Upper-Quarter Screening and the Cyriax Lens: A Practical Framework for Occupational Therapists

Written by: Melissa Quental, OTR/L

VHSF 24/25’

After more than 20 years as an Occupational Therapist, mostly in long-term care and home health, I thought my upper-extremity assessments were strong. I could measure ROM, grade strength, document pain, and write a plan of care quickly. In 2024, when I started the Virtual Hand to Shoulder Fellowship, I realized something humbling: I was often better at documenting impairments than at systematically identifying likely symptom drivers when a presentation didn’t match the referral diagnosis.

That gap became personal when a family member asked for help. Her symptoms were diffuse (“the whole arm”), variable with activity and duration, and inconsistent with the chart diagnosis. She also carried a diagnosis of cervical myelopathy associated with C6–C7 level pathology. Prior therapy attempts increased symptoms, causing her to end rehabilitation early. Fear of movement became part of her clinical picture. With her permission, I’m sharing this case in de-identified form.

Upper-quarter screen: the minimum dataset for smarter decisions

McClure describes the upper-quarter screening examination as serving two purposes: (1) identify which anatomic region of the upper quarter is contributing to symptoms (and therefore needs further examination) and (2) rule out gross sensory and motor deficits consistent with cervical radiculopathy or other neurologic sources (McClure, 2021). I like this definition because it keeps the screen practical. It’s not “do everything.” It’s “collect enough information to narrow the root cause.”

The screen is symptom-informed and proximal-to-distal:

1) Observation and functional movement. I start by watching posture and movement quality and noting guarding and compensation patterns. I’m especially attentive to scapular resting position, thoracic posture, and how the patient moves during simple tasks (reach, grooming simulation, carrying). I also ask what is new versus “how they’ve always moved,” because not every asymmetry is clinically meaningful.

2) Cervical-to-distal scan (AROM/PROM). I begin with cervical AROM (and PROM as appropriate), then move down the kinetic chain: scapula/shoulder, elbow/forearm, wrist/hand. I’m tracking symptom reproduction, end-feel, and side-to-side differences, not just degrees. Starting proximally matters in referred pain or neurologically influenced presentations; if I flare symptoms early, I lose valuable assessment time and the patient’s trust.

3) Strength with a myotome mindset. I test proximal-to-distal and interpret “weakness” cautiously. Pain inhibition, altered recruitment, and fear can mimic true strength loss. Scapular stabilizers deserve particular attention because poor control can drive distal overload and perpetuate irritation.

4) Sensation (and reflexes when indicated). A quick bilateral light-touch scan helps determine whether changes look dermatomal, follow a peripheral nerve distribution, or remain non-specific. When neurologic contribution is plausible and within competency, reflex screening adds context and strengthens interdisciplinary communication.

5) Palpation, entrapment sites, and neural tension. Palpation of common entrapment sites and neural tension testing (median, ulnar, radial bias) are now “must-haves” when the picture is unclear. I’m not using them to diagnose; I’m using them to improve my hypothesis and choose the next best test. This is also where the basic science matters: nerve compression is not simply “on/off.” It can involve ischemia, altered intraneural blood flow, edema, changes in conduction, and increased mechanosensitivity, mechanisms that help explain why symptoms can be variable, activity-dependent, and difficult to localize (Power & Moore, 2021). That perspective makes neural testing feel less like an “extra” step and more like responsible clinical reasoning.

When the pattern is still messy: selective tension and the Cyriax lens

Even with a thorough screen, some presentations don’t map neatly to one structure. What helped me was combining selective tissue tension reasoning with Cyriax-style concepts: apply controlled stress, observe symptom behavior (pain, limitation, weakness), and interpret the pattern through functional anatomy (Musculoskeletal Key, 2016; Upadhyay, n.d.).

In simple terms: if passive movement (primarily stressing inert tissues) and active movement in the same direction reproduce the primary complaint, inert tissue involvement (capsule/ligament/bursa) becomes more likely. If resisted isometric testing reproduces the complaint while passive motion is comparatively less provocative, contractile tissue involvement (muscle-tendon unit) becomes more likely (Musculoskeletal Key, 2016). If a contractile lesion is suspected, there needs to be one or more positive resisted range of motion tests. The Contractile tissue lesion will follow a pattern.

1.     Painful and strong is suggestive of a minor lesion.

2.     No pain and weakness are suggestive of a nerve lesion.

3.     Pain and weakness are suggestive of a gross lesion or partial rupture.

4.     All tests are painful and weak, suggesting a non-organic or centrally mediated component of pain. (Deisher, 2023)

I treat this as a decision aid, not a final answer, because complex cases often include multiple contributors (proximal factors, peripheral mechanosensitivity, and motor control deficits).

Case application: what changed in my reasoning

In my family member’s screen, I noted scapular posture and motor control deficits; symptom behavior consistent with median nerve mechanosensitivity (paresthesia into the thumb/index/middle fingers with median nerve biased positioning); a plausible proximal contributor given her cervical history; and clear fear-avoidance with compensatory movement. Instead of naming a diagnosis, I documented a clinical impression: likely multifactorial drivers with proximal and peripheral neural contributions, plus scapular motor control impairment and fear-avoidance amplifying symptoms.

That impression helped me change the plan. We moved away from symptom-flaring strengthening and toward low-load neuro re-education and graded exposure (mirror feedback for posture, tolerance-based scapular control), paired with gentle nerve glides, pacing, and reassurance about safe parameters. In my fellowship instruction, the structured hand and wrist examination reinforced how quickly distal symptoms can be over-attributed to the hand unless the entire upper quarter is screened and organized (Deisher, 2023). Based on screen findings and symptom behavior, I recommended follow-up with a cervical-focused physical therapist (given the myelopathy history) and an orthopedic/hand specialist for further evaluation of suspected median nerve entrapment, recognizing that medical confirmation is always outside OT scope of practice.

This was not a cure, and I don’t present it as one. But it was meaningful as she became less fearful, completed her exercise plan more consistently, and reported improved tolerance for important ADLs and valued roles. For me, the win was that the plan finally matched her symptom behavior and she felt believed.

Conclusion

This fellowship taught me that a thorough upper-quarter screen is not an “extra” step; it is often the minimum dataset needed when symptoms are unclear, referred, or neurologically influenced. When I pair that screen with selective tissue tension reasoning, a Cyriax-style inert-versus-contractile lens, and a basic science understanding of nerve compression, I form clearer hypotheses, educate patients more effectively, and choose interventions that are more targeted and tolerable while staying grounded in OT scope of practice.

References

Deisher, M. (2023). Clinical Exam of the Hand and Wrist. Virtual Hand to Shoulder Fellowship (course material).

McClure, P. (2021). Upper-Quarter Screen. In A. Skirven, A. Osterman, J. Fedorczyk, P. Amadio, J. Feldscher, & E. Shin (Eds.), Rehabilitation of the Hand and Upper Extremity (7th ed., pp. 117–124). Elsevier.

Musculoskeletal Key. (2016, June 5). Clinical diagnosis of soft tissue lesions. MusculoskeletalKey.com.

Power, H. A., & Moore, A. M. (2021). Basic Science of Nerve Compression. In A. Skirven, A. Osterman, J. Fedorczyk, P. Amadio, J. Feldscher, & E. Shin (Eds.), Rehabilitation of the Hand and Upper Extremity (7th ed., pp. 667–682). Elsevier.

Upadhyay, S. (n.d.). Cyriax Techniques [PowerPoint slides]. Uploaded by sakshiupadhyay88.