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The Cyriax Approach to Orthopaedic Manual Physical Therapy

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Sreeraj S R
Sreeraj S R

An overview on The Cyriax Approach to Orthopaedic Manual Physical Therapy for undergraduate physiotherapy students

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The Cyriax Approach to Orthopaedic Manual Physical Therapy Dr Sreeraj S R, Ph.D.
Sreeraj S R History • Dr James H Cyriax (1904-1985), an orthopaedic surgeon in London, was the first to approach the study of soft tissue injuries in a systemic way. • He laid out the foundation of a method of logical, clinically reasoned, differential diagnosis, which he called “selective tissue tension testing”.
Sreeraj S R Principles • The Principles of Cyriax concept are; 1. All pain arises from a lesion. 2. All treatment must reach the affected site. 3. All treatment must exert a beneficial effect on the affected site.
Sreeraj S R Core Concept 1. A good understanding of the phenomenon "referred pain“ 2. Examination by Selective Tissue Tension Test • Cyriax had three principles for examination by Selective Tissue Tension Test. 1. Passive movements test the function of the inert structures. 2. Capsular patterns differentiate between joint conditions and other inert structure lesions. 3. Isometric contractions test the function of the contractile tissues.
Sreeraj S R Contractile and Non-contractile Tissues • Contractile Structure • It includes muscles and its attachment. • Pain may be elicited by active contraction as well as passive stretching in opposite directions. • Non-contractile • These tissues posses no inherent capacity to contract and relax. • Extreme range of active movements will stretch the structures causing pain. • Testing a muscle in its neutral position eliminates the pain of impingement and instability.
Sreeraj S R Capsular Pattern • A distinctive feature of the Cyriax method is the capsular pattern. • Each joint has its own distinctive capsular pattern associated with injury. • This capsular pattern denotes inflammation due to injuries. • A non-capsular pattern implies that the capsule is not involved, and that intra - or extra - articular tissue is the source of pain due to inflamation or injury.
Sreeraj S R Selective Tissue Tension Testing (STT) Wise CH (2015)
Sreeraj S R Treatment • Treatment depends largely on the existing type of disorder and can be categorized as: Traumatic, inflammatory, degenerative, internal derangement, functional disorders, psychogenic pain. • The types of treatment options are: 1. Deep friction 2. Passive movements 3. Active movements and proprioceptive training 4. Injection and infiltration techniques
Sreeraj S R Deep Friction Massage • There are two forms of treatment. 1. The longitudinal in which the application of force runs parallel to fibers of the soft tissue structures. 2. The transverse friction massage in which the force is applied perpendicular to the fibers, separate each fiber, assisting in alignment of newly-formed collagen during healing. • Friction; • Should be applied with sufficient sweep to reach all the affected tissue and • Should produce movement between the individual connective tissue fibers of the affected structure.
Sreeraj S R Deep Friction Massage 1. No movement between finger and skin is allowed 2. The main goal of friction is to move fibres in relation to each other and adjacent structures, called Sweep. 3. Amount of pressure: The amount of pressure applied depends on three elements: 1. The depth of the lesion: increased pressure must be applied to deeper structures. 2. 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. 3. The tenderness of the lesion: 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. 4. Duration and frequency: 1. usually given for about 10–20 minutes and on every second day. 2. Massage immediately after an injury should be of very low intensity and short duration. 3. Treatment is stopped once the patient is pain-free during daily activities and functional tests are totally negative.
Sreeraj S R Deep Friction Massage • Effects • Increased blood supply relieves pain. • By moving the painful structure to and fro, helps to free it from adhesion. • The structures moved in the limitation of normal behavior but not stretched. • It increases tissue perfusion at damaged area and stimulates mechanoreceptor cells. • Friction itself is a painful technique.
Sreeraj S R Deep Friction Massage • Position of the Patient • The patient's position must be comfortable, and the lesion must be within finger's reach, • Full relaxation is necessary for a muscle belly to access a deeply seated lesion. • Tendons with a sheath must be kept taut. • Position of the Therapist and the Hands • The therapist should avoid flexed positions. • Movement is generated in the shoulder and conducted via elbow and forearm to the digits. Friction to the supraspinatus tendon: counterpressure is by the thumb. Friction to the infraspinatus tendon: counterpressure is by the fingers.
