STRAIN AND COUNTERSTRAIN FOR PELVIC PAIN Randall S. Kusunose

n Introduction

The gentle and atraumatic nature of the strain and counterstrain (SCS) techniques establishes it as a safe and effective primary mode of inter- vention in the treatment of painful hypertonic pelvic floor musctes and the joints they influence. Pelvic floor muscle hv~ertonicitv can cause mus- culoskeletal pain and adversely affect the uro- genital and colorectal systems they maintain (ICusunose 1993). This innovative treatment sys- tem uses passive body positioning of hypertonic muscles and dysfunctional joints toward posi- tions of con~fort or tissue ease that compress or shorten the offending structure. The purpose of movement toward shortening is to arrest aber- rant propriocep tive neuromuscular reflexes that maintain n~uscle hypertonicity, forcing eventual reduction of neuromuscular tone to tonic levels. The strain and counterstrain (SCS) technique is considered to be an indirect manipulative tech- nique, because its action for treatment moves away from the restrictive barriers (Jones 1964, Jones et al. 1995. I<usunose and Wendorff 1990. Travell and Simons 1992, Wilder 1997).

m History

The SCS technique was developed by the Ameri- can osteopath Dr. Lawrence Jones in the 1950s. It is categorized as an "afferent reduction techni- que" (Wilder 1997) and was originally called "spontaneous release by positioning" or "posi- tional release technique" (Travel1 and Simons 1992) before receiving its current name. Jones was motivated to experiment with the concept of positional release in part clue to his frustration with the rationale that was current in his time for treatment of osteopathic lesions (somatic dys- function). He was schooled to believe that some- how joints became loclced or subluxed and that the only way to treat them was to bust them loose via high-velocity thrust techniques. His re- sults were generally good, but occasionally a pa- tient would enter his office who resisted all of his manipulative skills-until, Jones states, "only stubbornness kept me from admitting I was stumped" (Wilder 1997). He recounts that he was treating just such a patient when he discov- ered positional release.

A young man with psoasitis (stooped posture, unable to come con~pletely erect, with severe pain across the low lumbar and sacroiliac area) had been treated by Jones using high-velocity techniques for 6 weeks with no relief of symp-

toms. He had been treated previously by two chiropractors for 10 weeks, with similar results. He complained of pain in bed and an inability to find a comfortable position that he could stay in for longer than 15 min. Jones therefore de- voted one treatment session to finding a reason- ably comfortable position for the patient to sleep in. After 20 min of experimentation, a position of amazing comfort was found. Jones relates that "He was nearly rolled into a ball, with the pelvis rotated about 45" and laterally flexed about 30°." This was the first positive response the patient had had after 4 months of treatment, so Jones propped him in the position 'and went off to treat another patient. When he returned. 20 min later, he helped the patient upright and was astonished to find he could stand completely erect in total comfort. Examination revealed a full and near pain-free range of motion. All Jones had done was put the patient in a positio~i of comfort and the results were dramatic- after his best efforts had previously repeatedly failed.

This was the inspiration that pron-ipted Jones to experiment with positional release, applying it to all joint and muscle dysfunction. During this developmentai period, he observed that fol- lowing the position-of-release treatment, a re- turn to neutral carried out very slowly was im- portant for the outcome of the treatment. If the patient was returned toward neutral too quickly, especially in the first 15" of the motion, the ben- efit from the positioning was lost. Also, after in- itially supporting the first patient in the position of release for 20 min, he was systematically able to reduce the period to 90s. If the position was held for less than 90s, the results were incon- sistent, but more than 90s did not appear to increase the benefit to the patient (Jones 1964, Travell and Simons 1992, Wilder 1997).

