CYRIAX

TECHNIQUE
SUBMITTED TO SUBMITTED BY
Dr. Tarang Srivastava, PT Akanksha
Assoc. Prof. MPT 1 st year
Dept. of Physiotherapy
SGRRU
Introduction
Cyriax had a straightforward opinion about treating orthopaedic problems:
■ All pain arises from a source
■ All treatment must reach the source
■ All treatment must exert a beneficial effect on it.

It is obvious that the method of treatment will depend largely on the existing type of disorder.
Before any form of treatment is undertaken, precise diagnosis is mandatory; it is the type,
extent and position of the disorder present which determines treatment. Therefore, training in
orthopaedic medicine must put great emphasis on how to reach a proper diagnosis. It is more
difficult and requires considerable delicacy of approach to teach and learn how to diagnose and
so to propose therapy chosen on logical grounds, than it is to instruct and learn treatment
techniques.
Techniques
The treatment techniques used in orthopaedic medicine thus depend entirely on the type of
disorder. The different types of treatment we describe are:
■ Manipulation techniques (rapid, small-amplitude, thrusting passive movement – also called
‘grade C mobilization’) are used to reduce small cartilaginous displaced fragments both in
the spine and in peripheral joints (loose bodies). Manipulation is also called for to restore
normal mobility in a joint restricted by ligamentous adhesion and in subluxation of bones.
■ Gentle passive mobilizations (grade A and B mobilizations) are used to stretch capsular
adhesions and to improve the function of ligaments and tendons. In the treatment of
traumatic injuries, they are often used in combination with deep transverse massage.
■ Active movements and proprioceptive training are needed in the treatment of functional
disorders and instability. In the treatment of minor muscular tears they are very useful in
avoiding the formation of abnormal intralesional adhesion formation.
■ Injection and infiltration techniques are used to reduce traumatic or rheumatoid
inflammation. They are most valuable in arthritis, bursitis, ligamentous and tendinous
lesions and in neurocompression syndromes.
 Deep friction is a very useful technique in treating traumatic and overuse soft tissue
lesions. The rationale for using deep friction (which is in fact a form of soft tissue
mobilization) is supported by experimental studies of the past several decades that
confirm and explain the beneficial effects of activity on the healing musculoskeletal
tissues.
 
Deep transverse friction imposes cyclic loading without bringing too much tension on
the healing longitudinal structures of tendon or ligament and can therefore be
considered as beneficial.
Deep Transverse Friction
Deep transverse friction (although the word friction is technically incorrect and would be
better replaced by ‘massage’) is a specific type of connective tissue massage developed in
an empirical way by Cyriax.
Transverse massage is applied by the finger(s) directly to the lesion and transverse to the
direction of the fibres. It can be used after an injury and for mechanical overuse in
muscular, tendinous and ligamentous structures.4–6 In many instances the friction
massage is an alternative to infiltrations with steroids. Friction is usually slower in effect
than injections but leads to a physically more fundamental resolution, resulting in more
permanent cure and less recurrence. Whereas steroid injection is usually successful in 1–2
weeks, deep friction may require up to 6 weeks to have its full effect.
The technique is often used before and in conjunction with mobilization techniques.
In minor muscular tears, friction is usually followed by active movement, in
ligamentous tears by passive movement and in tendinous lesions by active unloaded
movements until full resolution has been achieved.
It is vital that transverse massage is performed only at the site of the lesion. The
effect is so local that, unless the finger is applied to the exact site and friction given
in the right direction, relief cannot be expected. Over the years, and unfortunately
enough, the technique has developed a reputation for being very painful for the
patient. However, pain during friction massage is usually the result of a wrong
indication, a wrong technique or an unaccustomed amount of pressure. Friction
massage applied correctly will quickly result in an analgesic effect over the treated
area and is seldom a painful experience for the patient.
Mode of action
Transverse massage should be used empirically for what it is and what it achieves;
there is no scientific proof for any postulates about the underlying mechanism of
action.
Transverse massage either is effective quickly (after 6–10 sessions) or not at all.
The exact mode of action is not known; some theoretical explanations have been put
forward. It has been hypothesized that friction has a local pain-diminishing effect and
results in better alignment of connective tissue fibrils.
Relief of pain
It is a common clinical observation that application of local transverse friction leads to
immediate pain relief – the patient experiences a numbing effect during the friction and
reassessment immediately after the session shows reduction in pain and increase in
strength and mobility. The time to produce analgesia during the application of
transverse friction is a few minutes and the post-massage analgesic effect may last
more than 24 hours. The temporary relief at the end of a session may prepare the
patient for treatment with mobilization not otherwise possible, such as selective
rupture of unwanted adhesions.
Indications and contraindications to friction
Indications Contraindication
Diagnostic difficulties Ossification and calcification of soft tissues
Preparative massage Bacterial and rheumatoid-type tendinitis,
tenosynovitis and tenovaginitis
Therapeutic massage: Skin problems such as ulcers, psoriasis or
 To muscle bellies blisters
 To musculotendinous junctions Neighbouring bacterial infection
 To tendons Bursitis and disorders of nerve structures
 To ligaments Haematoma, if large
 To joint capsules  
 