Sreeraj S R Deep Friction Massage • Three main techniques can be distinguished. 1. To-and-fro Movements 2. Pronation-supination 3. Pinch Grip
Sreeraj S R Deep Friction Massage • 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. • Movement is with the arm; friction is given by use of the pulpy part of the finger • Counterpressure is usually provided to enable a good sweep. Friction to the supraspinatus tendon: counterpressure is by the thumb.
Sreeraj S R Deep Friction Massage • Pronation-supination • Used where the lesion is difficult to reach • For Example: the anterior aspect of the Achilles tendon • Is performed with the pulpy part of the third finger reinforced by the index finger. • No counterpressure is given. Active phase of pronation–supination friction technique to the anterior aspect of the Achilles tendon. a. starting position; b. end of supination. a b
Sreeraj S R Deep Friction Massage • Pinch grip • Normal technique for a muscle belly which is fully relaxed. • The pinch is between the thumb and the other fingers • 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. Pinch grip friction to the Achilles tendon
Sreeraj S R Passive movements • Treatment by passive movement is otherwise known as mobilization. • Depending on its velocity and the range of movement, it can be graded as: 1. Grade A 2. Grade B 3. Grade C
Sreeraj S R Passive movements • Grade A mobilization is a passive movement performed within the pain-free range. • Indications 1. To promote healing of injured connective tissue: Grade A mobilizations are applied early in the treatment of sprained ligaments to promote orientation of the regenerating fibres. 2. Distractions at the shoulder: Gentle and rhythmical grade A movements stretch the arthritic joint capsule fibres longitudinally, stimulate the mechanosensor mechanisms in the joint and so inhibiting somatosympathetic reflexes that are co-responsible for the vasoconstriction, muscle spasm, pain and increased inflammation of the joint. 3. Reduction of an intra-articular displacement in a peripheral joint: elements of traction combined with joint rotations/movements in the less painful direction and repeated several times with progressively increasing force.
Sreeraj S R Passive movements • Grade B mobilizations are passive movements performed to the end of the possible range indicated by an end-feel. All stretching and traction techniques are grade B mobilizations. • Indications 1. To maintain a normal range at the joint: Passive Movements with gentle stretching of the capsule, starting as soon as possible after the onset of paralysis, injury or surgery to prevent loss of capsular elasticity. 2. To stretch the capsule of a joint: Useful in all ‘non-irritable’ capsulitis where the condition is characterized by capsular pattern with hard-elastic end-feel. Stretching aims at restoring mobility and function by breaking micro-adhesions and stretching of shortened capsule. 3. To stretch a muscle: Children with short calf muscles can be helped by sustained stretching followed by full relaxation and active contraction of the muscle. 4. Traction: Traction is used to separate articular surfaces from each other. Can be used for reducing a displaced fragment by increasing joint space, pain reduction, relax of the muscle.
Sreeraj S R Passive movements • Grade C mobilization is a minimal thrust with a high velocity and over a small amplitude performed at the end of the possible range OR end-feel. Another word for grade C mobilization is manipulation. • Indications • Rupture of ligamentous adhesions: Small ligamentous adhesions from immobilizations can be ruptured by a high-velocity, small-amplitude thrust manipulation, along with intensive deep transverse friction. The joint is stretched as far as possible in the limited direction and manipulated with a single firm thrust, during which a typical ‘snap’ is often heard. • Rupture of tenoperiosteal adhesions: Aadherent and disorganized scar tissue which causes a self-perpetuating inflammation in conditions like Tendinitis (e.g. Tennis Elbow) can be ruptured to produce a permanent elongation of the tendon. . • To reduce a bony subluxation: A subluxation of one of the carpal bones or of the cuboid bone can easily be reduced by digital pressure combined with translatory movement during traction.
Sreeraj S R Contraindications to forced movements • Capsular inflammation • Muscle spasm: Grade C mobilizations is absolute Contraindication. Grade B mobilizations may be used. • Severe osteoporosis: Grade B and C mobilizations should always be carried out with caution for fear of avulsion fracturing. • Joints and ligaments not under voluntary tension control: This is the case for the acromioclavicular, the sternoclavicular and the sacroiliac joints and the sacrococcygeal ligament.
