Strain and Counterstrain

LC1
AC2
AC3
TR
AC4

AC5
AC6
ALC

Anterior AC7

Cervical
Tender AC8

Points

AC1 reg

AC1 rare
Lateral C1-LC1 (Rectus
Lateralis)
⚫ Treat this first before anterior tender points
⚫ Frontal headaches/eye pain
⚫ Always treat with AC1
 Tenderpoint
⚫ On the transverse process of C1
 Treatment
⚫ Supine
⚫ Sidebend toward the side of the tenderpoint
to exaggerate deformity. The mastoid
process and transverse process of C1 are
approximated on the involved side.
AC1

 Tender point
⚫ Posterior surface of ascending ramus of the
mandible 2 cm superior to mandibular angle
⚫ Approach posterioly
 Treatment
⚫ Supine
⚫ Neutral flexion/extension
⚫ Sidebend – away slightly
⚫ Rotate – away markedly
⚫ Direct motion with pressure on top of head
AC1 (Rare) - Scalenes
 Tender point
⚫ Beneath and medial ot the mandibular
angle 2 cm anterior to angle
⚫ Push superiorly on the inferior surface
 Treatment
⚫ Supine
⚫ Flexion – marked
⚫ Sidebend – slightly toward
⚫ Rotate – away as needed
⚫ Treat inion point posteriorly
AC2
 Tender point:
⚫ Anterior surface of the tip of C2
Transverse Process
 Treatment:
⚫ Supine
⚫ Flexion – slight ot none
⚫ Sidebend – Away (moderate – marked
usually)
⚫ Rotate – away (moderate – marked
usually)
AC3

 Tender point
⚫ Anterior surface of tip of C3
transverse process
 Treatment
⚫ Supine
⚫ Flexion – marked
⚫ Sidebend – usually toward
⚫ Rotate – away (moderate)
AC4

 Tender point
⚫ Anterior surface of tip of C4
transverse process
 Treatment
⚫ Supine
⚫ Extension – slight
⚫ Sidebend – away (moderate)
⚫ Rotate – away (moderate)
⚫ Exception to rule
AC5

 Tender point
⚫ Anterior surface of tip of transverse
process of C5
 Treatment
⚫ Supine
⚫ Flexion – moderate
⚫ Sidebend – away (moderate)
⚫ Rotate – away (moderate)
AC6

 Tender point
⚫ Anterior surface of tip of transverse
process of C6
 Treatment
⚫ Supine
⚫ Flexion – moderate
⚫ Sidebend – away (moderate usually)
⚫ Rotate – away (moderate usually)
AC7
 Shorten sternocleidomastoid muscle –
clavicle
 Tender point
⚫ Posterior superior surface of clavicle.
Approximately 3 cm lateral to medial end.
Push inferiorly on the superior surface of the
clavicle
 Treatment
⚫ Supine
⚫ Flexion – marked; support lower neck, not
head
⚫ Sidebend – toward markedly
⚫ Rotate – away slightly
AC8 (SCM-sternal)

 Tender point
⚫ Medial end of clavicle
⚫ Push laterally

 Treatment
⚫ Supine
⚫ Flexion – slight
⚫ Sidebend – away slightly
⚫ Rotate – away markedly
TR (trachea)
 Tight swallowing
 Longus coli spasm
 Tender point
⚫ Anywhere along either sid eof the trachea
⚫ More common near the superior aspect
 Treatment
⚫ Supine
⚫ Flexion – marked, support lower neck
⚫ Sidbend – toward markedly
⚫ Rotate – away, slightly
ALC (Anterior Lateral
Column)
 Longus coli muscle
 Common with flattened cervical lordosis
 Tender point
⚫ On a vertical line medial to the SCM muscle
and lateral to trachea
⚫ Push posteriorly toward anterior aspect of
vertebral bodies C3-6
 Treatment
⚫ Supine
⚫ Flexion – marked of neck
⚫ Sidebend – toward tender point side
⚫ Rotate – away form tender point side
 PC1 Inion

PC1

Posterior
Cervical PC2

Tender PLC
PC3
PC4

Points PC5

PC6

PC7

PC8
PC1 (Inion)
 Tender point
⚫ On medial border of main posterior muscle
mass of neck (semispinalis capitis), 3 cm
below posterior occipital protuberance (inion)
 Treatment
⚫ Supine
⚫ Flexion – marked (chin tuck position)
⚫ Sidebend – toward slightly
⚫ Rotate – away slightly
⚫ Usually works better to monitor PC1 than
aC1 (rare)
⚫ Treatment position very similar
PC1 (regular)
 Frontal Headaches
 Tender point
⚫ On occiput lateral to main muscle mass
⚫ Approximately 3.5 cm from midline
 Treatment
⚫ Supine
⚫ Extension – at C1 level. Lift heat to create flexion of
lower cervical region prior to extending C1. Allows
more extension. Augment extension of C1 by hand
pressure on top of head.
⚫ Sidebend – away slightly
⚫ Rotate – away slightly
PC2
 Frontal headaches and/or eye pain
 Tender point
⚫ 1. on lateral side of main muscle mass of
neck below occiput. 1.5 cm lateral to midline
⚫ 2. superior surface of the spinous process of
C2
 Treatment
⚫ Supine
⚫ Extension – same as PC1
⚫ Sidebend – away slightly
⚫ Rotate – away slightly
PC3

