1. Strain-Counterstrain Techniques Regis H. Turocy PT, DHCE Assistant Professor Graduate School of Physical Therapy Slippery Rock University

2. Stain/Counterstrain Techniques  Posterior Lumbars  Anterior Lumbars  Posterior Pelvis  Anterior Pelvis  Posterior Sacrals  Shoulder, Elbow, Ankle, Foot

3. Posterior Lumbars Clinically Clinically hyperlordotic hyperlordotic Increased pain with sitting Increased pain with sitting Difficulty with flexion Difficulty with flexion

4. Posterior Lumbars 1-5 Location of Tender Points: Location of Tender Points: Lateral aspect of the spinous processes Lateral aspect of the spinous processes Paraspinal sulcus Paraspinal sulcus Posterior aspect of transverse process Posterior aspect of transverse process

5. Posterior Lumbars 1-5 Position of Treatment: Position of Treatment: Athlete lies prone; pillow under chest Athlete lies prone; pillow under chest AT stands on the side opposite the TP AT stands on the side opposite the TP Grasp the anterior aspect of the pelvis on the TP side; pull posteriorly to create rotation 30 - 40^ Grasp the anterior aspect of the pelvis on the TP side; pull posteriorly to create rotation 30 - 40^ Good for severe, acute back pain Good for severe, acute back pain

6. Quadratus Lumborum Position of Tender Point: Position of Tender Point: Lateral aspects of transverse processes L1-L5 Lateral aspects of transverse processes L1-L5 Pressure anteriorly then medially Pressure anteriorly then medially clinically: limited flexion; tight hamstrings; clinically: limited flexion; tight hamstrings; + SLR + SLR

7. Quadratus Lumborum Position of Treatment: Position of Treatment: Athlete prone with pillow under chest Athlete prone with pillow under chest AT stands on opposite side and grasps ilium on affected side AT stands on opposite side and grasps ilium on affected side Athlete then flexes and abducts ipsilateral hip to 45^ Athlete then flexes and abducts ipsilateral hip to 45^

8. Quadratus Lumborum Position of Treatment (Alternate): Position of Treatment (Alternate): Athlete prone; sidebend trunk toward tender point; abduct and extend hip and rest on operator’s thigh; gently hike hip and fine tune with rotation Athlete prone; sidebend trunk toward tender point; abduct and extend hip and rest on operator’s thigh; gently hike hip and fine tune with rotation Athlete lies on unaffected side; hips and knees flexed to 90^; AT stands behind and grasps ankles and lifts them to induce sidebending; athlete protracts or retracts to fine tune Athlete lies on unaffected side; hips and knees flexed to 90^; AT stands behind and grasps ankles and lifts them to induce sidebending; athlete protracts or retracts to fine tune

9. UPL 5 Location of Tender Point: Location of Tender Point: superior medial surface of the PSIS; pressure applied inferiorly and laterally superior medial surface of the PSIS; pressure applied inferiorly and laterally KEY POINT – extended L5 KEY POINT – extended L5 tight hamstrings tight hamstrings + SLR + SLR

10. UPL 5 Position of Treatment: Position of Treatment: athlete prone; operator stands on opposite side of tender point athlete prone; operator stands on opposite side of tender point AT extends the hip on affected side and supports leg on thigh; slightly adduct with mild external rotation AT extends the hip on affected side and supports leg on thigh; slightly adduct with mild external rotation

11. LPL 5 Location of Tender Point: Location of Tender Point: 1.5 to 2 cm inferior to the PSIS in the sacral notch 1.5 to 2 cm inferior to the PSIS in the sacral notch Maverick Point: flexion dysfunction with TP located posteriorly; if anterior lumbars “check out” look at this point; may see with pain on backward bending Maverick Point: flexion dysfunction with TP located posteriorly; if anterior lumbars “check out” look at this point; may see with pain on backward bending