The second feature of SCS was the discovery of palpable myofascial tender points and their cor- relation with specific somatic dysfunction. Jones describes tender points as "small zones of tense, tender, edematous muscle and fascia1 tissue about a centimeter in diameter" (Wilder 1997). These points, found by moderate palpatory pres- sure, are directly related to somatic dysfunction and were found with such consistency that they became his diagnostic tool. Tender points are a rniilimum of four times more tender than normal tissue. Palpation with less than sufficient pres- sure to cause pain in normal tissue will elicit a sharp local pain or jump sign, characteristic of an SCS tender point. Most of the tender points

are found overlying the muscle involved in the dysfunction. Tender points found in the paraver- tebral musculature or over spinous processes are especially valuable for diagnosing segmental dys- function in the vertebral column (Jones 1964, Wilder 1997). - Evaluation with Tender Points

Tender points are not only found over spin- ous processes or paravertebral musculature. Figure 2.6 shows the magnitude of the number of diagnostic tender points that Jones has mapped out over the entire body. This illustra- tion represents just a small sample of the close to 240 tender points that Jones and colleagues have correlated with very specific muscle and joint neuromuscular dysfunctions (Jones 1964, 1981, Travel1 and Simons 1992, Wilder 1997).

Specificity in evaluating a structure as in- volved and complex as the pelvis and low back is what makes SCS tender points such a quick and valuable tool. An accurate assessment of which muscles and joints of the pelvic floor are invoived will be crucial to a successful outcome. Numerous tender points have been located in the anterior and posterior pelvis and hips, in the bellies of the iliacus, psoas, levator ani, glu- teals, quadratus femoris, piriformis, obturator in- ternus, and adductor muscles and many others, indicating local muscle dysfunctions as well as points that diagnose joint ilial-sacral and sa- cral-ilia1 motion restrictions, lumbosacral dys- functions, and pubic symphysis problems (Jones 1964, 1981, Travel1 and Simons 1992. Wilder 1997).

An added characteristic of tender points, besides their value as a diagnostic tool, is their use as monitoring points. By monitoring the ten- der point for changes in tissue tension and the patient's feedback of either increasing or decreas- ing sensitivity, the operator is guided to a posi- tion of maximum palpatory relaxation beneath the monitoring finger. A marked and prompt re- duction in subjective tenderness ensues. Jones calls this the "mobile point" Uones 1964, Wilder 1997). It is the point of maximum ease or relaxa- tion of the tissue beneath the monitoring finger, where movement in any direction will increase tissue tension. The mobile point signifies the ideal position for release (Jones 1964, 1981, Wilder 1997).

Jones explains the use of tender points in this way: "A clinician skilled in palpation techniques will perceive tenseness and/or edema as well as

tenderness, although the tenderness (often mul- tiple times greater than that of normal tissue) is for the beginner the most valuable diagnostic sign. He maintains his palpation finger over the tender point to monitor expected changes in cone and tenderness. With the other hand he po- sitions the patient into a posture of comfort and relaxation. He may proceed successfully just by questioning the patient as he probes intermit- tently while moving toward the position. If he is correct, the patient can report diminishing ten- derness in the tender point area. By intermittent deep palpation he monitors the tender point, seeking the ideal position at which there is at least a two-thirds reduction in tenderness" (Wilder 1997). Finding the position of release in this way, holding this position for 90s. and re- turning to neutral very slowly are the major com- ponents of the SCS technique.

A common question is the relationship of SCS tender points to Travell's trigger points, acupunc- ture points, Chapman's reflex points, shiatsu points, and the myriad of other systems that use points for diagnosis and treatment. There is, of course, considerable overlap in point locations and the palpatory feel of the tissue, but that is where the similarities end. SCS tender points are different. and recognizing the differences is essential to choosing the appropriate approach.

a Travell's trigger points are defined as foci ,

of hyperirritability in the muscle and/or fascia that produce a characteristic pat- tern of referral specific for the muscle in- volved (Korr 1975).

Trigger points are also associated with a taut band of skeletal muscle that is painful on com- pression and a local twitch in the muscle fibers containing the trigger point. A local twitch can be produced by stimulation, with a snapping pal- pation over the taut band eliciting a contraction of the muscle fibers (lcorr 1975). SCS tender points can refer to a similar distribution to that of trigger points, but the pain is dull and achy, rather than shooting. The tissue tension at the tender point site can be tight, tense, edematous, or boggy, unlike the fibrotic, dense tissue of a trigger point. Since SCS tender points are exqui- sitely painful to palpation, patients can react with a jump sign when they are palpated. This response is a full-body pain reaction to the pal- pation stimulus and not a local twitch of muscle fibers.

