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Counterstrain & Tender Points
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Counterstrain & Tender Points

Indirect technique using tender points and position of ease for 90 seconds.

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◆Concept

  • •Indirect technique — moves AWAY from the barrier
  • •Find tender point (1 cm diameter, sharply painful, no rebound)
  • •Position the patient to reduce pain by at LEAST 70% (ideally 100%)
  • •Hold position for 90 SECONDS (anterior cervical: 30 sec)
  • •Slowly return patient to neutral while monitoring tender point
  • •Reassess tenderness — should be markedly improved

◆Anterior cervical tender points

  • •AC1 (located on posterior aspect of ascending ramus of mandible): treat with marked flexion + side-bending and rotation AWAY
  • •AC2-AC6: located on anterolateral tip of transverse process; flexion + side-bending and rotation AWAY from tender point
  • •AC7: top of clavicle near sternoclavicular joint; flexion + side-bending AWAY + rotation TOWARD
  • •Anterior cervical tender points hold for 30 SECONDS only (not 90)

◆Posterior cervical tender points

  • •PC1-inion (occipital): extension + side-bending AWAY + rotation AWAY
  • •PC2-PC7 (on inferior aspect of spinous process or lateral): extension + side-bending and rotation AWAY
  • •Hold 90 seconds

◆Thoracic & lumbar tender points

  • •Anterior thoracic (on chest wall): treat with flexion + side-bending + rotation appropriately
  • •Posterior thoracic (on spinous processes or paravertebrals): extension + side-bending AWAY + rotation AWAY
  • •Anterior lumbar: psoas point (medial to ASIS) — treat with knee/hip flexion and side-bend toward
  • •Posterior lumbar: usually require extension, sometimes Sims position

◆Common upper extremity points

  • •Long head of biceps (anterior): flex elbow with slight abduction and external rotation
  • •Lateral epicondyle: flex elbow with supination
  • •Medial epicondyle: flex elbow with pronation

◆Common lower extremity points

  • •Piriformis: deep gluteal tender point — flex/abduct/externally rotate (FABER)
  • •Iliacus: medial to ASIS — bilateral hip flexion with knees pulled toward chest, ankles crossed

◆Indications

  • •ACUTE somatic dysfunction (where direct techniques would cause pain)
  • •Post-operative, hospitalized, frail elderly patients
  • •Pediatric patients
  • •Patients on anticoagulation (avoid HVLA)
  • •Acute rib pain, low back spasm

◆Contraindications

  • •Patient cannot tolerate the position
  • •Inability to relax (counterstrain requires patient relaxation)
  • •Severe systemic illness or unstable patient

High-yield pearls

  • ◆Reduce pain by ≥70% in the position of ease
  • ◆Hold for 90 SECONDS (anterior cervical = 30 seconds)
  • ◆SLOWLY return to neutral — fast return defeats the treatment
  • ◆Anterior tender points: usually require FLEXION + away from tender point
  • ◆Posterior tender points: usually require EXTENSION + away from tender point
  • ◆Iliacus tender point treatment position: bilateral hip flexion, knees to chest, ankles crossed
Quick check

4-question quiz on this note

Test yourself before moving on. ~1 min.

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