Technique
Introduction
Transverse massage is not an easy technique. In order to produce results, three
conditions must be satisfied.
First, the therapeutic movement should be applied to the exact site of the lesion which
may occupy only a very small volume of tissue. In other words, an identification of the
site to within 1 cm must be achieved which relies entirely on clinical diagnosis and
palpation of the lesion, based in turn on anatomical knowledge. In some instances, it
will be necessary to palpate carefully the entire structure at fault so as to find the point
that reproduces the patient’s pain.
Secondly, friction should be applied transversely across the longitudinally orientated
fibres, with sufficient sweep to reach all the affected tissue and firmly enough to
produce movement between the individual connective tissue fibres of the affected
structure.
Third, the movement can only reach deeply seated structures if the deep friction
technique of Cyriax is used; that implies attention must be paid to different elements
such as the position of the patient and of the therapist’s hand, which fingers are used,
the amount of pressure, the duration and frequency of the sessions.
The patient’s skin and the therapist’s finger must move as one, so that the deep layers
of the skin move over the affected fibres. Therefore, all cream, ointments, powder or
any other procedure, such as previous heat, that makes the skin sweat, must be
avoided. Six to 12 treatments are normally necessary. Except in acute ligamentous
disorders they are not given more often than every other day because otherwise the
site of the lesion may still be too tender from the previous treatment to permit
adequate massage.
Position of the patient
The patient’s position must be comfortable because it must be maintained for up to 15–
20 minutes. Sitting or lying is preferable. The lesion must be brought within finger’s
reach. In some structures this can be easily attained but others such as the
supraspinatus insertion and the anterior aspect of Achilles tendon, require more
specific positioning of the patient. In addition, positioning must place the affected
structure under the required amount of tension. Full relaxation is necessary for a
muscle belly in order not only to treat its surface but also to access a deeply seated
lesion. Tendons with a sheath must be kept taut otherwise friction will be ineffective
between tendon and sheath. The same applies in ligamentous lesions, which are also
placed in tension but within the limits of pain.
Position of the therapist and the hands
The bodily position of the patient should be the most comfortable and least tiring for the therapist.
Working height is of chief importance, so an adjustable high–low couch is ideal. To have some
economy of effort the therapist should adopt a position that utilizes body weight to a maximum.
Usually this is standing and with the patient on a slightly lower plane. The therapist should avoid
flexed positions. The shoulder should also not be in abduction because this quickly leads to pain and
cramp in the neck and shoulder girdle. Massage is performed by the whole arm and is not just an
activity of hand and digits. Movement is generated in the shoulder and conducted via elbow and
forearm to the digits. One set of muscles is used to apply force and another to provide movement, for
example pressure with the fingers, movement with the arms. Digits, hand and forearm should
generally form a straight line and are kept parallel to the direction of movement. The majority of
friction techniques are performed in two phases: an active movement, usually as a result of flexor
muscular activity and a passive movement, when the arm and hand are returned to the starting
position. At the end of the passive phase there should also be a moment of rest during which the
therapist fully relaxes the muscles. The hands can be used in a variety of ways depending on the
tissues to be treated and the surface worked on. The wrist and metacarpophalangeal joints should be
kept in an almost neutral position. The interphalangeal joints are slightly flexed to avoid traumatic
arthritis.
Three main techniques can be distinguished.
To-and-fro movements
These are used in the treatment of dense, round or flat collagenous bundles (tendons or ligaments)
and in the treatment of tenosynovitis. The active phase is a sweep with the tip(s) of one or two digits
across the tendinous structure. During the passive relaxation phase the finger is returned to the
