subjects displayed a noncapsu-
lar pattern. The frequencies of capsu-
lar 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 demonstrat-
ing 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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Table 4. Number of Subjects With Each Extension and Flexion End-feel
Tissue Springy
Capsular Approximation Block Bony Spasm Empty
Extension
Baselinea 59 0 4 5 7 4
Posttreatmentb 56 0 1 3 1 1
Follow-upb 45 0 2 2 3 0
Flexion
Baselinea 17 40 1 2 8 10
Posttreatmentb 1 1 38 2 1 3 4
Follow-upb 11 28 1 0 3 9
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 demonstrat-
ing 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 hypoth-
esis 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 differ-
ence 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
Pain After Pain With Pain Before
No Pain Resistance Resistance Resistance n
Extension
Baselinea [I 7dl [29 edl 62
Posttreatmentb 28 1 18 1 48
Follow-UP" 24 1 11 6 42
Flexion
Baselinea [I 7C sdl [29 1 1 62
Posttreatmentb 22 4 17 5 48
Follow-upb 17 2 17 5 41
"Used for validity analyses.
for reliability analyses.
'Category dropped for analysis of pain/resistance sequence as an indicator of chronicity.
d~ategories combined for analysis of paiwresistance sequence as an indicator of osteoarthritis.
category that combined pain with
resistance and pain before resistance.
Passive ROM of flexion differed de-
pending 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 coeffi-
cient 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 signifi-
cant) 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 exten-
sion and from .95 to .99 for knee
flexion. Passive extension and flexion
ROM did not differ between test occa-
sions (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 end-
feel were .17 and .48, respectively,
indicating slight agreement for exten-
sion and moderate agreement for
flexion.14 There were no significant
differences between the posttreatment
and follow-up measurements of pai d
resistance sequence for either exten-
sion (Z=-1.61) or flexion (Z=-0.65).
The kappa coefficients for the pain/
resistance sequence were .36 for
extension and .34 for flexion, indicat-
ing only fair agreement.14
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Table 6. Analysis-of-Variance Results for Passive Knee Extension Range of Motion
Source of Varlation dl SS MS F P
Examiner 1
Between people 2 1 1264.91 60.23 5.79 <.01
Within people 22 229.00 10.41
Between measures 1 1 1 .OO 11 .OO 1.06 NSa
Residual 21 218 00 10.38
Total 43 1493.91 34.74
ICCb(3,1)=.71
Examiner 2
Between people 6 369.43 61.57 14.62 < .01
Within people 7 29.50 4.21
Between measures 1 0.07 0.07 0.01 NS
Residual 6 29.43 4.90
Total 13 398.93 30 69
ICC(3,1)=.85
Examiner 3
Between people 17 1996.25 11 7.43 13.51 < .01
Within people 18 156.50 8.69
Between measures 1 8.03 8.03 0.92 NS
Residual 17 148.47 8.73
Total 35 2152.75 61.51
ICC(3,1)=.86
"NS=not significant.
b~~~=i nt racl ass 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 in-
volvement 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 major-
ity of these patients had not yet devel-
oped the capsular pattern. If the cap-
sular pattern did not develop until
very late in the disease, then the sys-
tem would not be of much assistance
in diagnosing OA. Cyriax stated, how-
ever, 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)
The relative absence of patients with a
capsular pattern is more likely a mat-
ter of definition. The method of defin-
ing 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 ob-
served 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 cap-
sular pattern. Most activities of daily
living do not require full flexion
ROM,I5 SO flexion ROM may be lost
more easily than extension ROM.
Function is affected by only a small
loss of e x t e n ~ i o n . ~ ~ J ~ Patients would
be inclined to retain more extension
ROM by using their knees in their
daily activities.
