Strain and Counterstrain

Strain and Counterstrain

Anterior Cervical Tender Points
AC3 AC4 LC1 AC1 reg AC1 rare AC2 AC5 AC8 AC7 AC6 TR ALC Anterior Cervical Tender Points

Lateral C1-LC1 (Rectus Lateralis)
Treat this first before anterior tender points Frontal headaches/eye pain Always treat with AC1 Tenderpoint On the transverse process of C1 Treatment Supine Sidebend toward the side of the tenderpoint to exaggerate deformity. The mastoid process and transverse process of C1 are approximated on the involved side.

AC1 Tender point Treatment
Posterior surface of ascending ramus of the mandible 2 cm superior to mandibular angle Approach posterioly Treatment Supine Neutral flexion/extension Sidebend – away slightly Rotate – away markedly Direct motion with pressure on top of head

AC1 (Rare) - Scalenes Tender point Treatment
Beneath and medial ot the mandibular angle 2 cm anterior to angle Push superiorly on the inferior surface Treatment Supine Flexion – marked Sidebend – slightly toward Rotate – away as needed Treat inion point posteriorly

AC2 Tender point: Treatment:
Anterior surface of the tip of C2 Transverse Process Treatment: Supine Flexion – slight ot none Sidebend – Away (moderate – marked usually) Rotate – away (moderate – marked usually)

Anterior surface of tip of C3 transverse process Treatment Supine Flexion – marked Sidebend – usually toward Rotate – away (moderate)

Anterior surface of tip of C4 transverse process Treatment Supine Extension – slight Sidebend – away (moderate) Rotate – away (moderate) Exception to rule

Anterior surface of tip of transverse process of C5 Treatment Supine Flexion – moderate Sidebend – away (moderate) Rotate – away (moderate)

Anterior surface of tip of transverse process of C6 Treatment Supine Flexion – moderate Sidebend – away (moderate usually) Rotate – away (moderate usually)

AC7 Shorten sternocleidomastoid muscle – clavicle Tender point
Posterior superior surface of clavicle. Approximately 3 cm lateral to medial end. Push inferiorly on the superior surface of the clavicle Treatment Supine Flexion – marked; support lower neck, not head Sidebend – toward markedly Rotate – away slightly

AC8 (SCM-sternal) Tender point Treatment Medial end of clavicle
Push laterally Treatment Supine Flexion – slight Sidebend – away slightly Rotate – away markedly

TR (trachea) Tight swallowing Longus coli spasm Tender point Treatment
Anywhere along either sid eof the trachea More common near the superior aspect Treatment Supine Flexion – marked, support lower neck Sidbend – toward markedly Rotate – away, slightly

ALC (Anterior Lateral Column)
Longus coli muscle Common with flattened cervical lordosis Tender point On a vertical line medial to the SCM muscle and lateral to trachea Push posteriorly toward anterior aspect of vertebral bodies C3-6 Treatment Supine Flexion – marked of neck Sidebend – toward tender point side Rotate – away form tender point side

Posterior Cervical Tender Points
PC2 PC1 PC1 Inion PC3 PC4 PC5 PC6 PC7 PC8 PLC Posterior Cervical Tender Points

PC1 (Inion) Tender point Treatment
On medial border of main posterior muscle mass of neck (semispinalis capitis), 3 cm below posterior occipital protuberance (inion) Treatment Supine Flexion – marked (chin tuck position) Sidebend – toward slightly Rotate – away slightly Usually works better to monitor PC1 than aC1 (rare) Treatment position very similar

PC1 (regular) Frontal Headaches Tender point Treatment
On occiput lateral to main muscle mass Approximately 3.5 cm from midline Treatment Supine Extension – at C1 level. Lift heat to create flexion of lower cervical region prior to extending C1. Allows more extension. Augment extension of C1 by hand pressure on top of head. Sidebend – away slightly Rotate – away slightly

PC2 Frontal headaches and/or eye pain Tender point Treatment
1. on lateral side of main muscle mass of neck below occiput. 1.5 cm lateral to midline 2. superior surface of the spinous process of C2 Treatment Supine Extension – same as PC1 Sidebend – away slightly Rotate – away slightly

PC3 Pain up back of head, tinnitus, vertigo Tender point Treatment
On the inferior surface of the spinous process of C2 Treatment Supine Flexion – marked Sidebend – away or toward Rotate – away