There are two major differences between SCS tender points and the other systems that use points (such as acupuncture and shiatsu). Firstly, SCS tender points tend to be more segmental in origin. Points along the vertebral column desig- nate segmental dysfunction at the corresponding vertebral level. The other philosophies identify points as related to full-body systems and are more holistic in nature. Secondly, Jones considers that SCS tender points are a sensory manifesta- tion of a neuromuscular or musculosl<eletal dys- function (Wilder 1997). The points are used to make the diagnosis and to monitor the effective- ness of the treatment technique. Treatment is not directed at the tender point, but at the muscle or joint dysfunction that produces the tender point. If the treatment is effective, the tender point diminishes in tenderness, tissue tension, and edema. In the other philosophies, the treatment is directed toward the painful point by injection, needling, deep pressure, electrical stimulation, and vapocoolants.

I Techniques

The techniques demonstrated in this section em- phasize evaluation and treatment procedures for muscle hypertonicity affecting the lumbosacral, and sacroiliac, sacrococcygeal joints, the pubic symphysis, and the hips, as well as the muscles that support the visceral organs. A thorough SCS evaluation of a patient with pelvic floor pain and other presenting complaints related to hy- pertonic dysfunction (dyspareunia, coccydynia, vaginismus, constipation, etc.) would be broa- dened to include the middle thoracic spine and ribs and extend below the knee. The SCS system includes techniques for all the areas of the body, but the details given here are limited due to space constraints.

Evaluation of specific dysfunctions is done by external palpation of the pelvic ring and attached muscles for SCS tender points. SCS tender points can also be found with internal palpation of the pelvic floor muscles and can be used for diagno- sis and as monitoring tools to sense the release of tone with the treatment technique, but inter- nal palpation will not be presented here (see sec- tion 2.1 above).

SCS evaluation and treatment steps (Figs. 2.7. 2.8):

1. Locate the tender point to make a diagnosis. 2. Find the position of comfort or the mobile

point to treat. 3. Monitor the point response but take all pres-

sure off the tissue. 4. Hold the position for 90 s. 5. Return to neutral slowly, especially in the

first 15". 6. Recheck the tender point (should be at least

70 % improved).

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Fig. 2.7 Tender points in the anterior pelvis and hips. Note: the arrows point in the direction of palpation. AL5 = Anterior 5th lumbar, IL = Iliacus, INC = Inguinal. LIFO = Lower ilium with flare-out, LlSl = Lower ilium sacroiliac, TFL = Tensor fasciae latae.

HlFO -y---

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Fig. 2.8 Tender points in the posterior pelvis and hip. Note: the arrows point in the direction of palpa- tion. G M = Cluteus medius, GMI = Cluteus minimus, HlFO = High ilium with flare-out, HlSl = High ilium sacroiliac, MPSl = Midpole sacroiliac, 01 = Obturator internus, PIR = Piriformis.

Anterior Fifth Lumbar (AL5) lliacus (IL)

Tender point location. This common tender point is found over the anterior surface of the pubic bone approximately 1.5-2.0cm lateral to the pubic sympliysis. The tissue tension feels thick- ened and dense and co~nmonly produces a burn- ing pain when palpated. Palpate in a posterior di- rection (Fig. 2.9).

Most common complaints. Deep achy posterior lumbar, sacroiliac, and buttock pain; also medial knee pain.

Treatment position. The patient lies supine. The hips are flexed from 80 to 120" and supported on the operator's thigh. The operator produces trunk rotation by drawing the knees toward the tender point side. The operator then produces trunk lateral bending by pushing the feet away from the tender point side. Fine-tune the position by adjusting all three planes of motion.

Tender point location. Found deep in the iliac fossa approximately 4cm medial and caudal to the anterior superior iliac spine (ASIS). Palpate deeply but gently in a posterior-medial and pos- terior-lateral direction, feeling for aberrant tone (Fig. 2.10).

Most common complaints. Sacroiliac pain ex- tending down along the medial buttocl<s. Diffuse lumbar ache. Increased symptoms with pro- longed standing or walking.

