THE FOUNDATION
Counterstrain Basics
Tap each card to reveal the answer. Know these cold before moving on.
What are the six steps of counterstrain?
1. Identify the tender point using a few ounces of pressure. 2. Establish a 1 to 10 tenderness scale. 3. Place the patient in the position of ease until tenderness drops by at least 70%. 4. Hold the position for 90 seconds. 5. Slowly return the patient to neutral. 6. Reassess: no more than 30% residual tenderness should remain. Treat the most painful tender point first.
Tap to flip
Anterior tender points: which direction do you treat?
Anterior tender points are flexion-related and are treated with FLEXION as the primary motion. Curl the patient toward the front to shorten the anterior tissue. Patient is supine. Fine-tune with sidebending and rotation, which often involves moving the ankles (sidebend) and the knees (rotation) while the hips and knees are flexed.
Tap to flip
Posterior tender points: which direction do you treat?
Posterior tender points are extension-related and are usually treated with EXTENSION. Patient is prone. For posterior lumbar points (PL1 to PL5), extend the ipsilateral hip and add sidebending and rotation AWAY from the point by adducting the ipsilateral leg. Several posterior pelvic points still use prone but blend extension with abduction or adduction and external or internal rotation.
Tap to flip
Why 90 seconds? What resets?
The 90-second hold resets the muscle spindle. The spindle was firing inappropriate stretch signals from a shortened, dysfunctional muscle (the pain-spasm cycleTender point fires pain signal, muscle guards by contracting, contraction perpetuates spindle dysfunction, spindle keeps firing. The cycle is self-sustaining until passive positioning interrupts it.). Holding the position of ease for 90 seconds lets the spindle recalibrate its resting length. The slow return to neutral is critical: a fast return reactivates the spindle and undoes the treatment.
Tap to flip
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Master rule: Anterior = flexion-related = supine. Posterior = extension-related = prone. Lateral = sidebending or rotation component. Within those buckets the fine-tuning varies by muscle.
ANTERIOR PELVIS & ANTERIOR LUMBAR
Anterior Tender Points
All treated supine. All flexion-related. Tap each card for full details.
Anterior Pelvic Points
A1
Psoas
Major hip flexor
Anterior
Location
Two-thirds of the way from the ASIS to the midline (roughly the lateral edge of the rectus abdominis at the lower abdomen)
Treatment
Supine. Flex both hips, sidebend toward the tender point, externally rotate the hips. The whole body curls toward and around the tender point.
🔑 Psoas = hip flexor = flex hips, fold toward the point, ER.
A2
Iliacus
Deep hip flexor, lines the iliac fossa
Anterior
Location
One-third of the way from the ASIS to the midline (more medial than psoas, deeper inside the iliac fossa)
Treatment
Supine. Operator stands on the same side. Flex the hip and externally rotate. Often described as a figure-4 or Patrick-style position to shorten the iliacus fibers.
🔑 Iliacus = inside the iliac fossa = closer to midline than psoas. Flex + ER.
A3
Low Ilium (Psoas Minor)
Inconstant trunk flexor
Anterior
Location
Anterior-superior pubic ramus, about 2 inches lateral to the pubic symphysis at the iliopubic eminence
Treatment
Supine. Operator stands on the same side. Hyperflex the ipsilateral hip (drive the knee as far toward the chest as tolerated). Maximal flexion is what shortens this deep structure.
🔑 Low Ilium = on the pubic ramus, lateral to symphysis. Treatment = hyperflex.
A4
Inguinal (Pectineus)
Hip adductor and flexor, medial thigh
Anterior
Location
Superior pubis near the medial end of the inguinal ligament
Treatment
Supine. Operator stands on the same side. Flex the hip and knee to about 90 degrees, then ADDuct and internally rotate the ipsilateral hip. Adduction matches the action of pectineus and shortens the muscle.
🔑 Pectineus is an adductor. Treatment uses ADDuction + IR. The action of the muscle = the direction of treatment.