starting position, without losing contact between finger and skin. Movement is with the arm; friction
is given by use of the pulpy part of the finger (Fig. 1). In large lesions, as in peroneal tendinitis, two or
three adjacent fingers are used together. In deep-seated lesions as in tendinitis of the long head of
biceps in the bicipital groove or at its insertion on the radius or in infraspinatus tendinitis, the thumb
performs friction.
Counterpressure is usually provided to enable a good sweep. The finger(s) applying counterpressure
and stabilization are most important in bringing those applying friction into the right position and
also determining the direction of the friction. The thumb is used (to give counterpressure) when the
sweep is performed by a movement of the index reinforced by the middle finger or the middle finger
aided by the index finger. When the thumb does the massage, counterpressure is from the fingers (Fig.
2). The most common way of applying friction around a round edge on a flat surface is to use the index
reinforced by the middle finger. Sometimes the opposite is done: the middle finger is reinforced by the
index. Sometimes counterpressure is not given, for example in friction to the quadriceps expansion or
intercostal muscles.
Figure 1. friction to the supraspinatus; counterpressure is by the thumb Figure 2. friction to the infraspinatus tendon; counterpressure
is by the fingers
Pronation–supination
This technique is often used where the lesion is difficult to reach: the anterior aspect of
the Achilles tendon, popliteus tendon and the dorsal interossei of the metacarpals.
Massage is performed with the pulpy part of the third finger (long finger), reinforced by
the index finger. The long finger is used because its long axis is the prolongation of the
axis of pronation– supination rotation of the forearm (Fig. 3). The active phase is
usually on supination. No counterpressure is given. Caution is taken not to move the
finger on the skin but rather to move the skin and the fingertip as a whole. The passive
phase is the pronation movement that brings the frictioning finger back to the starting
position without losing contact with the skin.
Figure 3. Active phase of pronation–supination friction technique to the anterior aspect of the
Achilles tendon. a, starting position; b, end of supination (active) movement
Pinch grip
This is the normal technique for a muscle belly. The pinch is between the thumb and the
other fingers. The muscle is fully relaxed. The fingers are placed at one side of the
affected area and the thumb at the opposite side (Fig. 4). By drawing the fingers
upwards over the affected area, the therapist feels the muscle fibres escape from the
grip until only skin and subcutaneous tissue remain. During the passive phase the
fingers are slightly relaxed and moved downwards into the previous deep position
where the same movement starts again. Sometimes the same technique is used in
tendinous lesions, for example, at the sides of the Achilles tendon.
Figure 4. Pinch grip friction to the Achilles tendon. a, starting position; b, end of active phase.
No movement between finger and skin is allowed
Deep friction can only be effective when skin and subcutaneous fascia are moved over
tendon ligaments or muscles. No movement is allowed between the therapist’s finger
and the patient’s skin. If movement occurs between finger and skin, blistering soon
takes place and usually indicates faulty technique. Sometimes it can be avoided by
keeping the skin dry by the use of 95% alcohol in water and/or by placing a piece of
cotton in between the finger and the skin. In the obese, subcutaneous soreness
and/or ecchymosis may occasionally occur and sometimes a nodule may form. For
this reason, the finger should not be in continuous contact with the same area but
should displace the skin slightly to one or other side, before pressure is applied.
Direction of friction must be transverse to the tissue fibres
Longitudinal massage improves the circulation of blood and lymph but has no effect on
musculoskeletal lesions. On the contrary, because lesions of tendons, muscles and ligaments
are normally caused by a longitudinal force, longitudinal massage can possibly be harmful in
that it may separate the ruptured ends further. To restore and/or maintain full mobility of a
lesion, massage must be given across the fibres, so moving all fibres in relation to each other.
To achieve this, the therapist must have a good anatomical knowledge of the direction of the
fibres.