Sreeraj S R Active movements • Physical activity is also the primary stimulus for the repair of musculoskeletal tissues especially during immobilization on skeletal muscle, tendon, ligament, joint capsule and articular cartilage. • These are in the form of; 1. Simple active movements to gain or preserve normal range in a joint 2. Isometric contractions 3. Isotonic contractions 4. Coordination exercises 5. Electrical contractions
Sreeraj S R Active movements • Simple active movements to gain or preserve normal range in a joint • Immobilization can lead to; • Capsular and ligamentous tightness or adhesion • Muscle shortening and wasting • Development of arthritis • Moving the joint early in injured as well as noninjured direction helps to maintain tissue integrity.
Sreeraj S R Active movements • Isometric contractions • Isometric contraction is the development of tension within a muscle without significant change in its fibre length, joint motion or work. • They are mainly performed to strengthen/stabilizing muscle groups early in injury. • Example is in treatment of shoulder instability: in order to provide a firm foundation for the scapula, the muscles of the shoulder girdle (trapezius, serratus anterior, rhomboids and pectoralis minor) are strengthened by isometric training.
Sreeraj S R Active movements • Isotonic contractions • Isotonic exercise is classically defined as the movement of a load at constant resistance through an arc of motion. • They are performed in the following situations: • In minor muscular tears after the lesion has been prepared by gentle transverse friction • To strengthen weakened muscles as in arthritis or after local or generalized immobilization. • To strengthen muscles so they can protect joints or inert structures from being painfully overstretched.
Sreeraj S R Active movements • Coordination exercises • A better coordination exercises of muscle groups should be included in the rehabilitation programe to deal with the problems of instability (e.g., in shoulder, knee and ankle). • The ability to control the position of a joint during active motions (proprioception) and to produce a voluntary muscular contraction to stabilize the joint and/or to alter the joint position to prevent excessive joint displacements is referred to as reactive neuromuscular control. • Most functional training techniques used to re-establish the proprioceptive skills make use of eccentric training in which the muscle–tendon unit is lengthened while active. Small weights and multiple repetitions of the movements are used. • PNF techniques may be used as a method promoting or hastening the neuromuscular mechanism through stimulation of the proprioceptors.
Sreeraj S R Active movements • Electrical contractions • In circumstances where a strong voluntary muscle contraction is not possible due to paralysis, paresis or severe injury daily application of electrical stimulation (ES) may retard the loss of muscle strength or even improve it in already weakened musculature. • The gains are not long-lasting, however, and electrical stimulations should only be used temporarily while awaiting neurological recovery.
Sreeraj S R Injection and infiltration techniques • In orthopaedic medicine three types of product are used: 1. Local anesthetics: Commonly used are procaine bupivacaine and lidocaine/lignocaine 2. Corticosteroids: The ability to suppress inflammation has made the glucocorticoids very useful but also potentially harmful. 3. Sclerosing agents: Chemical agents such as phenol and dextrose are infiltrated into weakened ligaments and tendons in order to create the formation of strong, thickened fibrous tissue. Because of its proliferative effect on connective tissue, the technique is called prolotherapy or sclerotherapy. • In Injection the tip of the needle is placed in exactly the right place and all the product is deposited at one single push, as is done in an ordinary intramuscular injection. This technique is mainly used for intra-articular and caudal epidural injections. • In Infiltration a drug is locally administered into a structure, as in bursitis, tendinitis, tenosynovitis, tenovaginitis, lesions of a muscle belly and also in ligamentous problems.
Sreeraj S R Reference 1. Ludwig O. Chapter 5. Principles of Treatment. A System of Orthopaedic Medicine, 3rd Ed. London, Elsevier, 2013, pp. 83– 115. 2. Yadav A. Chapter-05, Cyriax Mobilization Techniques. In: Advanced Techniques In Physiotherapy And Occupational Therapy. 1st ed. S.L.: Jaypee Brothers Medical P; 2019. p. 24– 32. 3. Woodman R. Chapter 5, The Cyriax Approach. In: Orthopaedic manual physical therapy : from art to evidence by Wise CH. 1st ed. Philadelphia, Pa: F.A. Davis Company; 2015. p. 110–29.