12. LPL 5 Position of Treatment: Position of Treatment: athlete prone; operator seated on side of tender point; patient moves toward the edge of the table so that leg can be dropped off the table and rest on the operator’s thigh; flex hip to 90^, slight adduction and internal rotation; can retract opposite ilium to fine tune athlete prone; operator seated on side of tender point; patient moves toward the edge of the table so that leg can be dropped off the table and rest on the operator’s thigh; flex hip to 90^, slight adduction and internal rotation; can retract opposite ilium to fine tune

13. LPL 5 Athlete prone, AT stands on opposite side of the TP and grasps the ilium at the level of the ASIS; athlete flexes and abducts leg on affected side; ilium is retracted and rotated toward TP Athlete prone, AT stands on opposite side of the TP and grasps the ilium at the level of the ASIS; athlete flexes and abducts leg on affected side; ilium is retracted and rotated toward TP

14. The Cowboys

15. Anterior Lumbars Clinically: Clinically: decreased lordosis decreased lordosis difficulty with extension difficulty with extension pain with sidebending pain with sidebending Increased pain with prolonged standing, walking Increased pain with prolonged standing, walking Work on these points before doing EIL Work on these points before doing EIL

16. Anterior Lumbar 1 Location of Tender Point: Location of Tender Point: medial surface of the ASIS; press laterally approximately ¾ inch deep medial surface of the ASIS; press laterally approximately ¾ inch deep

17. Anterior Lumbar 1 Position of Treatment: Position of Treatment: athlete supine; head of table can be raised; AT stands on side of TP and markedly flexes patient’s legs; rotate to side of TP and laterally flex toward TP side (or away) athlete supine; head of table can be raised; AT stands on side of TP and markedly flexes patient’s legs; rotate to side of TP and laterally flex toward TP side (or away)

18. Anterior Lumbar 2 Location of Tender Point: Location of Tender Point: inferior-medial surface of the ASIS; pressure applied superior-lateral (feels like a small gland) inferior-medial surface of the ASIS; pressure applied superior-lateral (feels like a small gland)

19. Anterior Lumbar 2 Position of Treatment: Position of Treatment: athlete is supine; head of table can be raised; AT stands on opposite side of the TP; AT flexes patient’s legs to 90^; moves knees away from TP side 60^ (rotation); slightly push feet toward floor to create side bending away from TP side athlete is supine; head of table can be raised; AT stands on opposite side of the TP; AT flexes patient’s legs to 90^; moves knees away from TP side 60^ (rotation); slightly push feet toward floor to create side bending away from TP side

20. AbL 2 (Psoas) Location of Tender Point: Location of Tender Point: on the abdomen 5 cm lateral to the umbilicus and slightly inferior; pressure posteriorly on the abdomen 5 cm lateral to the umbilicus and slightly inferior; pressure posteriorly

21. AbL 2 Position of Treatment: Position of Treatment: athlete is supine with the operator standing on the side of the TP; hips are flexed to 90^; rotates hips 60^ toward TP side and laterally flexes the hips away from the TP by elevating the feet athlete is supine with the operator standing on the side of the TP; hips are flexed to 90^; rotates hips 60^ toward TP side and laterally flexes the hips away from the TP by elevating the feet

22. PNC Park

23. Superior Sacroiliac (SSI) Location of Tender Point: Location of Tender Point: approximately 3 cm lateral to the PSIS; pressure medially approximately 3 cm lateral to the PSIS; pressure medially SI joint pain with sitting/ standing SI joint pain with sitting/ standing

24. Superior Sacroiliac (SSI) Position of Treatment: Position of Treatment: athlete is prone with the AT standing on the side of the TP; extend athlete’s hip resting leg on AT’s thigh; slightly abduct and rotate to fine tune athlete is prone with the AT standing on the side of the TP; extend athlete’s hip resting leg on AT’s thigh; slightly abduct and rotate to fine tune if athlete has limited hip extension, treat anteriors first if athlete has limited hip extension, treat anteriors first

25. Middle Sacroiliac (MSI) Location of Tender Point: Location of Tender Point: middle of the buttocks in a slight depression; press anteriorly and medially middle of the buttocks in a slight depression; press anteriorly and medially

