STRAINSTRAIN--COUNTERSTRAINCOUNTERSTRAIN

John Christiansen, John Christiansen, MS PT, OCS, ATCMS PT, OCS, ATC

Advanced Rehabilitation ClinicsAdvanced Rehabilitation Clinics

StrainStrain--CounterstrainCounterstrain

•• Developed by Lawrence Jones, D.O.Developed by Lawrence Jones, D.O.

•• Based on work of Irvin Based on work of Irvin KorrKorr, Ph.D. , Ph.D. ““ProprioceptorsProprioceptors and Somatic Dysfunctionand Somatic Dysfunction””

KorrKorr said:said:

•• ““To a physiologist it seems much more To a physiologist it seems much more reasonable that the limitation and reasonable that the limitation and resistance to motion of a joint that resistance to motion of a joint that characterizes an osteopathic lesion do not characterizes an osteopathic lesion do not arise within the joint, but are imposed by arise within the joint, but are imposed by one or more of the muscles that traverse one or more of the muscles that traverse and move the joint.and move the joint.””

KorrKorr, cont, cont

•• Increased gamma outflow in response to Increased gamma outflow in response to momentarily silent momentarily silent proprioceptorproprioceptor input input from from hypershortenedhypershortened musclemuscle

KorrKorr, cont, cont’’dd

•• Inappropriate Inappropriate ““gaingain”” in the primary in the primary proprioceptorproprioceptor reflexes in the muscle reflexes in the muscle spindlespindle

•• When muscle is returned to resting length, When muscle is returned to resting length, ““restretchedrestretched””, this increased gain causes , this increased gain causes an overreaction and spindle reports strain an overreaction and spindle reports strain before any real strainbefore any real strain

Dysfunctional StateDysfunctional State

•• ProprioceptorProprioceptor input to spindle is altered input to spindle is altered and gamma bias too highand gamma bias too high

•• Somatic reflexSomatic reflex•• SCS corrects the aberrant SCS corrects the aberrant proprioceptorproprioceptor

input, resets gamma bias and interrupts input, resets gamma bias and interrupts the reflexthe reflex

Definition 1Definition 1

•• A passive positional procedure that places A passive positional procedure that places the body in a position of greatest comfort, the body in a position of greatest comfort, thereby relieving pain by reduction and thereby relieving pain by reduction and arrest of inappropriate arrest of inappropriate proprioceptorproprioceptoractivity that maintains somatic activity that maintains somatic dysfunction.dysfunction.

Definition 2Definition 2

•• A mild overstretching applied in a direction A mild overstretching applied in a direction opposite to the false and continuing opposite to the false and continuing message of strain which the body is message of strain which the body is sufferingsuffering

TENDER POINTSTENDER POINTS

•• Over 200 distinct tender points Over 200 distinct tender points

•• Manifestations of somatic dysfunctionManifestations of somatic dysfunction

What is a tender point?What is a tender point?

•• Small zone of tense, tender edematous Small zone of tense, tender edematous muscle and muscle and fascialfascial tissuetissue

•• 1 cm in diameter1 cm in diameter

What is a tender point?What is a tender point?

•• Sensory manifestation of a neuromuscular Sensory manifestation of a neuromuscular or musculoskeletal dysfunctionor musculoskeletal dysfunction

•• At least 4x as tender to palpation than At least 4x as tender to palpation than normal tissuenormal tissue

What is a tender point?What is a tender point?

•• They are NOT trigger pointsThey are NOT trigger points

•• TravellTravell latent trigger pointlatent trigger point-- does not does not respond to spray and stretch or injectionrespond to spray and stretch or injection

TECHNIQUETECHNIQUE

•• Locate tender pointLocate tender point

•• Find position of comfort, or mobile point, Find position of comfort, or mobile point, at least 70% decrease in tenderness at least 70% decrease in tenderness

•• Monitor tender point as hold position of Monitor tender point as hold position of comfort 90 secondscomfort 90 seconds

TECHNIQUETECHNIQUE

•• Return to neutral slowlyReturn to neutral slowly

•• Recheck tender pointRecheck tender point-- at least 70% at least 70% decrease in tendernessdecrease in tenderness

Mobile PointMobile Point

•• Point of maximum tissue relaxation Point of maximum tissue relaxation beneath your monitoring fingerbeneath your monitoring finger

•• If you move in any direction, it will If you move in any direction, it will increase tissue tensionincrease tissue tension

Treatment PulseTreatment Pulse

•• If you have found the mobile point, as you If you have found the mobile point, as you hold the 90 seconds, youhold the 90 seconds, you’’ll feel a pulsing ll feel a pulsing

•• Probably blood flow returning to areaProbably blood flow returning to area

GENERAL RULESGENERAL RULES

•• Hold treatment position for 90 secondsHold treatment position for 90 seconds

•• Return to neutral slowlyReturn to neutral slowly

•• Anterior tender points are usually treated Anterior tender points are usually treated in flexionin flexion