Thank You

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The Cyriax Approach to Orthopaedic Manual Physical Therapy

  • 1. The Cyriax Approach to Orthopaedic Manual Physical Therapy Dr Sreeraj S R, Ph.D.
  • 2. Sreeraj S R History • Dr James H Cyriax (1904-1985), an orthopaedic surgeon in London, was the first to approach the study of soft tissue injuries in a systemic way. • He laid out the foundation of a method of logical, clinically reasoned, differential diagnosis, which he called “selective tissue tension testing”.
  • 3. Sreeraj S R Principles • The Principles of Cyriax concept are; 1. All pain arises from a lesion. 2. All treatment must reach the affected site. 3. All treatment must exert a beneficial effect on the affected site.
  • 4. Sreeraj S R Core Concept 1. A good understanding of the phenomenon "referred pain“ 2. Examination by Selective Tissue Tension Test • Cyriax had three principles for examination by Selective Tissue Tension Test. 1. Passive movements test the function of the inert structures. 2. Capsular patterns differentiate between joint conditions and other inert structure lesions. 3. Isometric contractions test the function of the contractile tissues.
  • 5. Sreeraj S R Contractile and Non-contractile Tissues • Contractile Structure • It includes muscles and its attachment. • Pain may be elicited by active contraction as well as passive stretching in opposite directions. • Non-contractile • These tissues posses no inherent capacity to contract and relax. • Extreme range of active movements will stretch the structures causing pain. • Testing a muscle in its neutral position eliminates the pain of impingement and instability.
  • 6. Sreeraj S R Capsular Pattern • A distinctive feature of the Cyriax method is the capsular pattern. • Each joint has its own distinctive capsular pattern associated with injury. • This capsular pattern denotes inflammation due to injuries. • A non-capsular pattern implies that the capsule is not involved, and that intra - or extra - articular tissue is the source of pain due to inflamation or injury.
  • 8. Sreeraj S R Treatment • Treatment depends largely on the existing type of disorder and can be categorized as: Traumatic, inflammatory, degenerative, internal derangement, functional disorders, psychogenic pain. • The types of treatment options are: 1. Deep friction 2. Passive movements 3. Active movements and proprioceptive training 4. Injection and infiltration techniques
  • 9. Sreeraj S R Deep Friction Massage • There are two forms of treatment. 1. The longitudinal in which the application of force runs parallel to fibers of the soft tissue structures. 2. The transverse friction massage in which the force is applied perpendicular to the fibers, separate each fiber, assisting in alignment of newly-formed collagen during healing. • Friction; • Should be applied with sufficient sweep to reach all the affected tissue and • Should produce movement between the individual connective tissue fibers of the affected structure.
  • 10. Sreeraj S R Deep Friction Massage 1. No movement between finger and skin is allowed 2. The main goal of friction is to move fibres in relation to each other and adjacent structures, called Sweep. 3. Amount of pressure: The amount of pressure applied depends on three elements: 1. The depth of the lesion: increased pressure must be applied to deeper structures. 2. 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. 3. The tenderness of the lesion: 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. 4. Duration and frequency: 1. usually given for about 10–20 minutes and on every second day. 2. Massage immediately after an injury should be of very low intensity and short duration. 3. Treatment is stopped once the patient is pain-free during daily activities and functional tests are totally negative.
  • 11. Sreeraj S R Deep Friction Massage • Effects • Increased blood supply relieves pain. • By moving the painful structure to and fro, helps to free it from adhesion. • The structures moved in the limitation of normal behavior but not stretched. • It increases tissue perfusion at damaged area and stimulates mechanoreceptor cells. • Friction itself is a painful technique.
  • 12. Sreeraj S R Deep Friction Massage • Position of the Patient • The patient's position must be comfortable, and the lesion must be within finger's reach, • Full relaxation is necessary for a muscle belly to access a deeply seated lesion. • Tendons with a sheath must be kept taut. • Position of the Therapist and the Hands • The therapist should avoid flexed positions. • Movement is generated in the shoulder and conducted via elbow and forearm to the digits. Friction to the supraspinatus tendon: counterpressure is by the thumb. Friction to the infraspinatus tendon: counterpressure is by the fingers.