A5
Low Ilium Flare-out
Inferior pubic ramus / adductor origin
Anterior
Location
Inferior-medial aspect of the descending ramus of the pubis
Treatment
Supine. Operator stands on the same side. Hyperflex the affected hip, then abduct and externally rotate. Hyperflexion is the differentiator versus iliacus.
🔑 Flare-out = hip flares out. Hyperflex first, then abduct + ER.
Anterior Lumbar Points (AL1 to AL5)
All AL points are treated supine with hips and knees flexed. Sidebending is added by moving the ankles, rotation by moving the knees.
AL1
AL1 (Internal Oblique)
Anterior abdominal wall
Anterior Lumbar
Location
Just medial to the ASIS
Treatment
Supine, hips and knees flexed. F STRA: Flex, Sidebend Toward, Rotate Away from the tender point.
🔑 AL1 is the loner: STRA. Sidebend toward, rotate away. Every other AL flips both directions.
AL2
AL2 (External Oblique)
Anterior abdominal wall
Anterior Lumbar
Location
Just medial to the AIIS
Treatment
Supine, hips and knees flexed. Operator stands on the opposite side. F SART: Flex, Sidebend Away, Rotate Toward the tender point.
🔑 AL2 to AL4 all use F SART. Sidebend away, rotate toward.
AL3
AL3 (Iliopsoas)
Hip flexor
Anterior Lumbar
Location
Just lateral to the AIIS
Treatment
Supine, hips and knees flexed. F SART: Flex, Sidebend Away, Rotate Toward.
AL4
AL4 (Iliopsoas)
Hip flexor
Anterior Lumbar
Location
Just inferior to the AIIS
Treatment
Supine, hips and knees flexed. F SART: Flex, Sidebend Away, Rotate Toward.
AL5
AL5 (Rectus Abdominis)
Anterior abdominal wall
Anterior Lumbar
Location
On the pubic tubercle, about 1 cm lateral to the symphysis on the superior pubic ramus
Treatment
Supine, hips and knees flexed. F SARA: Flex, Sidebend Away, Rotate Away from the tender point.
🔑 AL5 = rectus abdominis on the pubic tubercle. SARA = both away. The "all away" point.
🧠
AL mnemonic: AL1 = STRA (sidebend toward, rotate away). AL2 to AL4 = SART (sidebend away, rotate toward). AL5 = SARA (both away). Flexion is constant across all five.
Board Trap: Pectineus uses ADDUCTION
The inguinal (pectineus) tender point is the most-missed anterior pelvic point. Treatment is supine with hip and knee flexed about 90 degrees, then ADDUCT and internally rotate. Pectineus is an adductor, and the position of ease shortens it by mimicking its action. Do not confuse this with the FADIR provocative test for hip impingement, which uses ABduction. Counterstrain pectineus = ADDuction + IR.
POSTERIOR PELVIS & POSTERIOR LUMBAR
Posterior Tender Points
All treated prone. Extension-related. Tap each card for details.
Posterior Pelvic Points
P1
Piriformis
Deep external rotator of the hip
Posterior
Location
Between the lateral edge of the sacrum and the greater trochanter
Treatment
Prone. Operator sits on the same side. Flex the hip and knee off the table, abduct the hip away from the table, and externally rotate. Sitting on the side gives the operator a stable platform to support the abducted leg.
🔑 Piriformis = deep ER. Position mimics the action: flex, abduct off the table, ER.
P2
Upper Pole L5 (UPL5)
Lumbosacral paraspinals
Posterior
Location
Superomedial aspect of the PSIS. Find the PSIS, then slide just above and slightly medial.
Treatment
Prone. Operator stands on the opposite (contralateral) side. EXTEND the ipsilateral hip, then fine-tune with adduction and rotation until tenderness drops at least 70%.
🔑 UPL5 is UP and medial on the PSIS. Treat from the opposite side, extend the hip, fine-tune.