PC4 Occipital heacaches, common with TMJ dysfunction Tender point
1. on spinous process of C3 in the depression below the spinous process 2. in muscle mass between C4 spinous process and C4 transverse process Forward bending of neck helps to palpate these points Treatment Supine with head over end of table Extension – to level or flexion Sidebend – away Rotate – usually away

PC5 / PC6 / PC7 PC5: whole head hurts Tender point Treatment
On spinous process of corresponding vertebrae above i.e. PC6 on spinous process of C5 Treatment Supine Extension – marked to level Sidebend – usually away Rotate – away The main difference between these points and inferior to T2 is how much extension or backward bending is utilized

PC8 Tender points Treatment
Anterior to the trapezius at the base of the neck on the posterior surface of the tip of the tip of the C7 transverse process (push up on transverse process) Treatment Supine Extension – slight Sidebend – away markedly Rotate – away (slight to moderate)

PLC (Posterior Lateral Column)
Tender point 2 cm lateral to the spinous processes of C2-C7 Treatment Supine with head off end of plinth Extension – moderate Sidebend – toward moderate Rotate – away

Anterior Thoracic Tender Points
AT1 AT2 AT3 AT4 AT5 AT6 AT7 AT8 AT9 AT10 AT11 AT12 Anterior Thoracic Tender Points

AT5-AT8 Requires lots of force Optional technique involves placing patient supine and fulcruming at level over knee/thigh of clinician. This allows greater thoracic flexion at AT5-AT7

Anterior thoracic tender points are typically more tender supine than sitting
AT1-AT6 Increased thoracic kyphosis T4-T5 pain posteriorly Fatigued/ low energy Increased difficulty with respiration – deep breath

AT7-AT12 Chronic diarrhea AT10 Stomach problem AT7-AT12 Thoracolumbar pain posteriorly

AT1 Tender Point Treatment
Midline in suprasternal notch. Push inferiorly. Treatment Seated with fingers interlocked on top of head. Clinician places arms around patient and locks hands over the manubrium. Flexion – created by leaning patient’s trunk backward slightly

AT2 Tender Point Treatment Middle of Manubrium
Seated, same as AT1 but clinician locks hands lower at junction of manubrium and sternum

AT3 Tender point Treatment On sternum just below sternal angle
Seated with arms dropped back and off edge of plinth/table Clinician pulls backward/inferiorly on patient’s arms creating a fulcrum at the desired level. Clinician uses his chest and abdomen to force patient’s thoracic spine in flexion. Augment thoracic flexion by internally rotating arms Flexion of cervical region also

AT4 Lethargy Tender point Treatment
On body of sternum at level of 4th rib interspace Treatment Seated. Same as AT3 but 1.5 cm lower Flexion

AT5 Lethargy Tender point Treatment
On body of sternum at 5rth rib interspace level (at nipple line) Treatment Seated with arms at side. Clinician locks fingers anteriorly over the tender point. Flexion is created by pullingthe patient backward using medial edges of hands as the fulcrum. Clinician leans against patient’s upper thoracic area Flexion

AT6 Grumpy point Tender point Treatment Xiphisternal junction
Seated with arms at side. Same as AT5 but lower Flexion

AT7 Stomach pain, gastritis Tender point Treatment
1. Under the costochondral margin of 7th rib (pain with deep breath) 2. 2 cm below xiphoid. 1 cm lateral to midline Treatment Seated. Clinician has his foot on the table. Patient has opposite arm resting on pillow on clinician’s thigh who stands behind patient. Patient’s feet side-straddle (on table on side of tenderpoint) Flexion Sidebend – toward by translating trunk to opposite side Rotation – away by placing involved side arm across front of body

AT8 Tender point Treatment 2 cm below AT7. 1.5 cm lateral of midline
Same at AT7 with more thoracic flexion

AT9 Tender point Treatment
Just above umbilicus. 1.5 cm lateral to midline Treatment Same as AT7 with more thoracic flexion

Just below umbilicus. 1.5 cm lateral to midline Can often feel anterior body of L3 vertebrae 1.5” in Treatment 1. Supine with head of table raised. Rest patient’s flexed legs on clinician’s thigh. Clinician stands on side of tender point. Produced marked flexion at the level of dysfunction. Rotate knees slightly toward tender side for fine tuning 2. Straight table technique – place pillows under “hips” to obtain flexion of pelvis on lumbar spine. Then proceed as above