  • 13. Sreeraj S R Deep Friction Massage • Three main techniques can be distinguished. 1. To-and-fro Movements 2. Pronation-supination 3. Pinch Grip
  • 14. Sreeraj S R Deep Friction Massage • 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. • Movement is with the arm; friction is given by use of the pulpy part of the finger • Counterpressure is usually provided to enable a good sweep. Friction to the supraspinatus tendon: counterpressure is by the thumb.
  • 15. Sreeraj S R Deep Friction Massage • Pronation-supination • Used where the lesion is difficult to reach • For Example: the anterior aspect of the Achilles tendon • Is performed with the pulpy part of the third finger reinforced by the index finger. • No counterpressure is given. Active phase of pronation–supination friction technique to the anterior aspect of the Achilles tendon. a. starting position; b. end of supination. a b
  • 16. Sreeraj S R Deep Friction Massage • Pinch grip • Normal technique for a muscle belly which is fully relaxed. • The pinch is between the thumb and the other fingers • 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. Pinch grip friction to the Achilles tendon
  • 17. Sreeraj S R Passive movements • Treatment by passive movement is otherwise known as mobilization. • Depending on its velocity and the range of movement, it can be graded as: 1. Grade A 2. Grade B 3. Grade C
  • 18. Sreeraj S R Passive movements • Grade A mobilization is a passive movement performed within the pain-free range. • Indications 1. To promote healing of injured connective tissue: Grade A mobilizations are applied early in the treatment of sprained ligaments to promote orientation of the regenerating fibres. 2. Distractions at the shoulder: Gentle and rhythmical grade A movements stretch the arthritic joint capsule fibres longitudinally, stimulate the mechanosensor mechanisms in the joint and so inhibiting somatosympathetic reflexes that are co-responsible for the vasoconstriction, muscle spasm, pain and increased inflammation of the joint. 3. Reduction of an intra-articular displacement in a peripheral joint: elements of traction combined with joint rotations/movements in the less painful direction and repeated several times with progressively increasing force.
  • 19. Sreeraj S R Passive movements • Grade B mobilizations are passive movements performed to the end of the possible range indicated by an end-feel. All stretching and traction techniques are grade B mobilizations. • Indications 1. To maintain a normal range at the joint: Passive Movements with gentle stretching of the capsule, starting as soon as possible after the onset of paralysis, injury or surgery to prevent loss of capsular elasticity. 2. To stretch the capsule of a joint: Useful in all ‘non-irritable’ capsulitis where the condition is characterized by capsular pattern with hard-elastic end-feel. Stretching aims at restoring mobility and function by breaking micro-adhesions and stretching of shortened capsule. 3. To stretch a muscle: Children with short calf muscles can be helped by sustained stretching followed by full relaxation and active contraction of the muscle. 4. Traction: Traction is used to separate articular surfaces from each other. Can be used for reducing a displaced fragment by increasing joint space, pain reduction, relax of the muscle.
  • 20. Sreeraj S R Passive movements • Grade C mobilization is a minimal thrust with a high velocity and over a small amplitude performed at the end of the possible range OR end-feel. Another word for grade C mobilization is manipulation. • Indications • Rupture of ligamentous adhesions: Small ligamentous adhesions from immobilizations can be ruptured by a high-velocity, small-amplitude thrust manipulation, along with intensive deep transverse friction. The joint is stretched as far as possible in the limited direction and manipulated with a single firm thrust, during which a typical ‘snap’ is often heard. • Rupture of tenoperiosteal adhesions: Aadherent and disorganized scar tissue which causes a self-perpetuating inflammation in conditions like Tendinitis (e.g. Tennis Elbow) can be ruptured to produce a permanent elongation of the tendon. . • To reduce a bony subluxation: A subluxation of one of the carpal bones or of the cuboid bone can easily be reduced by digital pressure combined with translatory movement during traction.
  • 21. Sreeraj S R Contraindications to forced movements • Capsular inflammation • Muscle spasm: Grade C mobilizations is absolute Contraindication. Grade B mobilizations may be used. • Severe osteoporosis: Grade B and C mobilizations should always be carried out with caution for fear of avulsion fracturing. • Joints and ligaments not under voluntary tension control: This is the case for the acromioclavicular, the sternoclavicular and the sacroiliac joints and the sacrococcygeal ligament.