P3
Midpole Sacral
Piriformis attachment on the sacrum
Posterior
Location
Midway down the sacrum, at the piriformis attachment site
Treatment
Prone. Operator sits on the same side. Abduct and externally rotate the ipsilateral hip.
P4
Lower Pole L5 (LPL5)
Lumbosacral paraspinals
Posterior
Location
Just inferior to the PSIS. The bottom edge of the PSIS bony landmark.
Treatment
Prone. Operator sits on the same side. Flex the hip and knee off the table to about 90 degrees, then ADDUCT the hip and fine-tune with internal rotation.
Key contrast
UPL5 = extend the hip from the contralateral side. LPL5 = flex the hip off the table from the same side, then ADDUCT and IR. Both are at the PSIS, but the position is the opposite shape.
🔑 LPL5: Lower Pole = Lower on the PSIS. Flex off the table, ADDuct (cross midline), IR.
P5
Gluteus Medius (Lateral PL3 / PL4)
Hip abductor, lateral stabilizer
Posterior
Location
Lateral PL3: about two-thirds of the distance from the PSIS toward the TFL. Lateral PL4: at the posterior margin of the TFL.
Treatment
Prone. Operator stands on the same side. Extend the ipsilateral hip, then abduct and externally rotate.
🔑 Gluteus medius = lateral PL3/PL4. Extend, abduct, ER.
P6
High Ilium Flare-Out (HIFO)
Lower lateral sacrum
Posterior
Location
Lower lateral border of the sacrum / coccyx
Treatment
Prone. Extend the ipsilateral leg, then adduct and externally rotate.
P7
High Ilium Sacroiliac (HISO)
Posterior SI region
Posterior
Location
About 3 cm lateral to the PSIS
Treatment
Prone. Operator stands on the same side. Extend, abduct, and externally rotate the ipsilateral hip.
P8
Posteromedial Trochanteric
Deep gluteal region
Posterior
Location
About 3 inches inferior to the greater trochanter, medial to the ischial tuberosity
Treatment
Prone. Operator stands on the opposite side. Extend, adduct, and externally rotate the ipsilateral hip.
Posterior Lumbar Points (PL1 to PL5 and QL)
Most posterior lumbar points are prone. Extend the ipsilateral hip and add sidebending and rotation AWAY from the point by adducting the ipsilateral leg.
PL
PL1 to PL5 Spinous Process
Lumbar paraspinals at the spinous process
Posterior Lumbar
Location
Inferolateral aspect of the L1 to L5 spinous process
Treatment
Prone. E SARA: Extend the ipsilateral hip, sidebend and rotate AWAY from the tender point by adducting the ipsilateral leg.
🔑 All PL points = E SARA. Extension constant. Both sidebend and rotate AWAY (achieved by adducting the leg).
PL
PL1 to PL5 Transverse Process
Lumbar paraspinals at the TP
Posterior Lumbar
Location
Lateral aspect of the L1 to L5 transverse process
Treatment
Prone. E SARA: same as the spinous-process points. Extend, sidebend away, rotate away.
QL
Quadratus Lumborum (QL)
Deep posterior abdominal wall, hip hiker
Posterior Lumbar
Location
Between the inferior 12th rib and the superior iliac crest
Treatment
Prone. Extend the ipsilateral hip, then abduct and externally rotate the hip. Note: QL breaks the PL E SARA pattern.
🔑 QL is between rib 12 and iliac crest. Treatment is extend + abduct + ER. Different from the PL points around it.
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Posterior fine-tuning library: Piriformis = flex off table, abduct, ER. UPL5 = extend (operator opposite side). LPL5 = flex off table, ADDuct, IR. Glut Medius = extend, abduct, ER. HIFO = extend, adduct, ER. HISO = extend, abduct, ER. Posteromedial trochanteric = extend, adduct, ER (operator opposite). PL1 to PL5 = E SARA. QL = extend, abduct, ER.
