Strain-counterstrain

Last updated: January 2, 2024

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.

Overview

Tender points (Jones points)

Small, hypersensitive areas located in tendons, ligaments, or muscles that typically do not radiate pain when pressed
Caused by dysfunctional neuromuscular reflexes
Associated with somatic dysfunction
- 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
Treated with counterstrain

Tenderpoints do not radiate pain when pressed.

Technique

Description
- Counterstrain is a passive, indirect technique.
- Developed by Dr. L. H. Jones in 1955.
Goal: alleviate the pain (by at least 70%) by placing the patient in a position of ease
Indications: presence of a tender point
Contraindications
- Absolute: trauma, severe illness, severe spondylosis
- Relative: non-cooperative patient, connective tissue disease, pain while performing technique, acute injuries in the treatment area (e.g., infections, burns)

Procedure

Identify the tender point
- Apply a few ounces of pressure when palpating.
- Try to use the same amount of pressure when assessing the tender points.

Establish a tenderness scale: e.g., a 1–10 tenderness scale

Place the patient in a position of ease
- Continuously monitor the tender point using a light touch
- Reapply firm pressure to achieve at least a 70% reduction in tenderness

While the patient is relaxed, maintain the therapeutic position for 90 seconds and monitor for release

Slowly return the patient to a neutral position

Reassess for tenderness
- No more than 30% tenderness should remain.
- Monitor for post-treatment emotional reactions.

The most painful tender point should always be treated first.

Cervical tender points

Anterior cervical tender points

Overview of anterior cervical tender points
Tender point	Location	Anatomical Correlation	Treatment
AC1 (maverick point)	High on the posterior edge of the ramus of the mandible between the earlobe and the angle of the mandible (near the transverse process of C1)	Rectus capitis anterior muscle	Position: supine Marked rotation away from the tender point
AC2	Anterolateral tip of the anterior tubercle of transverse process Lateral muscle mass at the corresponding level	Rectus capitis muscles (anterior and lateralis)	Position: supine Flexion Sidebend and rotate away from the tender point. AC2–AC6 → F SARA
AC3		Longus capitis muscle
AC4		Longus capitis muscle
AC5		Longus colli muscle
AC6		Longus colli muscle	Position: supine Flexion Sidebend toward and rotate away from the tender point.
AC7 (maverick point)	Superior surface of the clavicle at the clavicular attachment of the sternocleidomastoid	Clavicular division of the sternocleidomastoid
AC8	Medial head of the clavicle at the sternal attachment of the sternocleidomastoid	Sternal division of sternocleidomastoid	Position: supine Flexion Sidebend and rotate away from the tender point.

Most anterior cervical points are treated with flexion, sidebending away, and rotating away from the tenderpoint (F SARA).

Maverick points are tender points that do not follow the general rules of counterstrain and do not resolve when the muscle is shortened (e.g., AC7, PC3 midline cervical tender points).

Anterior cervical tender points (osteopathy)

Posterior cervical tender points

Overview of posterior cervical tender points
Tender point	Location	Treatment
PC1 midline/inion (maverick point)	Inferior nuchal line, lateral to the inion	Position: supine Marked flexion
PC1 lateral/occiput	Just below the nuchal line, halfway between the inion and mastoid process	Position: supine Extension Sidebend and rotate away from the tender point.
PC2 lateral/occiput)	Inferior nuchal line at the attachment of the semispinalis capitis, midway between PC1 inion and PC1 occiput tender points Inferior nuchal line at the attachment of the semispinalis capitis (between inion and PC1 occiput tender point)	Position: supine Extension Side bending and rotation away from the tender point.
PC2 midline	Superior aspect of the C2 spinous process
PC3 midline (maverick point)	Inferior-lateral aspect of the C2 spinous process	Position: supine Flexion Sidebend and rotate away from the tender point.
PC3–PC7 lateral	Posterior-lateral surface of articular processes of each named point	Position: supine Extension Sidebend and rotate away from the tender point.
PC4–PC7 midline	Inferior aspect of the spinous process of the vertebra one segment above
PC8 midline	Inferior aspect of C7 spinous process

All posterior cervical points except PC1 midline and PC3 midline are treated with extension, sidebending away, and rotating away from the tender point E SARA.