  • 22. Sreeraj S R Active movements • Physical activity is also the primary stimulus for the repair of musculoskeletal tissues especially during immobilization on skeletal muscle, tendon, ligament, joint capsule and articular cartilage. • These are in the form of; 1. Simple active movements to gain or preserve normal range in a joint 2. Isometric contractions 3. Isotonic contractions 4. Coordination exercises 5. Electrical contractions
  • 23. Sreeraj S R Active movements • Simple active movements to gain or preserve normal range in a joint • Immobilization can lead to; • Capsular and ligamentous tightness or adhesion • Muscle shortening and wasting • Development of arthritis • Moving the joint early in injured as well as noninjured direction helps to maintain tissue integrity.
  • 24. Sreeraj S R Active movements • Isometric contractions • Isometric contraction is the development of tension within a muscle without significant change in its fibre length, joint motion or work. • They are mainly performed to strengthen/stabilizing muscle groups early in injury. • Example is in treatment of shoulder instability: in order to provide a firm foundation for the scapula, the muscles of the shoulder girdle (trapezius, serratus anterior, rhomboids and pectoralis minor) are strengthened by isometric training.
  • 25. Sreeraj S R Active movements • Isotonic contractions • Isotonic exercise is classically defined as the movement of a load at constant resistance through an arc of motion. • They are performed in the following situations: • In minor muscular tears after the lesion has been prepared by gentle transverse friction • To strengthen weakened muscles as in arthritis or after local or generalized immobilization. • To strengthen muscles so they can protect joints or inert structures from being painfully overstretched.
  • 26. Sreeraj S R Active movements • Coordination exercises • A better coordination exercises of muscle groups should be included in the rehabilitation programe to deal with the problems of instability (e.g., in shoulder, knee and ankle). • The ability to control the position of a joint during active motions (proprioception) and to produce a voluntary muscular contraction to stabilize the joint and/or to alter the joint position to prevent excessive joint displacements is referred to as reactive neuromuscular control. • Most functional training techniques used to re-establish the proprioceptive skills make use of eccentric training in which the muscle–tendon unit is lengthened while active. Small weights and multiple repetitions of the movements are used. • PNF techniques may be used as a method promoting or hastening the neuromuscular mechanism through stimulation of the proprioceptors.
  • 27. Sreeraj S R Active movements • Electrical contractions • In circumstances where a strong voluntary muscle contraction is not possible due to paralysis, paresis or severe injury daily application of electrical stimulation (ES) may retard the loss of muscle strength or even improve it in already weakened musculature. • The gains are not long-lasting, however, and electrical stimulations should only be used temporarily while awaiting neurological recovery.
  • 28. Sreeraj S R Injection and infiltration techniques • In orthopaedic medicine three types of product are used: 1. Local anesthetics: Commonly used are procaine bupivacaine and lidocaine/lignocaine 2. Corticosteroids: The ability to suppress inflammation has made the glucocorticoids very useful but also potentially harmful. 3. Sclerosing agents: Chemical agents such as phenol and dextrose are infiltrated into weakened ligaments and tendons in order to create the formation of strong, thickened fibrous tissue. Because of its proliferative effect on connective tissue, the technique is called prolotherapy or sclerotherapy. • In Injection the tip of the needle is placed in exactly the right place and all the product is deposited at one single push, as is done in an ordinary intramuscular injection. This technique is mainly used for intra-articular and caudal epidural injections. • In Infiltration a drug is locally administered into a structure, as in bursitis, tendinitis, tenosynovitis, tenovaginitis, lesions of a muscle belly and also in ligamentous problems.
  • 29. Sreeraj S R Reference 1. Ludwig O. Chapter 5. Principles of Treatment. A System of Orthopaedic Medicine, 3rd Ed. London, Elsevier, 2013, pp. 83– 115. 2. Yadav A. Chapter-05, Cyriax Mobilization Techniques. In: Advanced Techniques In Physiotherapy And Occupational Therapy. 1st ed. S.L.: Jaypee Brothers Medical P; 2019. p. 24– 32. 3. Woodman R. Chapter 5, The Cyriax Approach. In: Orthopaedic manual physical therapy : from art to evidence by Wise CH. 1st ed. Philadelphia, Pa: F.A. Davis Company; 2015. p. 110–29.