THE SYSTEM
The Pattern System
See the patterns. Stop memorizing, start recognizing.
Anterior Points
Front of body: SUPINE + FLEXION
| Tender Point | Position | Fine-tune |
|---|---|---|
| Psoas | Supine, flex hips | Sidebend toward, ER |
| Iliacus | Supine, flex hip | External rotation |
| Low Ilium (psoas minor) | Supine, hyperflex hip | Max flexion of ipsilateral hip |
| Inguinal (pectineus) | Supine, flex hip/knee 90° | ADDuct + IR |
| Low Ilium Flare-out | Supine, hyperflex hip | Abduct + ER |
| AL1 | Supine, hips/knees flexed | F STRA: SB toward, Rot away |
| AL2 to AL4 | Supine, hips/knees flexed | F SART: SB away, Rot toward |
| AL5 | Supine, hips/knees flexed | F SARA: SB away, Rot away |
💡Pattern: Every anterior point is supine with hip flexion as the foundation. The fine-tuning (rotation, sidebend, ab/adduction) varies by muscle. For AL points, ankles drive sidebending and knees drive rotation.
Posterior Points
Back of body: PRONE + EXTENSION (with exceptions)
| Tender Point | Position | Fine-tune |
|---|---|---|
| Piriformis | Prone, operator sits same side | Flex off table, abduct, ER |
| UPL5 | Prone, operator opposite side | Extend hip + adduction/rotation |
| Midpole sacral | Prone, operator sits same side | Abduct + ER |
| LPL5 | Prone, operator sits same side | Flex off table, ADDuct, IR |
| Gluteus medius (lat PL3/PL4) | Prone, operator same side | Extend, abduct, ER |
| HIFO | Prone | Extend, adduct, ER |
| HISO | Prone, operator same side | Extend, abduct, ER |
| Posteromedial trochanteric | Prone, operator opposite side | Extend, adduct, ER |
| PL1 to PL5 (spinous & TP) | Prone, extend ipsilateral hip | E SARA: SB and Rot away (adduct leg) |
| QL | Prone, extend ipsilateral hip | Abduct + ER |
💡Pattern: All posterior points are prone. Extension is the foundation for most lumbar and gluteal points, but the pelvic exceptions (piriformis, midpole sacral, LPL5) flex the hip OFF the table because the muscle attachments differ.
AL vs PL Lumbar Recipe
Anterior lumbar = supine + flex. Posterior lumbar = prone + extend.
Anterior Lumbar (AL1 to AL5)
- AL1 (just medial to ASIS) = F STRA
- AL2 (just medial to AIIS) = F SART
- AL3 (just lateral to AIIS) = F SART
- AL4 (just inferior to AIIS) = F SART
- AL5 (pubic tubercle) = F SARA
All supine with hips and knees flexed. Sidebending is set by moving the ankles, rotation by moving the knees. AL1 and AL5 are the exceptions to the SART middle.
Posterior Lumbar (PL1 to PL5 + QL)
- PL1 to PL5 spinous = E SARA
- PL1 to PL5 transverse = E SARA
- QL (rib 12 to iliac crest) = extend, abduct, ER
All prone. PL points use E SARA: extend ipsilateral hip, then sidebend and rotate AWAY by adducting the ipsilateral leg. QL is the outlier that uses abduction + ER.
💥
Direction rule: anterior (flexion-related) tender points generally have you sidebend or rotate toward the point to shorten anterior tissue. Posterior lumbar points (PL1 to PL5) use E SARA: sidebend and rotate away. The exceptions live in the pelvis and follow muscle-specific recipes, not a single rule.
Board Trap: LPL5 uses ADDuction, not abduction
UPL5 and LPL5 both sit at the PSIS, both are posterior, both are prone. The difference: UPL5 is treated by extending the ipsilateral hip from the contralateral side. LPL5 is treated from the same side, with the hip flexed off the table, then ADDUCTED (crossed across midline) and internally rotated. Boards love switching the rotation or the ab/adduction. Lock in: LPL5 = ADDuct + IR.