Sweep
The main goal of friction is to move fibres in relation to each other and adjacent structures.
Enough sweep must be given to the friction for this purpose, so the frictioning finger starts
at the far side of the lesion, glides over it and ends at the near edge. Pressure alone, however
hard and painful it may be, is totally ineffective. Adequate sweep is sometimes limited by the
amount and elasticity of the overlying skin. Initial displacement of skin over the lesion from
the near to the far side may help increase sweep and reduce the risk of blistering.
Amount of pressure
Over recent decades, friction has been held in some disrepute in that it was perceived by
some as synonymous with very painful treatment. Though it cannot be claimed as wholly
painfree, the pain should not be unbearable. When excessive pain is provoked, this is
usually the result of a failure to understand the meaning of the term ‘deep’, which means
‘as deep as needed to reach the lesion’. Many therapists misinterpret this in such a way that
they feel that they always have to work hard physically, which obviously leads to pain and
may do more harm than good. The amount of pressure applied depends on three elements:
• The depth of the lesion: that friction must always reach sufficient depth to move the
affected fibres in relation to their neighbours and sometimes the underlying bone or
capsule, increased pressure must be applied to deeper structures.
• The ‘age’ of the lesion: recent sprains and injuries require only preventive friction
because crosslinks or adhesions have not had time to form. In long-standing cases more
pressure is needed to get rid of these. However, pressure should always be associated with
movement and should not replace it because pressure alone is both painful and ineffective.
• The tenderness of the lesion: in severely inflamed lesions that are very tender to touch,
friction with the usual amount of force may be very painful. Pain can be avoided by
starting with a minimal amount of pressure – just enough to reach the lesion – and
progressively increasing the force as treatment proceeds.
In order to avoid painful sessions of deep transverse friction it is good practice to grade
its application. Begin with a sweep that is gentle and continue this for a few minutes;
some numbness of the treated area follows which allows slight intensification of the
amount of pressure, which in turn leads to more numbness. Finally, it will be possible to
give effective massage that is practically painless to the patient.
Duration and frequency
Friction is usually given for about 10–20 minutes and, because of tenderness, on every
second day. The ideal timing of the next treatment is when local tenderness caused by
the previous session has resolved. If tenderness persists after 2 days, the pressure used
during friction should not be diminished but the interval between sessions must be
increased. Massage immediately after a ligamentous sprain or a minor muscular rupture
may be applied daily for the first week but should be of very low intensity and short
duration. Treatment is stopped once the patient is pain-free during daily activities and
functional tests are totally negative. Local tenderness may persist longer but disappears
spontaneously because it is the outcome of repetitive hard pressure. However, in a minor
lesion of a muscle belly, massage is continued for 1 week after full clinical recovery to
prevent recurrence.
Passive movements
Treatment by passive movement is otherwise known as mobilization. It cannot be
performed by the patient and requires the intervention of a therapist. Depending on
its velocity and the range of movement that is aimed for, it can be graded as A, B and C
mobilization:
 Grade A mobilization is a passive movement performed within the pain-free range.
 Grade B mobilizations are passive movements performed to the end of the
possible range. The latter is indicated by an end-feel. All stretching and traction
techniques are grade B mobilizations.
 Grade C mobilization is a minimal thrust with a high velocity and over a small
amplitude. It is performed at the end of the possible range, i.e. the moment the
therapist has reached the end-feel. Another word for grade C mobilization is
manipulation.
Indications
Grade A mobilizations
 To promote healing of injured connective tissue
 Distractions at the shoulder
 Deformity correction
 Reduction of an intra-articular displacement in a peripheral joint
Grade B mobilizations