26. Middle Sacroiliac (MSI) Position of Treatment: Position of Treatment: athlete is prone with the AT standing on the side of the TP athlete is prone with the AT standing on the side of the TP markedly abduct leg markedly abduct leg fine tune with flexion/extension or internal/external rotation fine tune with flexion/extension or internal/external rotation

27. Inferior Scaroiliac (ISI) Location of Tender Point: Location of Tender Point: located in a line along the sacrotuberous ligament from the ischial tuberosity to posterior aspect of the inferior lateral angle; pressure anteriorly and laterally located in a line along the sacrotuberous ligament from the ischial tuberosity to posterior aspect of the inferior lateral angle; pressure anteriorly and laterally

28. Inferior Scaroiliac (ISI) Position of Treatment: Position of Treatment: athlete prone with the AT on the side opposite the TP athlete prone with the AT on the side opposite the TP AT reaches across and grasps the leg on the involved side and extends, adducts, externally rotates it across the uninvolved leg AT reaches across and grasps the leg on the involved side and extends, adducts, externally rotates it across the uninvolved leg

29. Piriformis (PRM – PRL) Location of Tender Point: Location of Tender Point: PRM – belly of the piriformis approximately halfway between the inferior lateral angle of the sacrum and the greater trochanter PRM – belly of the piriformis approximately halfway between the inferior lateral angle of the sacrum and the greater trochanter SI torsions, sciatic irritation, + SLR SI torsions, sciatic irritation, + SLR

30. Piriformis (PRM – PRL) Position of Treatment: Position of Treatment: Similar to LP5 Similar to LP5 athlete is prone with AT seated on side of TP athlete is prone with AT seated on side of TP leg on TP side suspended off table resting on AT’s thigh leg on TP side suspended off table resting on AT’s thigh flex hip from 60 – 120^, abducted; fine tune with internal/external rotation flex hip from 60 – 120^, abducted; fine tune with internal/external rotation

31. Iliotibial Band (ITB) D’Ambrogio and Roth 1997 Location of Tender Point: Location of Tender Point: on the iliotibial band along the lateral aspect of the thigh on the midaxillary line on the iliotibial band along the lateral aspect of the thigh on the midaxillary line check with hip and knee dysfunction check with hip and knee dysfunction

32. Iliotibial Band (ITB) Position of Treatment: Position of Treatment: athlete may be prone or supine athlete may be prone or supine AT stands on the side of the TP and grasps the patient’s leg and produces marked abduction AT stands on the side of the TP and grasps the patient’s leg and produces marked abduction Internal/external rotation to fine tune Internal/external rotation to fine tune

33. Heinz Field

34. Anterior Pelvis Clinically: Clinically: pain with standing and walking pain with standing and walking posture – anterior pelvis posture – anterior pelvis dysfunction of hip flexors, adductors, internal rotators dysfunction of hip flexors, adductors, internal rotators iliosacral dysfunction iliosacral dysfunction

35. Iliacus (IL) Location of Tender Point: Location of Tender Point: 3 cm medial to ASIS and deep in the iliac fossa; pressure posteriolaterally 3 cm medial to ASIS and deep in the iliac fossa; pressure posteriolaterally key point for chronic SI joint dysfunction key point for chronic SI joint dysfunction

36. Iliacus (IL) Position of Treatment: Position of Treatment: athlete supine with ankles supported on AT’s thigh; AT stands on side of TP athlete supine with ankles supported on AT’s thigh; AT stands on side of TP legs taken into extreme flexion and external rotation legs taken into extreme flexion and external rotation rotation toward the TP to fine tune rotation toward the TP to fine tune

37. Superior Pubis (SPB) Location of Tender Point: Location of Tender Point: superior aspect of lateral ramus of the pubis and approximately 2 cm lateral to the pubic symphysis; push inferiorly superior aspect of lateral ramus of the pubis and approximately 2 cm lateral to the pubic symphysis; push inferiorly