GENERAL RULESGENERAL RULES

•• Posterior tender points are usually treated Posterior tender points are usually treated in extensionin extension

•• Tender points on or near midline are Tender points on or near midline are treated with more flexion and extensiontreated with more flexion and extension

GENERAL RULESGENERAL RULES

•• Tender points lateral to midline are usually Tender points lateral to midline are usually treated with more rotation and treated with more rotation and sidebendingsidebending

•• With multiple points, treat the most severe With multiple points, treat the most severe firstfirst

GENERAL RULESGENERAL RULES

•• It tender points are in a row, treat the one It tender points are in a row, treat the one in the middle firstin the middle first

•• Tender points in the extremities are Tender points in the extremities are usually on the opposite side of painusually on the opposite side of pain

GENERAL RULESGENERAL RULES

•• Warn patient they may be sore after the Warn patient they may be sore after the treatmenttreatment

•• Only contraindication is (+) vertebral Only contraindication is (+) vertebral artery test for some cervical treatmentsartery test for some cervical treatments

Anterior rib 1 (AR1)Anterior rib 1 (AR1)

•• Tender Point: 1Tender Point: 1stst costal cartilagecostal cartilage

•• Treatment: Patient supineTreatment: Patient supine•• Mild cervical flexionMild cervical flexion•• Marked rotation toward tender pointMarked rotation toward tender point•• Mild cervical Mild cervical sidebendsidebend towardtoward

Anterior Rib 2 (AR2)Anterior Rib 2 (AR2)

•• Tender Point: 2Tender Point: 2ndnd rib mid rib mid clavicularclavicular lineline

•• Treatment: same as AR1Treatment: same as AR1

Anterior Anterior AcromioAcromio--clavicularclavicular (AAC)(AAC)

•• Tender Point: Anterior aspect distal Tender Point: Anterior aspect distal clavicleclavicle

•• Treatment: Patient supineTreatment: Patient supine–– Clinician stands on oppositeClinician stands on opposite–– Adduct obliquely across body, 0Adduct obliquely across body, 0--3030°°–– Slight traction of armSlight traction of arm

Bursa (BUR)Bursa (BUR)

•• Tender point: Under acromion with arm in Tender point: Under acromion with arm in 9090°° abductionabduction

•• Treatment: Patient supineTreatment: Patient supine–– Flexion of arm 120Flexion of arm 120°°–– Slight ER of arm with elbow flexedSlight ER of arm with elbow flexed

Long Head of Biceps (LH)Long Head of Biceps (LH)

•• Tender point: Over long head in Tender point: Over long head in bicipitalbicipitalgroovegroove

•• Treatment: Patient supineTreatment: Patient supine–– Flexion of arm, dorsum of hand on foreheadFlexion of arm, dorsum of hand on forehead–– Fine tune with IR or ER of armFine tune with IR or ER of arm

Short Head of Biceps (SH)Short Head of Biceps (SH)

•• Tender Point: Inferior lateral aspect of Tender Point: Inferior lateral aspect of coracoidcoracoid

•• Treatment: Patient supineTreatment: Patient supine–– Flexion of arm 90Flexion of arm 90°°, elbow flexed, forearm , elbow flexed, forearm

supinatedsupinated–– Moderate horizontal adductionModerate horizontal adduction

Medial Coracoid (MC)Medial Coracoid (MC)

•• Tender Point: Medial aspect of coracoid processTender Point: Medial aspect of coracoid process

•• Treatment: Patient sittingTreatment: Patient sitting–– Extend arm 30Extend arm 30°°–– Slight adductionSlight adduction–– IRIR–– Slight shoulder protraction and push elbow forwardSlight shoulder protraction and push elbow forward

Lateral Coracoid (LC)Lateral Coracoid (LC)

•• Tender Point: Superior aspect of coracoid Tender Point: Superior aspect of coracoid

•• Treatment: Patient supine, head off tableTreatment: Patient supine, head off table–– Marked cervical extensionMarked cervical extension–– SB awaySB away–– Rotate towardRotate toward

Subscapularis (SUB)Subscapularis (SUB)

•• Tender Point: Lateral margin of scapula, Tender Point: Lateral margin of scapula, anywhere in subscapularisanywhere in subscapularis

•• Treatment: Patient supine, edge of tableTreatment: Patient supine, edge of table–– Extend arm 30Extend arm 30°°–– Marked IRMarked IR–– Slight adductionSlight adduction

Latissimus Latissimus DorsiDorsi (LD)(LD)

•• Tender Point: Anterior humerus, Tender Point: Anterior humerus, elowelowbicipitalbicipital groovegroove

•• Treatment: Patient supine, edge of tableTreatment: Patient supine, edge of table–– Extend arm 30Extend arm 30°°–– Marked IRMarked IR–– Traction of armTraction of arm