Cyriax used passive motion testing to
indicate the pattern of restriction and
as a provocation test, that is, to deter-
mine whether the application of force
reproduces the patient's pain.l@50j We
did not use passive motion assess-
ment as a provocation test, but we
believe that this omission did not
de c t the results substantially. Provo-
cation 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 exten-
sion. The end-feel for passive exten-
sion 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 deteri-
orated to the point that osteophyte
formation prevents motion. Springy
block end-feels might be expected if
the patient has an intra-articular de-
rangement, such as an impacted loose
body. The small number of patients
with bony end-feels for either exten-
sion or flexion may have resulted
from selection bias; some referring
physicians may have screened poten-
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-
ment appropriately guides diagnosis
or treatment selection.
Table 7. Analysis-ojvariance Results for Passiz.re Knee Flexion Range of Motion
Pain/resistance sequence. The
Source of Variation dl SS MS F f number of subjects with no pain on
overpressure supports Cyriax's con-
tention that passive motion is often
Exam~ner 1
painless in OA.l(pl1) The poor reliabil-
Between people 21 28219.73 1343.80 52.51
ity for the pain/resistance sequence
Within people 22 563.00 25.59
data makes it difficult to draw conclu-
Between measures 1 29.45 29.45 1.16 NSa
Residual 2 1 533.55 25.41
Total 43 28782.73 669.37
ICCb(3,1)=.96
Examiner 2
Between people 6 4735.43 789.24 98.66 <.01
Within people 7 56.00 8.00
Between measures 1 23.14 23.14 4.23 NS
Residual 6 32.86 5.48
Total 13 4791.43 368.57
ICC(3,1)=.99
Examiner 3
Between people 17 14440.25 849.43 32.63 <.01
Within people 18 468.50 26.03
Between measures 1 66.69 66.69 2.82 NS
Residual 17 401.81 23.64
Total
"NS=not significant.
h ~ ~ ~ = i n t r a c l a s s correlation coefficient.
tial subjects having radiographic evi-
dence of bony blockage.
The accuracy of the number of sub-
jects in each end-feel category is af-
fected by the poor estimates of the
reliability of the end-feel data. Be-
cause 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 diagnos-
tic indicator would likely lead to fre-
quent underdiagnosis of the
condition.
The assumptions underlying the cate-
gories of end-feel proposed by Cyriax
have not been studied. For example,
when the end-feel feels like leather
being stretched, Cyriax claimed that
capsule or ligament is stopping move-
ment, and when motion ceases
abruptly, he assumed that bone is
hitting bone.l@53) There is no evi-
dence, however, that structures identi-
fied 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 Rid-
dle20 proposed operational definitions
for descriptive end-feels. He sug-
gested that a soft end-feel demon-
strates a gradual increase in resistance
to movement at end-range; a firm
end-feel is an abrupt increase in end-
range resistance, and a hard end-feel
entails an immediate cessation of
movement at end-range. This nomen-
clature avoids the problem of assum-
ing what structure stops motion, but
the classification still must be studied
to determine whether such assess-
sions about the use of the paidresis-
tance 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 long-
standing, more of them were ex-
pected to demonstrate pain after re-
sistance. The paidresistance sequence
measure may have misclasslfied sub-
jects as having a moderately acute
condition. Alternatively, perhaps some
of these subjects had experienced an
event, such as an acute flare or un-
usual activity, that triggered an acute
response in their joints.