 To maintain a normal range at the joint
 To stretch the capsule of a joint
 To stretch a muscle
 Traction
Grade C mobilizations
 Rupture of ligamentous adhesions
 Rupture of tenoperiosteal adhesions
 To reduce a bony subluxation
Contraindications to forced movements
 Capsular inflammation
 Muscle spasm
 Severe osteoporosis
 Joints and ligaments not under voluntary tension control
Manipulation of the spine
Introduction
Spinal manipulative therapy includes all procedures of mobilizing or adjusting the spine by means of
the hands. As in the peripheral joints, grade A and B mobilizations are movements of low velocity
with varying amplitude but remaining within physiological limits and within the patient’s tolerance
and control. A manipulation or grade C mobilization usually implies a single thrust of high velocity
performed at the end of a passive movement after the ‘slack’ has been taken up, and over a small
amplitude. It goes beyond the physiological limit but remains within the anatomical range. Precision
of the movement and control of the applied force are required. Spinal manipulative therapy is a
valuable method in the treatment of mechanical spinal disorders. Although it has not been
scientifically validated, some studies have shown beneficial effect.37–40 However, its potential
benefit should not be overestimated and the indications must be well defined and based on a sound
clinical diagnosis. It must never be done as a test to see if it is effective. Therefore, it should not be
used on all those with back and neck pain although it may well cure a proportion who actually
require it.
Manipulation either helps quickly or not at all. Therefore, if improvement does not occur after one or
two sessions, manipulation is not likely to be successful and it is pointless to continue with it.
Orthopaedic medicine technique
Before any manipulation is done an exact diagnosis must be made. The decision to
manipulate is followed by choice of the correct manœuvre. The patient is put in a
comfortable position and the manipulator adopts a stable stance. The floor and shoes
should not be slippery, so that there is no risk of inappropriate movement. Attention
must be given to the following general matters, which are important for all
manipulations.
Traction during manipulation
Most types of spinal manipulation in orthopaedic medicine are performed under
traction. For the cervical and thoracic spine, traction is applied by the manipulator with
the help of a fixing belt or by one or two assistants. At the lumbar level, traction is
usually already built into the manœuvre. Traction facilitates the reduction of a displaced
fragment and provides an important safety element against the possibility of a
protrusion contacting the spinal cord during manipulation.
End-feel on taking up the ‘slack’
All spinal manipulations are performed over only a small amplitude. Therefore, all
‘slack’ must be taken up by moving the vertebral joints passively to the end of the
normal passive range of movement. At this stage it is absolutely necessary to have a
clear idea of the end-feel, which is nominally elastic for the entire spine. An end-feel
that does not correspond with this – muscle spasm, or hard or empty end-feel – is an
absolute contraindication to any manipulation and the manœuvre is not continued.
Final thrust
Immediately after the slack has been taken up in the surrounding tissues, a minimal
amplitude, high-velocity thrust is given to affect the target tissue. The velocity is of
great importance because tissues loaded quickly are stiffer so that the manœuvre will
affect only the displaced fragment of disc and will not damage the surrounding
structures. The amount of force used for the final thrust depends mainly on the patient
and manipulator in that a tall manipulator will have to use less force in a small patient
and vice versa. The force should always be kept reasonable and may be progressively
increased, according to the immediate result.
Leverage
The amount of force used depends on the length of the lever. If for example a rotation
of the lumbar spine is forced via the shoulder and pelvis, the lever offered by the
shoulder is the same length as that offered by the pelvis, so an equal amount of force
must be used by both hands. But if the femur is used instead of the pelvis, the length of
the pelvic lever doubles. The hand on the shoulder must apply double the amount of
force that is used on the knee. The longer the lever, the less force is needed.
 
