Strain-counterstrain

Summary

Strain-counterstrain (or simply counterstrain) is a passive functional (indirect) technique developed by Dr. L. H. Jones in 1955. It was originally developed after he observed relief of pain from what he would later term “tender points,” and improvement of function after a patient assumed a pain-free position. Tender points are small, edematous, hypersensitive areas of tenderness located in the myofascial tissue that are elicited upon palpation. They are typically located near muscular attachments to the bone, overlying tendons, and in the belly of major muscles. There are more than 200 identified tender points typically correlating to specific positioning of the body with some exceptions called maverick points. However, the mainstay of the strain-counterstrain system is placing a particular joint or region of the body in the most comfortable and least painful position; this typically correlates to anatomically shortening the muscle between two attachments.

Description

Overview

  • Pioneered by Dr. Lawerence H. Jones in 1955
  • Tender points (Jones points) are small, edematous, painful areas elicited upon palpatory examination.
  • Differ from trigger points because they typically do not radiate pain
  • More than 200 identified points
  • Often correlate to somatic dysfunctions
  • Strain-counterstrain assumes the patient in a pain-free position to relieve the “strain”

Technique

  • There are three cardinal features of the strain-counterstrain system.
    1. Identification and monitoring of a palpable tender point
    2. Placing the body in the most comfortable or least painful position
      • This position is held for 90 seconds while the examiner monitors the tender point
    3. Slow examiner-assisted return to a neutral position
  • There are anterior, posterior, and lateral tender points.
    • Anterior tender points: typically related to flexion dysfunctions
    • Posterior tender points: typically related to extension dysfunctions
    • Lateral tender points: typically have more of a side bending and rotational component
  • The most painful tender point should always be treated first.
  • The examiner should monitor for post-treatment emotional reactions.

Cervical tender points

Anterior cervical tender points

Tender Points Locations Anatomical Correlation Treatment
AC1
  • Position: supine
  • Marked rotation away from tender point
  • Fine-tune with flexion and side bending.

AC2
  • Anterolateral tip of the anterior tubercle of transverse process
  • Lateral muscle mass at the corresponding level
  • Rectus capiti muscles (anterior & lateralis)
  • Position: supine
  • Flexion
  • Side bend and rotate away from tender point.

AC3
AC4
AC5
AC6
AC7
  • Position: supine
  • Flexion
  • Side bend towards and rotate away from tender point.
AC8
  • Position: supine
  • Flexion
  • Side bend and rotate away from tender point.

Posterior cervical tender points

Tender Point Location Treatment
PC1 midline (inion)
  • Inferior nuchal line, lateral to the inion
  • Position: supine
  • Marked flexion
  • Fine-tune with side bending and rotation away from tender point.

PC1 lateral (occiput)
  • Position: supine
  • Extension
  • Side bend and rotate away from tender point.

PC2 midline
  • Position: supine
  • Extension
  • Fine-tune with side bending and rotation away from tender point.

PC2 lateral (occiput)
  • Inferior nuchal line at the attachment of the semispinalis capitis (between inion and PC1 occiput tender point)
PC3 midline
  • Position: supine
  • Flexion
  • Side bend and rotate away from tender point.

PC3–PC7 lateral
  • Position: supine
  • Extension
  • Side bend and rotate away from tender point.

PC4–PC7 midline
PC8 midline

Rib tender points

Anterior rib tender points

Tender Point Location Treatment
AR1
  • Position: supine
  • Flexion
  • Side bend and rotate neck away from tender point.

AR2
AR3
  • Medial: adjacent to the sternal border, 3rd intercostal space (ICS)
  • Lateral: along the anterior axillary line, on the 3rd rib
  • Position: seated
  • Side bend upper torso toward tender point.
    • Examiner stands behind patient with contralateral (to the tender point) foot on table.
    • Patient's contralateral arm is draped over the examiner's leg.
    • Patient curls ipsilateral legs onto the table.
  • Fine-tune with cervical side bending toward tender point.

AR4
  • Medial: adjacent to the sternal border, 4th ICS
  • Lateral: along the anterior axillary line, on the 4th rib
AR5
  • Medial: adjacent to the sternal border, 5th ICS
  • Lateral: along the anterior axillary line, on the 5th rib
AR6
  • Medial: adjacent to the sternal border, 6th ICS
  • Lateral: along the anterior axillary line, on the 6th rib

Posterior rib tender points

Tender Point Location Treatment
PR1
  • 1st rib angle
  • Position: seated
  • Extend, side bend away, and rotate the neck towards the tender point.

PR2
  • 2nd rib angle
  • Position: seated
  • Side bend and rotate neck and upper torso away from tender point.
  • Fine-tune with flexion or extension.

PR3
  • 3rd rib angle
PR4
  • 4th rib angle
PR5
  • 5th rib angle
PR6
  • 6th rib angle
PR7
  • 7th rib angle
PR8
  • 8th rib angle
PR9
  • 9th rib angle
PR10
  • 10th rib angle
PR11
  • 11th rib angle
PR12
  • 12th rib angle

Thoracic tender points

Anterior thoracic tender points

Tender Point Location Treatment
AT1
  • Midline, just below the sternal notch
  • Position: supine
  • Marked flexion of the neck
  • Fine tune with side bending and rotation.
AT2
  • Midline, level of T2
AT3
  • Midline, level of T3
AT4
  • Midline, level of T4
AT5
  • Midline, level of T5
AT6
  • Midline, level of T6
AT7
  • Position: supine
  • Flexion of the neck and upper torso
  • Side bend toward and rotate away from tender point.
AT8
AT9
  • Three points
    • Midline, just above umbilicus, level of L2
    • Midclavicular line, just above the umbilicus, bilaterally
AT10
  • Three points
    • Midline, just below the umbilicus, level of L4
    • Midclavicular line, just below the umbilicus, bilaterally
  • Position: supine
  • Flexion of the hip and knees
  • Side bend and rotate by bringing knees and ankle toward the tender point.
AT11
AT12