Adduction Shoulder (ADD)Adduction Shoulder (ADD)

•• Tender Point: High in Tender Point: High in axillaaxilla on medial on medial humerushumerus

•• Treatment: Patient supineTreatment: Patient supine–– Adduction of arm tight to bodyAdduction of arm tight to body–– Compression through shaft of humerus Compression through shaft of humerus

Subclavius (SUBC)Subclavius (SUBC)

•• Tender Point: Under surface of midTender Point: Under surface of mid--clavicleclavicle

•• Treatment: Patient supineTreatment: Patient supine–– Clinician on opposite sideClinician on opposite side–– Adduction of arm horizontallyAdduction of arm horizontally

Posterior Posterior AcromioAcromio--clavicularclavicular (PAC)(PAC)

•• Tender Point: Posterior clavicleTender Point: Posterior clavicle

•• Treatment: Patient proneTreatment: Patient prone–– Adduct arm obliquely across body 0Adduct arm obliquely across body 0--3030°°–– Traction of armTraction of arm

Supraspinatus (SUP)Supraspinatus (SUP)

•• Tender Point: Belly of muscleTender Point: Belly of muscle

•• Treatment: Patient supineTreatment: Patient supine–– Flexion of arm 45Flexion of arm 45°°–– Abduction of arm 45Abduction of arm 45°°–– Marked ERMarked ER

Medial Second Thoracic Shoulder Medial Second Thoracic Shoulder (MTS2)(MTS2)

•• Tender Point: Superior vertebral angle of Tender Point: Superior vertebral angle of scapulascapula

•• Treatment: Patient supineTreatment: Patient supine–– Flexion of arm 110Flexion of arm 110--120120°° with elbow flexionwith elbow flexion–– Fine tune with rotationFine tune with rotation

Lateral Thoracic Shoulder (LTS2) Lateral Thoracic Shoulder (LTS2) InfraspinatusInfraspinatus

•• Tender Point: Infraspinatus fossa ~2 cm Tender Point: Infraspinatus fossa ~2 cm below spinebelow spine

•• Treatment: Patient supineTreatment: Patient supine–– Flexion of arm 90Flexion of arm 90--110110°°–– Moderate horizontal abductionModerate horizontal abduction–– Maybe ERMaybe ER

Point of Spine (POS)Point of Spine (POS)

•• Tender Point: On spine of scapulaTender Point: On spine of scapula

•• Treatment: Same as LTS2Treatment: Same as LTS2

Third Thoracic Shoulder (TS3)Third Thoracic Shoulder (TS3)

•• Tender Point: Belly of infraspinatusTender Point: Belly of infraspinatus

•• Treatment: Patient SupineTreatment: Patient Supine–– Flexion of arm 135Flexion of arm 135°°–– Fine tune with ad/abduction and rotationFine tune with ad/abduction and rotation

Trapezius (TRP)Trapezius (TRP)

•• Tender Point: Upper trapezius Tender Point: Upper trapezius

•• Treatment: Patient supineTreatment: Patient supine–– SidebendSidebend head towardshead towards–– Flexion of arm overheadFlexion of arm overhead–– Traction of scapula superiorly pulling on armTraction of scapula superiorly pulling on arm

Levator Scapula (LS)Levator Scapula (LS)

•• Tender Point: In muscleTender Point: In muscle

•• Treatment: Patient supineTreatment: Patient supine–– Arm by side, elbow flexedArm by side, elbow flexed–– SidebendSidebend head towardshead towards–– Elevate scapula by pushing Elevate scapula by pushing cephaladcephalad through through

humerushumerus

Teres Major (TM)Teres Major (TM)

•• Tender Point: Tender Point:

•• 1. Dorsal surface inferior angle of scapula1. Dorsal surface inferior angle of scapula•• 2. Posterior 2. Posterior axillaaxilla, lateral to subscapularis , lateral to subscapularis

pointpoint

Teres Major (TM)Teres Major (TM)

•• Treatment: Patient sittingTreatment: Patient sitting–– Extension of arm 30Extension of arm 30°°–– Slight adductionSlight adduction–– Marked IRMarked IR

Teres Minor (Teres Minor (TMiTMi))

•• Tender point: Lateral border of scapula in Tender point: Lateral border of scapula in belly of musclebelly of muscle

•• Treatment: Patient sitting or supineTreatment: Patient sitting or supine–– Extension of arm 30Extension of arm 30°°–– Slight adductionSlight adduction–– Marked ERMarked ER

Rhomboids (RHM)Rhomboids (RHM)

•• Tender Point: Medial border of scapulaTender Point: Medial border of scapula

•• Treatment: Patient prone, arm by sideTreatment: Patient prone, arm by side–– Clinician stands oppositeClinician stands opposite–– Adduction of scapulaAdduction of scapula–– Elevation of scapulaElevation of scapula