Cyriax might disagree with the diag-
nosis of the majority of these subiects,
and in some cases, he would proba-
bly be correct. In this study, medical
diagnosis of OA was used as the "gold
standard" for comparison Although
the combination of radiographic evi-
dence and clinical signs can have very
good sensitivity and specificity,' clini-
cal diagnosis is not flawless. Nonethe-
less, we advise against intrepreting the
variables examined in our study, es-
pecially a proportional definition of
the pattern of restriction, as sensitive
indicators of OA for treatment pur-
poses. According to our data, if the
capsular pattern were incorrectly
assumed to be highly sensitive and
I
specific for OA, such an assumption
would cause many false negative
results. As a consequence, patients
might be treated as if they had a re-
mediable. 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
5
ways. Patients would not be directed
toward self-management, joint protec-
tion, 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
Subjects with tissue approximation
end-feels had more ROM than sub-
jects with capsular end-feels, support-
ing a relationship between end-feel
and the underlying basis, or construct,
for joint motion. Subjects with tissue
approxirr~ation end-feels were ex-
pected to have more ROM than sub-
jects with spasm end-feels, but they
did not. In addition, subjects with
spasm or empty end-feels were ex-
pected to have more pain than sub-
jects with other types of end-feel, and
they did not report more pain. Bear-
ing in mind the poor reliability for
the end-feel data, these results tenta-
tively support Cyriax's claim that as
the disease progresses, the flexion
end-feel changes from tissue approxi-
mation to c a p ~ u l a r , ~ @p 5 ~ ~ ~ ~ ~ ) but refute
his idea that pain causes muscles to
act to limit motion.
Pain intensity on the previous day is a
composite of pain experienced during
rest and activity, both weight bearing
and non-weight bearing, and may not
be related to the level of pain experi-
enced during end-feel testing. The
relationship might be stronger if pain
intensity had been assessed at the
time of end-feel testing, as is com-
monly done clinically.
The correlation between pain/resis-
tance 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
~nrel i abi l i t y. ~~ Because no reliability
data were available for the pain mea-
sure, it was assumed to have been
measured without error. The cor-
rected Spearman rank correlation
coefficients were .58 for extension
and .52 for flexion. This outcome
suggests that the paidresistance se-
quence is related to pain intensity but
is nonredundant, contributing a
unique bit of information beyond
pain averaged over daily activity.
The correlation between pain/resis-
tance sequence and the number of
months of stiffness was extremely low,
suggesting that the paidresistance
sequence is not a measure of chronic-
ity. Even when corrected for unreli-
ability, assuming that the number of
months of stiffness was measured
without error, the correlation coeffi-
cients 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.
In this study, the measure of chronic-
ity was the length of time the patient
felt joint stiffness. In discussing the
paidresistance sequence, Cyriax re-
ferred to the activity of the
lesi0n.l@5~) Although the two con-
cepts are related, months of stiffness
may not reflect the chronicity of the
tissue reaction. Nonetheless, the lack
of correlation between paidresistance
sequence and months of stiffness
diminishes the validity of using the
paidresistance sequence to indicate
the chronicity of the lesion.
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 diagnos-
tic 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 general-
ized to other joints, similar studies
should examine different joints, par-
ticularly their capsular patterns.
Reliability
The reliability estimates for measure-
ments 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 ex-
tension and the inability of a goniom-
eter to account for the rotation of the
tibia that occurs as the knee com-
pletes e~t ensi on. ~5 This lower reliabil-
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 assess-
ments may have been low because
there was limited variability in the
group on both variables. Conse-
quently, chance agreement would be
high, decreasing the kappa coeffi-
~ i e n t . ~ ~ Kappa changes with the prob-
abilities of each of the possible cate-
gories and is best when the
probabilities are approximately equal.
The maximum possible kappa coeffi-
cient can be calculated for a given set
of marginal probabilities.13 Given the
distributions in this study, the maxi-
mum kappa coefficient would be .78
for extension end-feel, .78 for flexion
end-feel, .75 for paidresistance se-
quence in extension, and .88 for pai d
resistance in flexion. For both vari-
ables, the reliability estimates are
considerably below these values. The
reliability of the paidresistance se-
quence assessments may be low be-
cause the time interval between the
onset of pain and the onset of resis-
tance 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
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the same time period. We believe that
actual changes in end-feel and pai d
resistance sequence are unlikely. The
reliability of both end-feel and pai 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 examin-
ing tests that rely on physical thera-
pists' 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 vari-
ability in their sample. Chance agree-
ment, therefore, would be high but
was not reported.30 The results of this
study underscore the dependence of
validity on reliability. It must be possi-
ble to classlfy patients consistently in
the same category of end-feel or pai d
resistance sequence to have confi-
dence in relationships cited as evi-
dence for or 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 mo-
tion components of the soft tissue
diagnosis system proposed by Cyriax.