Posterior thoracic tender points

Tender Point Location Treatment
PT1
PT2
PT3
  • Position: prone
  • Place the patient's arms forward.
  • From opposite side of the tender point, extend the neck by gently lifting the chin until the mobile point is reached.
  • Side bend and rotate away for transverse process tender points.
PT4
PT5
PT6
  • Position: prone
  • Place the patient's arms forward.
  • From opposite side of the tender point, extend the upper torso and rotate towards you until the mobile point is reached.
PT7
PT8
PT9
PT10
PT11
PT12

Lumbar tender points

Anterior lumbar tender points

Tender Point Location Treatment

AL1

(Internal oblique)

  • Just medial to the anterior superior iliac spine
  • Position: supine
  • Stand on same side as tender point.
  • Hyperflex the hips.
  • Rotate legs (bring knees towards you) and side bend hips (bring ankles towards you) toward the tender point.

AL2

(External oblique)

  • Just medial to the anterior inferior iliac spine
  • Position: supine
  • Stand on opposite side of tender point.
  • Flex the hips.
  • Markedly rotate legs and side bend hips away from the tender point.

AL3

(Iliopsoas)

  • Just lateral to the anterior inferior iliac spine
  • Position: supine
  • Stand on opposite side of tender point.
  • Flex the hips.
  • Rotate legs and side bend hips away from the tender point.

AL4

(Iliopsoas)

  • Just inferior to the anterior inferior iliac spine

AL5

(Rectus abdominis)

  • Anterior surface of the pubis
  • Position: supine
  • Stand on same side as tender point.
  • Markedly flex the hips.
  • Slightly rotate legs and side bend hips toward the tender point.

Pelvic tender points

Anterior pelvic tender points

Tender Point Location Treatment
Psoas
  • ⅔ Between anterior superior iliac spine and midline
  • Position: supine
  • Hyperflex and externally rotate the hip.
  • Side bend ipsilateral lumbar spine for fine-tuning.

Low ilium

(psoas minor)

  • Anterior-superior aspect of the pubic ramus
  • ∼ 2 inches lateral to the pubic symphysis
    • Iliopubic eminence
    • Iliopectineal eminence
  • Position: supine
  • Stand on same side as tender point.
  • Hyperflex the ipsilateral hip.

Inguinal

(pectineus)

  • Superior pubis near medial end of the inguinal ligament
  • Position: supine
  • Stand on same side as tender point.
  • Flex hips and knees to ∼ 90 degrees.
  • Cross contralateral thigh over the ipsilateral thigh.
  • Pull ipsilateral lower leg laterally (creates internal rotation of the hip on the affected side).
Iliacus
  • ⅓ Between the anterior superior iliac spine and the midline
  • Position: supine
  • Stand on same side as tender point.
  • Hyperflex hips and cross one leg over the other (externally rotates both hips).

Low ilium flare-out
  • Inferior-medial surface of the descending ramus of the pubic bone
  • Position: supine
  • Stand on same side as tender point
  • Hyperflex the affected hip
  • Abduct and externally rotate the hips

Posterior pelvic tender points

Tender Point Location Treatment

Piriformis

  • Multiple points between lateral edge of the sacrum and greater trochanter
  • Position: prone
  • Sit on same side as tender point.
  • Flex hip and knee off table.
  • Abduct hip away from table.
  • Fine-tune with rotation.

Upper pole L5 (UPL5)

  • Superior medial aspect of the posterior superior iliac spine
  • Position: prone
  • Stand on contralateral side.
  • Extend hip.
  • Fine-tune with adduction and rotation.
Midpole sacral
  • Position: prone
  • Sit on same side as tender point.
  • Abduct and externally rotate hip.

Lower pole L5 (LPL5)

  • Just inferior to the posterior superior iliac spine
  • Position: prone
  • Sit on same side as tender point
  • Flex hip and knee off table (∼ 90 degrees).
  • Adduct hip.
  • Fine-tune with internal rotation.

Gluteus medius (lateral posterior lumbar L3 & L4)

  • Position: prone
  • Stand on same side as tender point
  • Extend the hip.
  • Fine-tune with abduction and external rotation.

Lumbar transverse process

  • Position: prone
  • Stand on opposite side of tender point
  • Extend, adduct, and slightly externally rotate the hip

Lumbar spinous process

  • Position: prone
  • Extend, adduct, and slightly externally rotate the hip.
High ilium flare-out (HIFO)
  • Position: prone
  • Extend and adduct the hip.
High ilium sacroiliac (HISO)
  • ∼ 3 cm lateral to the posterior superior iliac spine
  • Position: prone
  • Stand on same side as tender point.
  • Extend, abduct, and externally rotate the hip.

Posteromedial trochanteric

  • ∼ 3 inches inferior to the greater trochanter and medially inferior to the ischial tuberosity
  • Position: prone
  • Stand on opposite side of tender point.
  • Extend, adduct, and externally rotate the hip.
  • Seffinger M. Foundations of Osteopathic Medicine. LWW; 2018.
  • Destefano L. Greenman's Principles of Manual Medicine. Wolters Kluwer Law & Business; 2015.
  • Dvořák J, Gilliar W. Musculoskeletal Manual Medicine. Thieme; 2008.
  • Nicholas A. Atlas of Osteopathic Techniques. LWW; 2011.
last updated 07/31/2019
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