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

Rib tender points

Anterior rib tender points

Overview of anterior rib tender points
Tender point	Location	Treatment
AR1	1^st chondrosternal junction	Flexion Sidebend and rotate toward the tender point. AR1–AR10 → F STRT
AR2	2^nd rib, midclavicular line
AR3–AR10	Located along the anterior axillary line of the corresponding rib

Anterior rib dysfunctions are associated with exhalation dysfunctions.

All anterior rib tender points are treated with flexion, sidebending, and rotating toward the tender point F STRT.

Anterior ribs tender points (osteopathy)

Posterior rib tender points

Overview of posterior rib tender points
PR1	Superior aspect of 1^st rib, lateral to the costovertebral articulation	Extension Sidebend away and rotate toward the tender point. PR1 → E SART
PR2–PR10	Superior aspect of the corresponding rib	Flexion Sidebend and rotate away the tender point. PR2–PR10 → F SARA

Overview of posterior rib tender points

Tender point

Location

Treatment

PR1

Superior aspect of 1^st rib, lateral to the costovertebral articulation

Extension
Sidebend away and rotate toward the tender point.

PR1 → E SART Counterstrain somatic dysfunction inhaled 1st rib

PR2–PR10

Superior aspect of the corresponding rib

Flexion
Sidebend and rotate away the tender point.

PR2–PR10 → F SARA Counterstrain somatic dysfunction inhaled rib 2 thru 6

Posterior rib dysfunctions are associated with inhalation dysfunctions.

Posterior rib tender points

Thoracic tender points

Anterior thoracic tender points

Overview of anterior thoracic tender points
Tender point	Location	Treatment
AT1	Midline of the sternum, just below the sternal notch	Position: supine Pure flexion of the neck AT1–AT6 → Flexion
AT2	Midline of the sternum, level of T2 (junction of manubrium and the sternum)
AT3	Midline of the sternum, level of T3
AT4	Midline of the sternum, level of T4
AT5	Midline of the sternum, level of T5
AT6	Midline of the sternum, level of T6
AT7	Three points Midline of the sternum, inferior to the xiphoid process Midclavicular line, level of 7^th ICS, bilaterally	Position: supine Flexion of the neck and upper torso Sidebend toward and rotate away from the tender point. AT7–AT12 → F STRA
AT8	Three points Midline of the sternum, level of T12 Midclavicular line, level of T12, bilaterally
AT9	Three points Midline of the sternum, just above umbilicus, level of L2 Midclavicular line, just above the umbilicus, level of L2 bilaterally
AT10	Three points Midline of the sternum, just below the umbilicus, level of L4 Midclavicular line, just below the umbilicus, level of L4 bilaterally
AT11	Three points Midline of the sternum, level of L5 Midclavicular line, level of sacral base, bilaterally
AT12	Midaxillary line, anterior superior surface of the iliac crest, bilaterally

Anterior thoracic tender points

Posterior thoracic tender points

Overview of posterior thoracic tender points
PT1–12 (Spinous process)	Inferolateral aspect of the corresponding spinous process	Position: prone Stand on the opposite side of the tender point. Extend the neck by gently lifting the chin until the mobile point is reached. Sidebend and rotate away from the tender point. PT1–12 → E SARA
PT1–12 (Transverse process)	Lateral aspect of the corresponding transverse process	Position: prone Stand on the opposite side of the tender point Extend the upper torso and rotate toward you until the mobile point is reached. Sidebend away and rotate toward the tender point. PT1–12 → E SART

Overview of posterior thoracic tender points

Tender point

Location

Treatment

PT1–12

(Spinous process)

Inferolateral aspect of the corresponding spinous process

Position: prone
Stand on the opposite side of the tender point.
Extend the neck by gently lifting the chin until the mobile point is reached.
Sidebend and rotate away from the tender point.

PT1–12 → E SARA

PT1–12

(Transverse process)

Lateral aspect of the corresponding transverse process

Position: prone
Stand on the opposite side of the tender point
Extend the upper torso and rotate toward you until the mobile point is reached.
Sidebend away and rotate toward the tender point.