Suprapubic region. 2 cm lateral to midline. Medial to ASIS levels Treatment Same as AT10 with fine tuning

Crest of ilium at mid-axillary line. On inner table of iliac crest. Push caudad at iliac crest Treatment Same as AT10. Fine tune

Posterior Thoracic Tender Points
PT1-2 PT3-5 PT6-9 PT10-12 Posterior Thoracic Tender Points

T1-5 – most often tender on sides of spinous processes.
T6-12 – usually more sensitive paravertebrally or just lateral to spinous processes. TL junction – usually most sensitive on the posterior tips of the transverse processes. At times, lateral to the spinous processes.

With posterior thoracic, the closer the tender point to the midline the more backward bending force is needed (split table helpful). The further the tender point from the midline, the more sidebending is needed. Sidebend away from the side of the tender point

Pre-position trunk or legs to create some sidebending away if/as necessary
Transverse process – more sidebend than rotation Spinous process – more rotation than sidebend Diffuse posterior pain – usually have anterior tender points as well Localized specific posterior pain – posterior tender points

PT1 / PT2 Tender point Treatment
On the side of the spinous process of T1 and T2 Occassionaly, PT1 also has a tender point 2 cm above the lateral epicondyle at the elbow Treatment Prone with arms alongside body or supine with head off end of table Extension – if prone, cradle chin in palm and extend to level Sidebend – away Rotate – away T1-T5 similar to lower posterior cervicals

PT3 / PT4 / PT5 Tender point Treatment
On the side of the spinous process T3, T4, T5 Sometimes PT 4 has a tender point 2 cm above the medial epicondyle at the elbow Treatment Prone with arms along side the head. Arm assists in obtaining extension Extension – cradle chin in palm, extend to level Sidebend – away Rotate – away T1-T5 similar to lower posterior cervicals

PT6 / PT7 / PT8 / PT9 Tender point Treatment
Lateral to spinous process, 2 cm or less Treatment PT6 through PL2 Prone. Arm of involved side alongside head. Opposite arm hangs off side of table. Raise arm of involved side by grasping axilla. Pull arm cephalad with slight traction effect Extension – slight, more for lower levels Sidebend – away, main force used is sidebending Rotate – trunk toward Place cervical spine in rotation to side of tender point

PT10 / PT11 / PT12 / PL1 / PL2 PL Tender point Treatment
Lateral to spinous process or on tip of transverse process Treatment Prone Raise cephalic end of table to extend to level Pull back on anterior pelvic on tender point side to sidebend and rotate Sidebend – away Rotate – pelvis toward 30o-45o PL

Anterior Ribs – Depressed Tender Points
AR1 AR2 AR3-6 INT4-6 Anterior Ribs – Depressed Tender Points

AR1 Tender point Treatment
Beneath the clavicle on the first costal cartilage to the sternum Treatment Supine Mild cervical flexion Rotate – toward, markedly Sidebend – toward. Greatest force is applied in sidebending

AR2 Tender point Treatment
1. On second ribs in mid-clavicular line 2.. High in medial axilla Treatment Same as AR1 With decreased shoulder abduction, be sure to check AR1-AR2

AR3 – AR6 Tender point Treatment
On anterior axillary line inferior rib margins at corresponding levels Treatment Sitting Flexion – slight, neck and trunk Sidebend – toward. This is accomplished by leaning patient to opposite side with the patient’s axilla on clinician’s knee (who is standing behind patient). Sidebend toward by translating patient’s trunk away from tender point. If patient’s feed are on plinth on tender point side, the sidebend can be increased Rotate – toward. Let involved side arm hang behind patient to augment

INT4 – INT6 Tender point Treatment
On or between costal cartilage just lateral to sternum at the corresponding level Treatment Patient seated and leaning toward opposite side with opposite axilla supported on clinician’s knee. Clinician standing behind patient. Cervical flexion Patient’s feet on table on tender point side Trunk flexion Sidebend – toward. Created by translating trunk away Rotate – away, by placing patients involved side arm across front of body

Posterior Ribs – Elevated Tender Points
PR2-6 PR1 Posterior Ribs – Elevated Tender Points