Treatment position. The patient lies supine with the ankles supported on the operator's thigh. The hips are flexed to approximately 90" and the knees are allowed to flop outward, creating marked external rotation of the femurs. Fine- tune the position, adjusting hip flexion and rota- tion to find the mobile point.

Fig. 2.9a, b Tender point anterior fifth lumbar (AL5). Fig. Z.lOa, b Tender point iliacus (IL).

'I Low Ilium Sacroiliac (LISI; Correlates with Posterior Innominate Rotation)

Tender point location. On the superior surface of the lateral ramus of the pubic bone, approxi- mately 2 cm lateral to the pubic symphysis. Pal- pation is directed inferiorly (Fig. 2.1 l).

Most common complaints. Deep ache in the pos- terior lumbars, sacroiliac, and posterior lateral hip.

Treatment position. The patient lies supine. The operator stands on the tender point side and flexes the hip to between 80 and 120°, depending on the patient's flexibility. The position is main- tained with mild pressure on the front of the shin.

Fig. 2.11a, b Tender point low ilium sacroiliac (LISI).

I Low Ilium with Flare-Out (LIFO) Most common complaints. Deep ache in buttocl<s and posterior lateral hip.

Tender point location. Found on the inferior medial surface of the descending ramus of the Treatment position. The patient lies supine. The pubic bone. Palpate in a superolateral direction hip is flexed and the knee is allowed to flop later- along the length of ramus from just below the ally, with the foot being kept on the midline, pubic symphysis to just above the ischial tuber- producing abduction and external rotation of osities (Fig. 2.12). the femur. Fine-tune the position primarily with

flexion.

Fig. 2.12a. b Tender point low ilium with flare-out (LIFO).

H Inguinal (ING) Most common complaints. Groin pain, medial thigh pain, and anterior-medial knee pain.

Te~ltler point location. On the lateral borcler of the pubic bone, just caudal and lateral to the inguinal tubercle. Palpate in a medial direction (Fig. 2.13).

Fig. 2.13a. b Tender point inguinal (INC).

Gluteus Minimus (CMI) and Tensor Fasciae Latae (TFL)

Tender point location. 1 ) The GMI tender point lies 4 cm above the greater trochanter. Palpate the anterior fibers of the gluteus minimus in a poster- omedial direction. 2 ) The TFL tender point lies 4c1n above and in front of the greater trochanter. Palpate the muscle belly of the tensor fasciae latae in an antesomedial direction (Fig. 2.14).

Treatment position. The patient lies supine. The hips and knees are flexed to approximately 90°, supported on the operator's thigh. The unaffected leg is crossed over the affected leg at the knee, producing hip adduction. The operator holds the anl<le of the affected leg and draws it laterally to produce internal rotation of the hip. Fine- tune the position with rotation.

Most common complaint- Pain in the buttocks, lateral hip joint, and thigh.

Treatment position. The patient lies supine. The affected hip joint is flexed to about 90" and slightly abducted. The hip is internally rotated by pulling the foot laterally. Fine-tune position with rotation.

Note: Both of these lesions are treated in the same position.

Fig. 2.14a, b Tender points gluteus minimus (CMI) and fasciae latae (TFL).

I Adductors (ADD)

Tender point location. Tender points can be found at the muscles' origin from the inferior pubic rarnus and down the length of the muscle bellies (Fig. 2.15).

Most common complaints. Groin pain and rned- ial thigh pain to the knee.

Fig. 2.15a, b Tender points adductors (ADD).

I High Ilium Sacroiliac (HISI; Correlates with Anterior Innominate Rotation)

Tender point location. Approximately 3 crn lat- eral to the posterior superior iliac spine (PSIS). Palpation is directed rnedially to the lateral sur- face of the PSIS (Fig. 2.16).

Fig. 2.16a, b Tender point high ilium sacroiliac (HIS]).

Treatment position. The patient lies supine. The operator stands on the opposite sicle from the tender point. The affected hip is flexed just enough to clear the opposite leg, and then adducted. Fine-tune the position with adduction.

Note: Tender points in the adductor magnus prefer hip extension (see p. 158, high ilium with flare-ou t treatment).

Most common complaint. This is a common dys- function that produces a sharp, localized pain i l l

the area of the tender point.