38. Superior Pubis (SPB) Position of Treatment: Position of Treatment: athlete is supine with the AT standing on side of TP athlete is supine with the AT standing on side of TP AT flexes the hip 90 – 120^ with no abduction or rotation AT flexes the hip 90 – 120^ with no abduction or rotation

39. Adductors (ADD) Location of Tender Point: Location of Tender Point: origin of adductors to pubic bone or belly of muscle origin of adductors to pubic bone or belly of muscle SI joint flare-outs, trochanteric bursitis, ITB SI joint flare-outs, trochanteric bursitis, ITB

40. Adductors (ADD) Position of Treatment: Position of Treatment: athlete is supine with the AT standing on the side opposite of the TP athlete is supine with the AT standing on the side opposite of the TP AT reaches across and grasps the athlete’s distal tibia and adducts the leg (pulling medially) AT reaches across and grasps the athlete’s distal tibia and adducts the leg (pulling medially)

41. Cahill

42. Posterior Sacrals Present in sacroiliac dysfunction (torsions) Present in sacroiliac dysfunction (torsions) Clear L5 before treating sacrals Clear L5 before treating sacrals

43. Posterior First Sacral (PS 1) Location of Tender Point: Location of Tender Point: sacral sulcus, medial and slightly superior to PSIS sacral sulcus, medial and slightly superior to PSIS backward sacral torsions backward sacral torsions

44. Posterior First Sacral (PS 1) Position of Treatment: Position of Treatment: athlete is prone athlete is prone AT applies a downward pressure on inferior lateral angle opposite of TP AT applies a downward pressure on inferior lateral angle opposite of TP

45. Coccyx (COX) Location of Tender Point: Location of Tender Point: inferior or lateral edges of the coccyx inferior or lateral edges of the coccyx Pressure superiorly and medially Pressure superiorly and medially

46. Coccyx (COX) Position of Treatment: Position of Treatment: athlete is prone athlete is prone apply a downward pressure to the apex of the sacrum apply a downward pressure to the apex of the sacrum rotate sacrum toward side of tender point rotate sacrum toward side of tender point

47. Shoulder Supraspinatus Supraspinatus  Tender Point: just inferior to the acromion process and deep to the belly of the lateral deltoid  Treatment Position: athlete is supine; place shoulder into combination of flexion, abduction to 120^; add ER to fine tune

48. Shoulder Serrated Anterior Serrated Anterior  Tender Point: along the lateral aspect of the ribs, c ostal attachment  Treatment Position: Athlete can be seated or supine; AT contacts TP with ipsilateral hand and with other hand grasps the involved arm which is drawn across the chest into horizontal adduction and flexion

49. Shoulder Pectoralis Major Pectoralis Major  Tender paint: anterior to anterior axillary line along the lateral border of pec major  Treatment Position: athlete can nbe supine or seated; AT contacts tender point and then places involved arm into horizontal hyperadduction; fine tune with flexion.

50. Elbow Lateral Epicondylitis Lateral Epicondylitis  Tender Points: over the common extensor tendon or ECRL  Treatment Position: athlete is supine, AT flexes elbow and extends the wrist while palpating the tender point; fine tune with pronation/supination

51. Ankle Lateral Ankle (Inversion sprain) Lateral Ankle (Inversion sprain)  Tender Point: over the anterior talofibular ligament  Treatment Position: athlete lies on involved side with involved ankle over edge of table; towel placed under the fibula; one hand palpates the tender point; the other hand garasps the calcaneus and applies floorward / everting force to calcaneus

52. Foot Plantar Calcaneus (Plantar Fascia) Plantar Calcaneus (Plantar Fascia)  Tender Point: over the plantar fascia at attachment to calcaneus  Treatment Position: athlete is prone, knee flexed; AT grasps the dorsum of the foot and places it into plantar flexion; grasps the calcaneus and forces it into dorsiflexion (folding foot over TP)

53. The End – Questions?