PR1 Tender point Treatment
Posterolateral aspect of first rib, beneath the margin of trapezius at side on neck Treatment Sitting Opposite axilla over clinician’s knee, lean patient mildly toward opposite side, then position head/neck Extension – mild Sidebend – away, mild Rotate – toward, moderate

PR2 – PR6 Tender point Treatment
Posteriorly at angle of ribs on superior surface. Adduct patient’s arm across front of body to move scapula laterally and allow easier palpation of rib angles Treatment Sitting Axilla on affected side is resting on clinician’s knee. Lean patient toward tender point side. Opposite arm is hanging loosely behind patient’s back. Patient’s feet are on table opposite of tender point side. Sidebend – away by translating trunk toward tender point side. Rotate – away For 2nd rib, rotate neck away moderately also Treat spinal tender points (thoracic) before rib tender points, even if somewhat more tender

Anterior Lumbar Tender Points
AbL2 AL1 AL2 AL3 AL4 AL5 Anterior Lumbar Tender Points

AT9-AL1 AL1 & AL 2 AL3 & AL4 AL2 & AL5 Similar procedure for 5 levels
Often involved with patient who can’t stand upright AL3 & AL4 Virtually no rotation. Sidebend through legs AL2 & AL5 Are the “key” tender ponts in this area

AL1 Tender point Treatment
Medial to anterior superior iliac spine. ¾” deep. Push medial to lateral Treatment Supine with head of table elevated Patient’s flexed legs rest on clinician’s thigh Clinician on tender point side Flexion – marked at level of dysfunction Sidebend – mild, toward Rotate – knees toward tender point side

Medial inferior surface to anterior inferior iliac spine Treatment Supine Clinician opposite tender point side Flexion – patient’s legs flexed 90o Rotate – knee away from tender point 60o (markedly) Sidebend – away, slightly. Push feet toward floor

AbL2 (Abdominal Tender point Treatment 5 cm lateral to umbilicus
Supine Clinician on tender point side Flexion – more than AL2 Rotate – knee toward tender point (60o) Sidebend – away. Elevate feet upwards to create

Lateral surface of anterior inferior iliac spine Treatment Supine Clinician opposite tender point side Flexion – flex thighs 50o – 90o Sidebend – away markedly by pulling feet toward clinician Rotate – slightly to fine tune

Inferior surfaced of anterior inferior iliac spine Treatment Same as AL3 with fine tuning

Anterior surface of pubic bone, 1.5 cm lateral to pubic symphysis Treatment Supine Clinician on tender point side Flexion – flex thighs 60o – 135o Sidebend – away, slightly Rotate – knees toward side of tender point

Posterior Lumbar Tender Points
PL1 PL2 PL3 PL4 PL5 QL UPL5 PL3 (Iliac) PL4 (Iliac) LPL5 PLRL2 Posterior Lumbar Tender Points

PL3 (Iliac) Tender point Treatment
3 cm below margin of ilium and about 7 cm lateral to posterior superior iliac spine Treatment Prone Clinician on side opposite tender point Extension – lift leg on affected side and support on clinician’s thigh Adduct – mild Rotate – full external. The higher the hand placement o the thigh by the operator, the greater the external rotation created

PL4 (Iliac) Tender point Treatment
4 cm below margin of ilium and just posterior to the border of the tensor fascia lata Treatment Prone Clinician on side opposite the tender point Extension – same as PL3 Adduct – slight Rotate – moderate external rotation

UPL5 (Upper Pole) Tender point Treatment
Superior medial surface of the posterior superior iliac spine. Apply pressure caudad and lateral toward posterior superior iliac spine (45o angle) Treatment Prone Clinician on side opposite tender point Extension – via leg. Major movement required Adduct – very slight Rotate – mild external rotation

LPL5 (Lower Pole) Tender point Treatment
1. 2 cm below posterior superior iliac spine in small saddle between posterior superior iliac spine and posterior inferior iliac spine 2. on sacral promontory in midline Treatment Prone Clinician seated on tender point side Leg on tender point side is dropped off table and resting on clinician’s thigh. Patient’s hip flexed approximately 90o patient’s pelvis is rotated posteriorly and hip adducted slightly by pressure at the knee Flexion – hip 90o Adduction – slight Rotation – pelvis rotate posteriorly