Treatment position. The patient lies prone. The hip should be extended and supported on the operator's thigh. Fine-tune the position with hip extension and slight abduction.

High Ilium with Flare-Out (HIFO)

Tender poitlt location. 1 ) A first point can be found anywhere from 4 to 7 cm below and slightly medial to the PSIS, extending along the lateral border of the sacrum to the inferior lateral angles. Palpate in a medial direction along the lateral sa- cral edge. 2) A second point found on the ischial

tuberosities can diagnose adductor magnus dys- function. Palpate the bone in a superior direction from underneath the gluteal folds (Fig. 2.17).

Most comlnon complaints. Sacroiliac, coccyx, and medial thigh pain, and ischial tuberosity pain with sitting.

Treatment position. The patient lies prone. The operator stands 011 the opposite side from the ten- der point. The affected hip is extended and ad- ducted across the opposite leg. Fine-tune with ab- duction and adduction until relaxation is felt.

Fig. 2.17a, b Tender point high ilium with flare-out (HIFO).

Midpole Sacroiliac (MPSI; Correlates Most colnlnon complaints. Sacroiliac pain, but- with In-Flare Dysfunction) tack pain, dysmenorrhea.

Tender point location. Found in the middle of Treatment position. The patient lies prone. The each buttoclc, sometimes in a small depression. affected hip is abducted. Fine-tune the position Palpation is superficial in a medial direction. usually with slight hip flexion and external rota- The buttock should be seen rising like an accor- c:~. .

L I U I I . dion in the middle as the operator's palpating Note: Decreased cramping is noticed in patients fingers travel 3-4 cm medially (Fig. 2.18). with dysmenorrhea by the second menstruation.

Fig. 2.18a. b Tender point midpole sacroiliac (MPSI).

= Piriformis (PIR) Tender point location. 1 ) Found in the mid-belly of the piriformis muscle between the lateral sa- crum and the greater trochanter of the hip. Pal- pate in an anterior direction. 2) The second ten- der point is found over the posterior, lateral, and superior aspect of the greater trochanter. Pal- pate in an anterior-medial direction (Fig. 2.19).

Most common complaints. Buttoclc pain, tro- chanter pain, sciatica.

Fig. 2.19a, b Tender points piriformis (PIR).

Cluteus Medius (GM) Tender point location. Multiple tender points can be found on a line 2 cm below the top of the iliac crest, between the PSlS and the posterior border of the tensor fasciae latae muscle. Palpate in an anterior direction (Fig. 2.20).

. .

Fig. 2.20a, b Tender point gluteus medius (CM).

Treatment positions. 1 ) The patient lies prone. The affected hip is flexed approximately 90" off the edge of the table and abducted from moder- ate to marked while resting on the operator's thigh. Fine-tune the position with flexion, abduc- tion, and hip rotation by drawing the foot medi- ally and laterally.

2) The patient lies prone. The affected hip is extended and slightly abducted, supported on the operator's thigh. The patient's leg is allowed to roll down the operator's thigh, producing marked external rotation of the hip (Fig.2.19).

Most common complaints. Sharp pain over the top of the iliac crest, pain in the buttoclcs, and sa- cral pain.

Treatment position. The patient lies prone. The affected hip is extended and abducted, and then supported on the operator's thigh. The operator grasps the inner aspect of the patient's leg and with the elbow extended, leans backward to produce internal rotation of the hip. Fine-tune with abduction and rotation.

D Obturator lnternus (01) Most common complaints. Deep ache in ipsilat- era1 hip, coccyx pain, posterior thigh pain.

Tender point location. Found on the inner sur- face of ;he obturator membrane and rim of the Treatment position. The patient lies prone. The obturator foramen. It can be found by pushing knee on the affected side is flexed to 90" and cephalad from the medial side of the ischial the foot is then allowed to flop medially to pro- tuberosity and then pushing laterally into the duce marked external rotation of the hip. Fine- obturator membrane (Fig. 2.21). tune the position with rotation.

Fig. 2.21a, b Tender point obturator internus (01).