 Pain up back of head, tinnitus, vertigo

 Tender point
⚫ On the inferior surface of the spinous
process of C2
 Treatment
⚫ Supine
⚫ Flexion – marked
⚫ Sidebend – away or toward
⚫ Rotate – away
PC4
 Occipital heacaches, common with TMJ
dysfunction
 Tender point
⚫ 1. on spinous process of C3 in the
depression below the spinous process
⚫ 2. in muscle mass between C4 spinous
process and C4 transverse process
⚫ Forward bending of neck helps to palpate
these points
 Treatment
⚫ Supine with head over end of table
⚫ Extension – to level or flexion
⚫ Sidebend – away
⚫ Rotate – usually away
PC5 / PC6 / PC7
 PC5: whole head hurts
 Tender point
⚫ On spinous process of corresponding
vertebrae above i.e. PC6 on spinous
process of C5
 Treatment
⚫ Supine
⚫ Extension – marked to level
⚫ Sidebend – usually away
⚫ Rotate – away
⚫ The main difference between these points
and inferior to T2 is how much extension or
backward bending is utilized
PC8

 Tender points
⚫ Anterior to the trapezius at the base of the
neck on the posterior surface of the tip of the
tip of the C7 transverse process (push up on
transverse process)
 Treatment
⚫ Supine
⚫ Extension – slight
⚫ Sidebend – away markedly
⚫ Rotate – away (slight to moderate)
PLC (Posterior Lateral
Column)
 Tender point
⚫ 2 cm lateral to the spinous processes
of C2-C7
 Treatment
⚫ Supine with head off end of plinth
⚫ Extension – moderate
⚫ Sidebend – toward moderate
⚫ Rotate – away
 AT1

AT2
AT3

AT7
AT4

Anterior AT5
AT6
AT8

Thoracic
AT9
Tender AT10
AT12

Points
AT11
 AT5-AT8
 Requires lots of force

 Optional technique involves placing

patient supine and fulcruming at level
over knee/thigh of clinician. This
allows greater thoracic flexion at AT5-
AT7
 Anterior thoracic tender points are
typically more tender supine than
sitting
 AT1-AT6
⚫ Increased thoracic kyphosis
⚫ T4-T5 pain posteriorly
⚫ Fatigued/ low energy
⚫ Increased difficulty with respiration –
deep breath
 AT7-AT12
 Chronic diarrhea AT10

 Stomach problem AT7-AT12

 Thoracolumbar pain posteriorly

AT1

 Tender Point
⚫ Midline in suprasternal notch. Push
inferiorly.
 Treatment
⚫ Seated with fingers interlocked on top
of head. Clinician places arms around
patient and locks hands over the
manubrium.
⚫ Flexion – created by leaning patient’s
trunk backward slightly
AT2

 Tender Point
⚫ Middle of Manubrium
 Treatment
⚫ Seated, same as AT1 but clinician
locks hands lower at junction of
manubrium and sternum
AT3
 Tender point
⚫ On sternum just below sternal angle
 Treatment
⚫ Seated with arms dropped back and off edge
of plinth/table
⚫ Clinician pulls backward/inferiorly on
patient’s arms creating a fulcrum at the
desired level. Clinician uses his chest and
abdomen to force patient’s thoracic spine in
flexion. Augment thoracic flexion by
internally rotating arms
⚫ Flexion of cervical region also
AT4

 Lethargy
 Tender point
⚫ On body of sternum at level of 4th rib
interspace
 Treatment
⚫ Seated. Same as AT3 but 1.5 cm
lower
⚫ Flexion
AT5
 Lethargy
 Tender point
⚫ On body of sternum at 5rth rib interspace
level (at nipple line)
 Treatment
⚫ Seated with arms at side. Clinician locks
fingers anteriorly over the tender point.
Flexion is created by pullingthe patient
backward using medial edges of hands as
the fulcrum. Clinician leans against patient’s
upper thoracic area
⚫ Flexion
AT6