QL (Quadratus Lumborum)
Tender point 1. On the lateral tips of the transverse processes of L2-4 2. In the angle between the transverse process of L1 and the 12th rib Treatment Prone Sidebend trunk toward tender point side Sidebend legs toward tender point side Abduct and extend hip of (on tender point side) and rest on clinician’s thigh Gently hike hip and fine tune with mild rotation (internal or external Extension –hip, mild Abduction – hip, moderate Rotate – fine tune, mild

May complain of Lateral trunk shift Decreased sidebend away
Pain with prolonged sitting Pain rolling in bed

PLRL2 (Posterior Flexed L2) (Psoas Major Muscle)
Tender point Over the posterior aspect of transverse process of L2 Treatment Prone Clinician sits on same side as tender point Flexion – hip off edge of table to 90o and support patient’s knee on clinician’s thigh Abduction – hip, slight to nont Rotation – fine tune by using clincian’s t high to direct a force up the shaft of femur to rotate pelvis

Vertical lumbar pain on tender point side
Difficulty finding comfortable sleep position Restless leg syndrome

Anterior Pelvis / Hip Tender Points
IL ALT AMT LISI ING LIFO ADD GMi/TFL Anterior Pelvis / Hip Tender Points

LISI (Low Ilium – Sacoiliac)
Tender point On superior surface of lateral ramus of pubic bone. 2 cm lateal to pubic symphysis Push cadad Treatment Supine Flexion – 90o to 110o of hip on tender point side Sidebend – none Rotate – none

LIFO (Low Ilium – Flareout)
Tender point Inferior medial surface of the descending ramus of the pubic bone (start palpation at ischial tuberosity) Treatment Supine Flexion –patient’s thigh Abduct femur moderately to accentuate the low flareout Rotate femur externally – markedly by pushing the foot toward the midline Treat LIFO before LISI

AMT (Anterior Medial Trochanter) (Rectus Femoris)
Tender point 1 cm lateral to the anterior inferior iliac spine (AIIS) Treatment Supine Flex hip 130o Abduct – none Rotate – none

ALT (Anterior Lateral Trochanter) (Sartorius)
Tender point 2 cm lateral to AIIS. Flex the hip to find this tender point Treatment Supine Flex hip 90o Abduct – moderate Rotate – external, little or none

IL (Iliacus) Tender point Treatment
Anterior and deep in iliac fossa (push posterior and medial) Treatment Supine Patient’s ankles supported on clinician’s thigh. Extreme flexion of hips and external rotation of both femurs. Full abduction

ING (Inguinal Ligament)
Hip internal rotator dysfunction Tender point Lateral surface of pubic bone just below the inguinal ligament attachment. Push medial Treatment Supine Clinician stands on tender point side Flexion – flex hip 90o and rest on clinician’s thigh. Move the leg on the tender point side under opposite leg of patient. This produces crossing of knees and thighs Adduction of femur Rotate – internal rotation of femur Groin pain

ADD (Adductor) Tender point Treatment
1. Origin of adductors to pubic bone 2. Occasionally in muscle belly Treatment Supine Adduction – marked Cross leg of tender point side in front of opposite leg Flexion – slight

GMi (Gluteus Minimus) Tender point Treatment
Anterior border of gluteus minimus muscle. Superior and anterior to the greater trochanter. Push posterior and medical above greater trochanter Treatment Supine Flexion – hip to 90o Abduction – slight Rotate – marked internal

TFL (Tensor Fascia Lata)
Tender point Belly of TFL muscle approximately 6 cm cephalad and anterior to the greater trochanter Treatment Supine Flexion – hip 90o-100o Abduction – hip, slight Rotation – draw foot laterally to create internal rotation of hip

SAR (Sartorius) (Connection with RK Technique)
Tender point 1. Proximal tendon 2 cm lateral from anterior inferior iliac spine 2. Mid belly of muscle 3. Distal sartorius on medial side of knee (RK) Treatment Supine Flexion – hip and knee 90o Abduction – hip, moderate Rotation – external, moderate

Posterior Pelvis / Hip Tender Points
HISI MPSI PLT HFO-SI PIR PMT GM LT Posterior Pelvis / Hip Tender Points