- Levator Ani (LA) Tender point location. Found in the bellies of the pubococcygeus and iliococcygeus muscles. Pal- pate in a cephalad and lateral direction, starting 2cm anterior and lateral from the coccyx and moving in an anterior-lateral direction (Fig. 2.22).

Most common complaints. Sacral and coccyx pain, suprapubic ache, rectal pain, constipation, and urinary urgency.

Fig. 2.22a, b Tender point levator ani (LA).

Treatment position. The patient lies supine with the hips and knees flexed. A towel roll is placed under the sacrum to facilitate sacral extension. The operator monitors the tender point with one hand while the opposite hand contacts the anterior aspect of the pubic bone over the sym- physis. Mild compression is applied in a posterior direction. Fine-tuning is achieved by gently twisting the treatment hand in a clockwise or counterclockwise direction.

Quadratus Lumborum (QL) Tender point location. 1 ) Found on the lateral tips of the transverse processes of lumbar vertebrae 2-4. Palpate in a medial direction. 2) Less com- mon, but can be picked up in the area between the transverse process of lumbar vertebra 1 and the 12th rib. Palpate in an anterior direction. 3) Can also be found 2 cm above the posterior crest of the ilium, pushing in an anterior direction (Fig. 2.23).

Most common complaints. Sharp posterior lum- bar, sacroiliac. buttoclz, and hip pain. Lateral

Fig. 2.23a, b Tender point quadratus lumborum

Posterior First Sacral (PSI) Tender point location. Found 1.5 cm medial to the inferior aspect of the posterior superior iliac spine (PSIS), slightly caudal to the sacral sulcus. Palpate in an anterior direction (Fig. 2.24).

Most common complaints. Sacroiliac and coccyx pain.

Fig. 2.24a, b Tender point posterior first sacral (PSI).

trunk shift. Pain with prolonged sitting. Can also present with groin and testicular pain.

Treatment position. The patient lies prone. Bend the trunlz laterally toward the tender point side by sliding the patient's shoulders laterally. Bend the lower body laterally toward the tender point side by sliding the legs laterally. Abduct the hip on the affected side and bend the knee to 90". Let the foot drop medially to produce external rotation of the hip. Fine-tune with hip rotation and abduction.

Note: Patients with greater than normal hip extension often need to have this motion added to the technique.

Treatment position. The patient lies prone. With the heel of the hand, apply anterior pressure on the corner of the sacral apex opposite to the ten- der point. The pressure is light to moderate. This pressure will produce a slight backward torsion of the sacrum in relation to the ilium. Fine-tune by slowly twisting the hand back and forth.

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= Posterior Second Sacral (PSZ) and Posterior Third Sacral (PS3)

Tender point locations. Found midline on the sa- crum between the first and second sacral spines and the second and third sacral spines. Both are com~non tender points, but are frequently missed because the gaps between the spines are small. The tip of an index finger has to be used to pal- pate these points (Fig. 2.25).

Fig. 2.25a, b Tender points posterior second sacral (PS2) and posterior third sacral (PS3).

Most common complaints. Sacroiliac and coccyx pain, and diffuse pain down the posterior aspect of the buttocl< and leg.

Treatment position. The patient lies prone. With the flat of the hand, contact the entire surface area of the sacrum. Scoop the sacrum into exten- sion, following the line of the sacrum. This will create an anterior pressure over the sacral apex in midline, producing rotation around a trans- verse axis. Fine-tune by slowly twisting the hand i n a clocl<wise and counterclocl<wise direction.

Sacrum - Posterior Fourth Sacral (PS4) Tender point location. Found midline on the sa- crum just above the sacral hiatus. Palpate in an anterior direction (Fig. 2.26).

Most common complaints. Sacroiliac and coccyx pain.

Treatment position. The patient lies prone. With the heel of the hand, apply an anterior pressure to the sacral base in midline, producing sacral flexion around a transverse axis. Fine-tune by slowly twisting hand in a clocl<wise and counter- clocl<wise direction.

Fig. 2.26a, b Tender point fourth sacral (PS4).

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Posterior Fifth Sacral (PS5) Tender point location. Found on the corners of the sacral apex, I c n ~ cephalad and medial to the inferior lateral angles of the sacrum. Palpate in an anterior direction (Fig. 2.27).