THE CLINIC
Clinical Connections
Tap each scenario to see how tender points connect to real patients
Psoas tender point with chronic hip flexor tightness
Think: what muscle is always tight in desk workers?
A patient who sits for long stretches develops a chronically shortened psoas. The muscle spindle adapts to the shortened length and fires inappropriate signals when the psoas is loaded (standing, walking). On exam you palpate two-thirds of the way from the ASIS to the midline and find a tender point. Counterstrain treatment: supine, flex both hips, sidebend toward the tender point, externally rotate. Reaching at least 70% tenderness reduction confirms psoas somatic dysfunction and locks in the treatment position for the 90-second hold.
Piriformis tender point with sciatica-like symptoms
Not every "sciatica" is a disc herniation
The sciatic nerve runs deep to (or in some anatomical variants through) the piriformis muscle. When the piriformis spasms, it can compress the sciatic nerve and produce buttock pain that radiates down the leg, often called piriformis syndrome. You find a tender point between the lateral edge of the sacrum and the greater trochanter. Counterstrain treatment: prone, operator sits on the same side, flex the hip and knee off the table, abduct away from the table, externally rotate.
Differentiator from disc-related radiculopathy: a true L4 to S1 radiculopathy from disc herniation typically has a positive straight leg raise with a dermatomal distribution. Piriformis-related symptoms can have a negative SLR while reproducing buttock pain on positions that load the piriformis. The tender point pattern guides the OMT plan.
Differentiator from disc-related radiculopathy: a true L4 to S1 radiculopathy from disc herniation typically has a positive straight leg raise with a dermatomal distribution. Piriformis-related symptoms can have a negative SLR while reproducing buttock pain on positions that load the piriformis. The tender point pattern guides the OMT plan.
UPL5 or LPL5 with low back pain radiating to buttock
The PSIS tells the story
Tender points at the PSIS (upper or lower pole) point to L5 somatic dysfunction. UPL5 sits at the superomedial PSIS. LPL5 sits just inferior to the PSIS. Both can produce low back pain that radiates to the buttock and overlaps with SI joint complaints.
The differentiator: UPL5 responds to prone extension of the ipsilateral hip from the contralateral side. LPL5 responds to flexing the hip off the table from the same side, then ADDucting and internally rotating. Two PSIS points, two opposite recipes. Use the position that drops tenderness by at least 70% to decide.
The differentiator: UPL5 responds to prone extension of the ipsilateral hip from the contralateral side. LPL5 responds to flexing the hip off the table from the same side, then ADDucting and internally rotating. Two PSIS points, two opposite recipes. Use the position that drops tenderness by at least 70% to decide.
Tender points as both diagnosis and treatment
The position of ease IS the diagnostic test
Counterstrain tender points do double duty. The location tells you which muscle or segment is involved. The position that drops tenderness by at least 70% confirms the dysfunction and IS the treatment position.
The standard procedure:
1. Identify the tender point with a few ounces of pressure
2. Establish a 1 to 10 tenderness scale
3. Position the patient until tenderness drops at least 70%
4. Hold for 90 seconds
5. SLOWLY return to neutral
6. Reassess: no more than 30% residual tenderness should remain
Treat the most painful tender point first. Anterior points correspond to flexion-related dysfunctions; posterior points correspond to extension-related dysfunctions.
The standard procedure:
1. Identify the tender point with a few ounces of pressure
2. Establish a 1 to 10 tenderness scale
3. Position the patient until tenderness drops at least 70%
4. Hold for 90 seconds
5. SLOWLY return to neutral
6. Reassess: no more than 30% residual tenderness should remain
Treat the most painful tender point first. Anterior points correspond to flexion-related dysfunctions; posterior points correspond to extension-related dysfunctions.
PROVE IT
Clinical Vignettes
Six questions. All original. No peeking back at the cards.