HISI (High Ilium – Sacroiliac)
Common Tender point 3 cm lateral to the posterior superior iliac spine Treatment Prone Extension – hip, supported on clinician’s thigh Abduct - slight

HFO-SI (High Flare-Out Sacroiliac)
May be associated with coccygodynia Tender point 1. 4 cm below and slightly medial to PSIS in the area of the inferior lateral angles of the sacrum Occasionally on the ischial tuberosity Treatment Prone Clinician on side opposite tender pont Raise leg on the tender point side high enough to clear opposite leg and adduct across, scissoring the legs Correction is by increasing/accentuating the high ilium and flareout. Occasionally, the opposite leg is extended mildly and adducted

MPSI (Mid-Pole Sacoiliac)
Ilium flare in - superiorly Tender point Middle of the buttocks in slight depression Direct palpating finger medially (located medial to piriformis) Treatment Prone Extension – slight, occasionally slight flexion Abduction – moderate, major component Helpful with dysmenorrhea, may decrease cramping intensity by 50-60%

PIR (Piriformis) Tender point Treatment
In the muscle belly, 8 cm medial and slightly cephalad to the greater trochanter Treatment 1. Similar to LP5 Prone Clinician seated on tender point side Leg on tender point side suspended off side of table with patient’s anterior aspect on ankle resting on operator’s thigh Flexion – 120o at hip Abduct –moderate, horizontally rotate – usually internal Piriformis – muscle belly 2. Occasionally will clear with the posterior lateral trochanter technique (easier) Piriformis - tendon

PLT (Posterior Lateral Trochanter)
Hip external rotator dysfunction Tender point Posterosuperior lateral surface of greater trochaner Tender point is near the insertion of the piriformis muscle Push anterior and medial Treatment Prone Clinician on tender point side Extension – hip, support thigh on clinician’s knee Abduction – slight Rotate – marked external

PMT (Posterior Medial Trochanter)
Tender point On a line from the lateral inferior surface of ischial tuberosity to the medial aspect of the posterior surface of the femur Treatment Prone Clinician on side opposite tender point Clinician pins patient’s ankle in his/her axilla Extension – hip, moderate Adduction – marked Rotate – marked external

LT (Lateral Trochanter (LT)
Tender point 12 cm below greater trochanter on lateral side of the shaft of the femur. Push medially Treatment Prone Flexion – hip, minimal Abduction – hip Rotate – hip, internal or external, slight

GM (Gluteus Medius) Tender point Treatment
On a line 1 cm below the iliac crest Follow medial to lateral with palpation Treatment Prone Clinician on tender point side Extension – hip, clinician places knee under patient’s thigh Abduction – hip, moderate Rotate – marked, internal

S2 S3 S4 S5 S1 Sacral Tender Points

PS1 Backward sacral torsion dysfunction Tender point Treatment
1.5 cm medial to inferior aspect of PSIS bilaterally Treatment Prone Apply a downward pressure (toward table) on the opposite corner of the sacrum from which the tender point is found to produce rotation around an oblique axis Twist heel of hand for subtle fine tuning/rotation

PS2 Sacral extension dysfunction Tender point Treatment
Midline on sacrum between the first and second spinous tubercles Treatment Prone Apply a downward pressure to the apex of the sacrum in midline to produce rotation around a transverse axis Twist heel of hand for subtle fine tuning/rotation

PS3 Sacral extension dysfunction Tender point Treatment
Midline on sacrum between the second and third spinous tubercles Treatment Prone Apply a downward pressure to the apex of the sacrum in midline Twist heel of hand for subtle fine tuning/rotation

PS4 Sacral flexion dysfunction Tender point Treatment
Midline on sacrum just above sacral hiatus Approach inferior to superior Treatment Prone Apply a downward pressure to the sacral base in midline Twist heel of hand for subtle fine tuning/rotation

PS5 Forward sacral torsion dysfunction Tender point Treatment
1 cm medial and 1 cm superior to the inferior lateral angles bilaterally Treatment Prone Apply a downward pressure to the opposite corner of the sacrum from where the tender point is found Twist heel of hand for subtle fine tuning/rotation

CYX (Coccyx Point) Coccygodynia Tender point Treatment
Either side of tip of coccyx Treatment Prone Apply a downward pressure to the apex of the sacrum Rotate sacrum toward side of tender point (95%). Rotate away from the side of tender point (5%)

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