 Is the lesion discodural or discoradicular?
Reassessment Is the lesion an indication for manipulation?
Are there contraindications?
Does the patient have a positive attitude?

Decision to manipulate

choice of manoeuvre

Positions of patient and manipulators determined

Technique
Take up the slack
Check end-feel
Thrust
Reasssess
Selectivity of a manipulative treatment
Selectivity of diagnosis
Diagnosis is mainly based on segmental mobility tests: joint play, springing test or tests
of passive physiological movements. Movement can be tested by exerting local pressure
at one side of a vertebra while counterpressure is applied to the contralateral side of the
vertebra above or below. For the lumbar spine, it can be done with the patient on the
side with both hips flexed to 90°. Small movements of the thighs cause the lumbar spine
to flex or extend which can be detected by palpation of the spinous processes.
Other practitioners look mainly for palpable soft tissue changes, such as local
subcutaneous thickening or exquisite tender spots (trigger points) in muscles,
ligaments (iliolumbar, sacroiliac) and over bony prominences. All these are considered
to be important diagnostic and therapeutic factors.
Selectivity of manipulation
Manipulation is often accompanied by immediate relief of symptoms and signs which, since
success has been obtained, is logically taken as absolute confirmation of the precision of diagnosis
and treatment. Such a deduction may be – and often is – totally wrong. The only thing proved is
that the manipulation was efficacious. The erroneous reasoning that successful manipulation
necessarily confirms the diagnosis has been and is still today an important argument for the false
belief of some schools that manipulation can cure all kinds of disorders even including visceral
diseases. A typical example is pectoral pain, resulting from a thoracic discodural interaction which
is misdiagnosed as angina. The patient goes to an osteopath who manipulates the thoracic spine
and the pectoral pain ceases immediately. Both patient and manipulator, misled by the wrong
diagnosis, will believe that the manipulation has altered autonomic tone and cured the angina,
whereas what it actually did was interrupt the discodural interaction. In orthopaedic medicine
most manœuvres used are nonspecific long-lever manipulations. These include all procedures in
which a force is exerted on a part of the body some distance away from the area where it is
expected to have its beneficial effect.
Non-specific long-lever manipulations are quickly effective, do not take long to perform and are
simple to learn. Moreover, they can take only about 180 hours of tuition, provided that the student
has already gained qualifications in medicine or physiotherapy.
Mode of action of spinal manipulation
To date, the mode of action of manipulation has not been totally clarified, although
many different models have been put forward. All pose unsolved questions, lack
objective confirmation and are subject to dispute. Different attitudes towards spinal
disorders determine theories and explanations.
We strongly believe that spinal pain is the result of disc protrusion that gives rise to a
conflict between the posterocentral or posterolateral rim of the disc and the pain-
sensitive dura mater or dural nerve sleeve, and that a displaced fragment of an
intervertebral disc can be moved by manipulation. This was the hypothesis of Cyriax
and Maigne and has been supported by the observations of Mathews and Yates, who
have shown by epidurography that in acute lumbago small lumbar disc protrusions
diminished in size after manipulation. Manipulative interruption of contact, moving
the displaced cartilaginous rim away from sensitive structures, is the objective for
relief of pain and is best obtained by a non-specific long-lever, high-velocity
manipulation.
Indications for spinal manipulation
Spinal manipulation is useful for all annular disc protrusions in the absence of any
contraindications or of any signs or symptoms that indicate that manipulative reduction
would not succeed. All these factors may vary for the cervical, thoracic and lumbar spine.

Contraindications to spinal manipulation

 Bleeding disorders and anticoagulant use
 Spinal tumours, unstable fractures, vertebral infections and severe osteoporosis
 Rheumatoid arthritis, psoriatic arthritis, Reiter’s syndrome and ankylosing spondylitis
 Neurological deficit and spinal cord compression
 Hypermobility
 Spinal manipulation under anaesthesia

 Complications of spinal manipulation

 Postmanipulation pain
 Increased pain
 Fracture
 Onset of neurological deficit
 Vascular interference and cord compression
Measures to prevent complications
History:
 Exclude anticoagulants
 Check for warning signs
 Ascertain duration of root pain
Clinical examination:
 Check for warning signs
 Assess end-feel
 Exclude neurological deficit
Radiographic appearances:
 Exclude structural alterations
 Do not rely on radiography alone; negative radiography does not guarantee absence of disease
When manipulating:
 Avoid dangerous techniques
 Check end-feel
 Use traction
 Start gently
 Reassess after each manipulation
 Do not overtreat
Thank You