PT1–12 → E SART

Posterior thoracic tender points

Lumbar tender points

Anterior lumbar tender points

Overview of anterior lumbar tender points
Tender point	Location	Treatment
AL1 (Internal oblique)	Just medial to the anterior superior iliac spine	Position: supine Flex the hips. Sidebend towards the tenderpoint. Rotate away from the tenderpoint. AL1 → F STRA
AL2 (External oblique)	Just medial to the anterior inferior iliac spine	Position: supine Stand on the opposite side of the tender point. Flex the hips. Sidebend away from the tenderpoint. Rotate towards the tenderpoint. AL2–AL4 → F SART
AL3 (Iliopsoas)	Just lateral to the anterior inferior iliac spine
AL4 (Iliopsoas)	Just inferior to the anterior inferior iliac spine
AL5 (Rectus abdominis)	Public tubercle (1cm lateral to the pubic symphysis on the superior ramus)	Position: supine Flex the hips. Sidebend away from the tenderpoint. Rotate away from the tenderpoint. AL5 → F SARA

Anterior lumbar tender points are treated by placing the patient in the supine position with the hips and knees flexed. Sidebending is added by moving the ankles right or left. Rotation is added by pulling the knees right or left.

Anterior lumbar tender points

Posterior lumbar tender points

Overview of posterior lumbar tender points
Tender point	Location	Treatment
PL1–PL5 (Spinous process)	Inferolateral aspect of the spinous process of L1–L5	Position: prone Extend the ipsilateral hip. Sidebend and rotate the hip away from the tender point by adducting the ipsilateral lower extremity. PL1–PL5 → E SARA
PL1–PL5 (Transverse process)	Lateral aspect of the transverse process of L1–L5
Quadratus lumborum	Inferior aspect of 12^th rib and the superior aspect of the iliac crest	Position: prone Extend the ipsilateral hip. Abduct and externally rotate the hip.

Most posterior lumbar tender points are treated with the patient in the prone position, followed by extension, sidebending, and rotating away from the tender point.

Pelvic tender points

Anterior pelvic tender points

Overview of anterior pelvic tender points
Tender point	Location	Treatment
Psoas	⅔ Between anterior superior iliac spine and midline	Position supine Flex the hips. Sidebend towards the tender point. Externally rotate the hips.
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 the same side as the tender point. Hyperflex the ipsilateral hip.
Inguinal (pectineus)	Superior pubis near the medial end of the inguinal ligament	Position: supine Stand on the same side as the tender point. Flex hips and knees to ∼ 90 degrees. Adduct and internally rotate the hips.
Iliacus	⅓ Between the anterior superior iliac spine and the midline	Position: supine Stand on the same side as the tender point. Flex the hip and externally rotate
Low ilium flare-out	Inferior-medial surface of the descending ramus of the pubic bone	Position: supine Stand on the same side as the tender point. Hyperflex the affected hip. Abduct and externally rotate the hips.

Anterior pelvic tender points

Posterior pelvic tender points

Overview of posterior pelvic tender points
Tender point	Location	Treatment
Piriformis	Multiple points between the lateral edge of the sacrum and the greater trochanter	Position: prone Sit on the same side as the tender point. Flex hip and knee off the table. Abduct the hip away from the table. Externally rotate the hip.
Upper pole L5 (UPL5)	Superior medial aspect of the posterior superior iliac spine	Position: prone Stand on the contralateral side of the tender point. Extend hip. Fine-tune with adduction and rotation.
Midpole sacral	Midway down the sacrum (attachment of piriformis muscle)	Position: prone Sit on the same side as the tender point. Abduct and externally rotate the hip.
Lower pole L5 (LPL5)	Just inferior to the posterior superior iliac spine	Position: prone Sit on the same side as the tender point Flex hip and knee off the 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 the same side as the 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 the opposite side of the 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 the leg. Adduct and externally rotate the hip.
High ilium sacroiliac (HISO)	∼ 3 cm lateral to the posterior superior iliac spine	Position: prone Stand on the same side as the 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 the opposite side of the tender point. Extend, adduct, and externally rotate the hip.

Posterior pelvic tender points

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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