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.
  • 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

AC2
  • Rectus capiti muscles (anterior & lateralis)

AC3
AC4
AC5
AC6
AC7
AC8

Posterior cervical tender points

Tender Point Location Treatment
PC1 midline (inion)
  • Inferior nuchal line, lateral to the inion

PC1 lateral (occiput)

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

PC2 lateral (occiput)
PC3 midline

PC3–PC7 lateral

PC4–PC7 midline
PC8 midline

Rib tender points

Anterior rib tender points

Tender Point Location Treatment
AR1

AR2
AR3
  • 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
AR5
AR6

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
AT8
AT9
AT10
AT11
AT12

Posterior thoracic tender points

Tender Point Location Treatment
PT1
PT2
PT3
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)

  • 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)

AL3

(Iliopsoas)

AL4

(Iliopsoas)

AL5

(Rectus abdominis)

Pelvic tender points

Anterior pelvic tender points

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

Low ilium

(psoas minor)

Inguinal

(pectineus)

  • 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

Low ilium flare-out
  • Inferior-medial surface of the descending ramus of the pubic bone

Posterior pelvic tender points

Tender Point Location Treatment

Piriformis

  • Multiple points between lateral edge of the sacrum and greater trochanter

Upper pole L5 (UPL5)

  • Position: prone
  • Stand on contralateral side.
  • Extend hip.
  • Fine-tune with adduction and rotation.
Midpole sacral

Lower pole L5 (LPL5)

Gluteus medius (lateral posterior lumbar L3 & L4)

Lumbar transverse process

Lumbar spinous process

  • Position: prone
  • Extend, adduct, and slightly externally rotate the hip.
High ilium flare-out (HIFO)
High ilium sacroiliac (HISO)

Posteromedial trochanteric

  • ∼ 3 inches inferior to the greater trochanter and medially inferior to the ischial tuberosity
  • 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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