Most common complaint, Sacroiliac and coccyx pain.

Treatment position. The patient lies prone. With the heel of the hand, apply an anterior pressure to the corner of the sacral base opposite to the tender point. Pressure is light to moderate. This pressure will produce a slight forward torsion of the sacrum in relation to the ilium. Fine-tune by twisting the hand back and forth.

Coccyx (CYX) Tender point location. Follow the coccyx as dis- tally as possible and palpate on either side of the tip in a cephalad direction (Fig. 2.28).

Most common complaints. Coccyx and groin pain.

Treatment position. The patient lies prone. With the flat of the hand, contact the entire surface area of the sacrum. Scoop the sacrum into exten- sion, following the line of the sacrum. This will create anterior pressure over the sacral apex in the midline, producing sacral extension around a transverse axis. If the point is on the left tip of the coccyx, fine-tune by gently twisting the hand in a cloclzwise direction; if the point is on the right tip of the coccyx, twist counterclockwise.

Fig. 2.27a, b Tender point fifth sacral (PS5).

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Fig. 2.28a. b Tender point coccyx (CYX).

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Case studv 1 References M. 6.. a 38-year-old woman, presented with pel- vic floor pain of 5 years' duration. The diagnosis at the initial evaluation was a history of endo- metriosis, which had been confirmed by laparo- scopic surgery. She had been treated with various hormonal therapies and at the time of initial evaluation was being treated with medroxyprogesterone (Depo-Provera). This had resulted in poor pain control. Pain was con- stant, with acute episodes following any activity or exercise causing stress to the pelvic floor. The initial evaluation revealed bilateral iliacus strain and counterstrain tender points. These were treated, and the patient was asked to return for follow-up after 1 week. At the second evaluation, strain and counterstrain tender points for the right iliacus, right obturator inter- nus, and right mid-pole sacroiliac were found and treated. After the second treatment, the patient was subjectively pain-free. Three fol- low-up treatments over a 6-week period re- sulted in long-term pain relief and discontinua- tion of medication.

Jones LH. Spontaneous release by positioning. J Am Osteopath Assoc 1964: 4: 109-1 6.

Jones LH. Strain and counterstrain. Colorado Springs. CO: American Academy of Osteopathy, 1981.

Jones LH, I<usunose RS. Goering El<. Jones strain- counterstrain. Boise, ID: Jones Strain-Counter- strain. 1995.

I<orr IM. Proprioceptors and somatic dysfunction. J Am Osteopath Assoc 1975; 74:638-50.

I<usunose R. Strain and counterstrain. In: Basmajian JV, Nyberg R, eds. Rational manual therapies. Bal- timore: Williams and Willcins, 1993; 13:323-33.

I<usunose RS, Wendorff R. Strain and counterstrain syllabus. Carlsbad. CA: Jones Institute. 1990.

Travel1 JG, Simons DJ. Myofascial pain and dysfunc- tion: the trigger point manual. Vol. 2: The lower extremities. Baltimore: Williams and Wilkins, 1992.

Wilder E, ed. The gynecological manual. St. Louis, MO: American Physical Therapy Association, Section on Women's Health, 1997.

5. H., a 42-year-old woman, presented with a complaint of sharp right labial pain postpartum. She had been evaluated by her obstetrician following the delivery of her first child several years before and was diagnosed with a labial var- icosity. She underwent surgery for resection of the offending structure. During the procedure, the surgeon dissected the round ligament and at- tempted to evaluate the right inguinal canal. After surgery, the patient experienced a worsen- ing of the symptoms. These changes had re- mained constant until the time of her initial eva- luation. She had tried multiple interventions for the pain, including physical therapy, massage therapy, and acupuncture. At the initial evalua- tion, the patient was found to have scarring in the region of the right labium in the form of thick, fibrous connective tissue. Extreme tender- ness to palpation in this structure was noted. Strain and counterstrain tender points that were present included the bilateral iliacus and the right low ilium sacroiliac. These were treated, and the patient was instructed in home treatment techni- ques for these tender points. A follow-up evalua- tion showed almost complete absence of right la- bial tenderness, and the patient reported com- plete cessation of the sharp labial pain symptoms.