We examined validity by studying
whether the three passive motion
components were indicators of sub-
jects 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 reli-
ability of measurements of each of the
three components.
The results of this study provide evi-
dence of the need to question and
further examine selective tension
testing as a diagnostic system. Test-
retest reliability estimates were ac-
ceptable for passive ROM measure-
ments but not for end-feel and pai d
resistance sequence classification.
Very few subject. exhibited a capsular
pattern by Cyriax's quantitative defini-
tion. A proportional definition of a
capsular pattern should be aban-
doned, but the concept of a pattern of
ROM loss may be useful. When cor-
rected for unreliability, paidresistance
sequence is an indicator of pain in-
tensity but not chronicity. Poor reli-
ability estimates limit our ability to
interpret additional findings. For ex-
ample, more subjects retained tissue
approximation end-feels than pre-
dicted; fewer subjects had painless
end-feels or pain after resistance dur-
ing end-feel testing than predicted,
and end-feel was related to joint mo-
tion but not to pain intensity. More
investigation of selective tension test-
ing is needed to improve the reliabil-
ity and examine other facets of valid-
ity, particularly the use of the system
to guide treatment decisions.
Acknowledgments
We thank the Biostatistical and Data
Management Core of the Northwest-
ern 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 con-
sulting with us.
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Invited Commentary
James Cyriax's views on many aspects
of diagnosis and treatment still re-
main important within the areas of
manual therapy and orthopedic physi-
cal therapy. His position within physi-
cal medicine, his appointment at St
Thomas' Hospital in London, his for-
midable 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 contribu-
tion toward the development of or-
thopedic physical therapy, promoted
active physical therapy among his
medical colleagues, and added sub-
stantially to theory on the topic. At the
same time, it also seems certain that
this very dominance was counterpro-
ductive in a number of important
ways.
Cyriax was primarily a gifted clinician,
but many of his observations on pa-
thology, 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 thor-
ough understanding of the basic mor-
phology and subsequent pathological
change of the structures he so author-
itatively described. For these reasons,
it is very timely that Hayes and col-
leagues should objectively consider
Cyriax's passive motion tests for pa-
tients with osteoarthritis (OA) of the
knee.
It is extremely important for physical
therapists to critically review aspects
of current treatment dogma and sub-
ject 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 the-
ory development quickly became
established dogma, and were ac-
cepted with little questioning by at
least a generation of physical thera-
pists 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 prop-
erly 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 de-
scribed as being characteristic of
various manifestations of OA. The
information provided is clear, concise,
and informative and properly docu-
ments Cyriax's viewpoint. The authors
then carefully show how they set out
to review and examine both the con-
struct 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
29 Potter NA, Rothstein JM. Intenester reliabil-
ity for selected clinical tests of the sacroiliac
joint. Phys Ther 1985;65:1671-1675.
30 Patla CE, Paris SV. Reliability of interpreta-
tion of the Paris classification of normal end
feel for elbow flexion and extension. Journal
of Manual and Manipulative the rap.^. 1993;l:
60-66.
scope, something the authors readily
accept. The subjects were also part of
a study of the effects of ultrasound on
chronic soft tissue tightness, presum-
ably 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 exam-
ined 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 addi-
tional confounding variable to the
equation under consideration.
It is also puzzling to note that the
four examiners involved were se-
lected on the basis of their knowl-
edge 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 en-
sure 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 consider-
able drawback to the study, as it raises
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1994; 74:697-707. PHYS THER.
Karen W Hayes, Cheryl Petersen and Judith Falconer
With Patients Having Osteoarthritis of the Knee
An Examination of Cyriax's Passive Motion Tests
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