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Counterstrain Powerpoint
Counterstrain Powerpoint
LC1
AC2
AC3
TR
AC4
AC5
AC6
ALC
Anterior AC7
Cervical
Tender AC8
Points
AC1 reg
AC1 rare
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
⚫ 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
⚫ 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:
⚫ 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)
AC3
Tender point
⚫ Anterior surface of tip of C3
transverse process
Treatment
⚫ Supine
⚫ Flexion – marked
⚫ Sidebend – usually toward
⚫ Rotate – away (moderate)
AC4
Tender point
⚫ Anterior surface of tip of C4
transverse process
Treatment
⚫ Supine
⚫ Extension – slight
⚫ Sidebend – away (moderate)
⚫ Rotate – away (moderate)
⚫ Exception to rule
AC5
Tender point
⚫ Anterior surface of tip of transverse
process of C5
Treatment
⚫ Supine
⚫ Flexion – moderate
⚫ Sidebend – away (moderate)
⚫ Rotate – away (moderate)
AC6
Tender point
⚫ 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
⚫ 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
⚫ 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
PC1 Inion
PC1
Posterior
Cervical PC2
Tender PLC
PC3
PC4
Points PC5
PC6
PC7
PC8
PC1 (Inion)
Tender point
⚫ 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
⚫ 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
⚫ 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
Tender points
⚫ 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
AT1
AT2
AT3
AT7
AT4
Anterior AT5
AT6
AT8
Thoracic
AT9
Tender AT10
AT12
Points
AT11
AT5-AT8
Requires lots of force
Tender Point
⚫ 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
⚫ Middle of Manubrium
Treatment
⚫ Seated, same as AT1 but clinician
locks hands lower at junction of
manubrium and sternum
AT3
Tender point
⚫ On sternum just below sternal angle
Treatment
⚫ 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
⚫ 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
⚫ 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
⚫ Xiphisternal junction
Treatment
⚫ Seated with arms at side. Same as
AT5 but lower
⚫ Flexion
AT7
Stomach pain, gastritis
Tender point
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
⚫ 2 cm below AT7. 1.5 cm lateral of
midline
Treatment
⚫ Same at AT7 with more thoracic
flexion
AT9
Tender point
⚫ Just above umbilicus. 1.5 cm lateral to
midline
Treatment
⚫ Same as AT7 with more thoracic
flexion
AT10
Tender point
⚫ 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
AT11
Tender point
⚫ Suprapubic region. 2 cm lateral to
midline. Medial to ASIS levels
Treatment
⚫ Same as AT10 with fine tuning
AT12
Tender point
⚫ Crest of ilium at mid-axillary line. On
inner table of iliac crest. Push caudad
at iliac crest
Treatment
⚫ Same as AT10. Fine tune
PT1-2
PT3-5
PT6-9
Posterior
Thoracic
Tender
Points PT10-12
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
⚫ 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
⚫ 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
⚫ 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
Tender point
⚫ 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
AR1
AR2
Anterior
Ribs –
Depressed
Tender AR3-6
Points
INT4-6
AR1
Tender point
⚫ 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
1. On second ribs in mid-clavicular line
2.. High in medial axilla
Treatment
⚫ Same as AR1
Posterior
Ribs – PR2-6
Elevated
Tender
Points
PR1
Tender point
⚫ 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
⚫ 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 AbL2
Lumbar AL1
Tender
AL2
Points AL3
AL4
AL5
AT9-AL1
⚫ Similar procedure for 5 levels
AL1 & AL 2
⚫ 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
⚫ 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
AL2
Tender point
⚫ 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
⚫ 5 cm lateral to umbilicus
Treatment
⚫ Supine
⚫ Clinician on tender point side
⚫ Flexion – more than AL2
⚫ Rotate – knee toward tender point
(60o)
⚫ Sidebend – away. Elevate feet
upwards to create
AL3
Tender point
⚫ 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
AL4
Tender point
⚫ Inferior surfaced of anterior inferior
iliac spine
Treatment
⚫ Same as AL3 with fine tuning
AL5
Tender point
⚫ 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
PL1
QL
PLRL2
PL2
PL3
Lumbar
Tender PL4 (Iliac)
Points
LPL5
PL3 (Iliac)
Tender point
⚫ 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
⚫ 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
⚫ 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
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
IL
ALT
AMT
Anterior LISI
Tender
Points
GMi/TFL
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
Tender point
⚫ 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
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
⚫ 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
HISI
PLT
Posterior MPSI
Pelvis / Hip
Tender HFO-SI
PMT
GM
Points PIR
LT
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
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
⚫ 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
S1 S1
Sacral
Tender S2
Points S3
S5 S5
S4
PS1
Backward sacral torsion dysfunction
Tender point
⚫ 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
⚫ 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
Coccygodynia
Tender point
⚫ 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%)