Strain-counterstrain

Last updated: May 25, 2021

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.
- Surrounding tender points may resolve spontaneously.
The examiner should monitor for post-treatment emotional reactions.

Cervical tender points

Anterior cervical tender points

Tender Points	Locations	Anatomical Correlation	Treatment
AC1	High on the posterior edge of the ramus of the mandible between the earlobe and angle of the mandible (near the transverse process of C1)	Rectus capitis anterior muscle	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		Longus capitis muscle
AC4		Longus capitis muscle
AC5		Longus colli muscle
AC6		Longus colli muscle
AC7	Superior surface of the clavicle at the clavicular attachment of the sternocleidomastoid	Clavicular division of the sternocleidomastoid	Position: supine Flexion Side bend toward and rotate away from tender point.
AC8	Medial head of the clavicle at the sternal attachment of the sternocleidomastoid	Sternal division of sternocleidomastoid	Position: supine Flexion Side bend and rotate away from tender point.

Anterior cervical tender points (osteopathy)

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)	Just below the nuchal line, midway between the inion and mastoid process	Position: supine Extension Side bend and rotate away from tender point.
PC2 midline	Superior aspect of the C2 spinous process	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	Inferior-lateral aspect of the C2 spinous process	Position: supine Flexion Side bend and rotate away from tender point.
PC3–PC7 lateral	Posterior-lateral surface of articular processes of each named point	Position: supine Extension Side bend and rotate away from tender point.
PC4–PC7 midline	Inferior aspect of the spinous process of the vertebra above the named point
PC8 midline	Inferior aspect of C7 spinous process

Posterior cervical tender points (osteopathy) Base of skull tender points

Rib tender points

Anterior rib tender points

Tender Point	Location	Treatment
AR1	Lateral to the sternum, just below the sternoclavicular joint	Position: supine Flexion Side bend and rotate neck toward tender point.
AR2	2^nd rib midclavicular line
AR3	Medial: adjacent to the sternal border, 3^rd intercostal space (ICS) Lateral: along the anterior axillary line, on the 3^rd 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, 4^th ICS Lateral: along the anterior axillary line, on the 4^th rib
AR5	Medial: adjacent to the sternal border, 5^th ICS Lateral: along the anterior axillary line, on the 5^th rib
AR6	Medial: adjacent to the sternal border, 6^th ICS Lateral: along the anterior axillary line, on the 6^th rib

Anterior ribs tender points (osteopathy)

Posterior rib tender points

Tender Point	Location	Treatment
PR1	1^st rib angle	Position: seated Extend, side bend away, and rotate the neck toward the tender point.
PR2	2^nd rib angle	Position: seated Side bend and rotate neck and upper torso away from tender point. Fine-tune with flexion or extension.
PR3	3^rd rib angle
PR4	4^th rib angle
PR5	5^th rib angle
PR6	6^th rib angle
PR7	7^th rib angle
PR8	8^th rib angle
PR9	9^th rib angle
PR10	10^th rib angle
PR11	11^th rib angle
PR12	12^th rib angle

Posterior rib tender points

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	Three points Midline, xiphoid process Midclavicular line, level of 7^th ICS, bilaterally	Position: supine Flexion of the neck and upper torso Side bend toward and rotate away from tender point.
AT8	Three points Midline, level of T12 Midclavicular line, level of T12, bilaterally
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	Three points Midline, level of L5 Midclavicular line, level of sacral base, bilaterally
AT12	Inner surface of the iliac crest superior to the ASIS, bilaterally

Anterior thoracic tender points

Posterior thoracic tender points

Tender Point	Location	Treatment
PT1	T1 spinous process or transverse process	Position: prone 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.
PT2	T2 spinous process or transverse process
PT3	T3 spinous process or transverse process	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	T4 spinous process or transverse process
PT5	T5 spinous process or transverse process
PT6	T6 spinous process or transverse process	Position: prone Place the patient's arms forward. From opposite side of the tender point, extend the upper torso and rotate toward you until the mobile point is reached.
PT7	T7 spinous process or transverse process
PT8	T8 spinous process or transverse process
PT9	T9 spinous process or transverse process
PT10	T10 spinous process or transverse process
PT11	T11 spinous process or transverse process
PT12	T12 spinous process or transverse process

Posterior thoracic tender points

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 away from the tender point and side bend hips toward the tender point. AL1 → F STRA
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. AL2 → F SART
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. AL¾ → F SART
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. Rotate legs and side bend hips away from the tender point. AL5 → F SARA

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 away from the tender point and side bend hips toward the tender point.

AL1 → F STRA

Anterior 1st Lumbar Counterstrain

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.

AL2 → F SART

Anterior 2nd Lumbar Counterstrain

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.

AL¾ → F SART

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.
Rotate legs and side bend hips away from the tender point.

AL5 → F SARA

Anterior lumbar tender points

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

Anterior pelvic tender points

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	Midway down the sacrum (attachment of piriformis muscle)	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)	Lateral PL3: ⅔ between the posterior superior iliac spine and the tensor fascia latae Lateral PL4: posterior margin of the tensor fascia latae	Position: prone Stand on same side as tender point Extend the hip. Fine-tune with abduction and external rotation.
Lumbar transverse process	Any point along the transverse processes of L1–L5	Position: prone Stand on opposite side of tender point Extend, adduct, and slightly externally rotate the hip
Lumbar spinous process	Inferior or inferolateral aspect of any spinous process of L1–L5	Position: prone Extend, adduct, and slightly externally rotate the hip.
High ilium flare-out (HIFO)	Lower lateral border of the sacrum and/or coccyx	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.

References

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 ; 2015

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