 Grumpy point
 Tender point
⚫ Xiphisternal junction
 Treatment
⚫ Seated with arms at side. Same as
AT5 but lower
⚫ Flexion
AT7
 Stomach pain, gastritis
 Tender point
1. Under the costochondral margin of 7th rib (pain with
deep breath)
2. 2 cm below xiphoid. 1 cm lateral to midline
 Treatment
⚫ Seated. Clinician has his foot on the table. Patient has
opposite arm resting on pillow on clinician’s thigh who
stands behind patient. Patient’s feet side-straddle (on
table on side of tenderpoint)
⚫ Flexion
⚫ Sidebend – toward by translating trunk to opposite
side
⚫ Rotation – away by placing involved side arm across
front of body
AT8

 Tender point
⚫ 2 cm below AT7. 1.5 cm lateral of
midline
 Treatment
⚫ Same at AT7 with more thoracic
flexion
AT9

 Tender point
⚫ Just above umbilicus. 1.5 cm lateral to
midline
 Treatment
⚫ Same as AT7 with more thoracic
flexion
AT10
 Tender point
⚫ Just below umbilicus. 1.5 cm lateral to midline
⚫ Can often feel anterior body of L3 vertebrae 1.5” in
 Treatment
1. Supine with head of table raised. Rest patient’s flexed
legs on clinician’s thigh. Clinician stands on side of
tender point. Produced marked flexion at the level of
dysfunction. Rotate knees slightly toward tender side
for fine tuning
2. Straight table technique – place pillows under “hips”
to obtain flexion of pelvis on lumbar spine. Then
proceed as above
AT11

 Tender point
⚫ Suprapubic region. 2 cm lateral to
midline. Medial to ASIS levels
 Treatment
⚫ Same as AT10 with fine tuning
AT12

 Tender point
⚫ Crest of ilium at mid-axillary line. On
inner table of iliac crest. Push caudad
at iliac crest
 Treatment
⚫ Same as AT10. Fine tune
 PT1-2
PT3-5

PT6-9

Posterior
Thoracic
Tender
Points PT10-12
 T1-5 – most often tender on sides of
spinous processes.
 T6-12 – usually more sensitive
paravertebrally or just lateral to
spinous processes.
 TL junction – usually most sensitive
on the posterior tips of the transverse
processes. At times, lateral to the
spinous processes.
 With posterior thoracic, the closer the
tender point to the midline the more
backward bending force is needed
(split table helpful).
 The further the tender point from the
midline, the more sidebending is
needed. Sidebend away from the side
of the tender point
 Pre-position trunk or legs to create some
sidebending away if/as necessary
 Transverse process – more sidebend than
rotation
 Spinous process – more rotation than
sidebend
 Diffuse posterior pain – usually have
anterior tender points as well
 Localized specific posterior pain – posterior
tender points
PT1 / PT2
 Tender point
⚫ On the side of the spinous process of T1 and
T2
⚫ Occassionaly, PT1 also has a tender point 2
cm above the lateral epicondyle at the elbow
 Treatment
⚫ Prone with arms alongside body or supine
with head off end of table
⚫ Extension – if prone, cradle chin in palm and
extend to level
⚫ Sidebend – away
⚫ Rotate – away
 T1-T5 similar to lower posterior cervicals
PT3 / PT4 / PT5
 Tender point
⚫ On the side of the spinous process T3, T4, T5
⚫ Sometimes PT 4 has a tender point 2 cm above the
medial epicondyle at the elbow
 Treatment
⚫ Prone with arms along side the head. Arm assists in
obtaining extension
⚫ Extension – cradle chin in palm, extend to level
⚫ Sidebend – away
⚫ Rotate – away
 T1-T5 similar to lower posterior cervicals
PT6 / PT7 / PT8 / PT9
 Tender point
⚫ Lateral to spinous process, 2 cm or less
 Treatment
⚫ PT6 through PL2
⚫ Prone. Arm of involved side alongside head.
Opposite arm hangs off side of table. Raise
arm of involved side by grasping axilla. Pull
arm cephalad with slight traction effect
⚫ Extension – slight, more for lower levels
⚫ Sidebend – away, main force used is
sidebending
⚫ Rotate – trunk toward
⚫ Place cervical spine in rotation to side of
tender point
PT10 / PT11 / PT12 / PL1 /
PL2
 Tender point
⚫ Lateral to spinous process or on tip of
transverse process
 Treatment
⚫ Prone
⚫ Raise cephalic end of table to extend to level
⚫ Pull back on anterior pelvic on tender point
side to sidebend and rotate
⚫ Sidebend – away
⚫ Rotate – pelvis toward 30o-45o

PL
 AR1
AR2

Anterior
Ribs –
Depressed
Tender AR3-6

Points
INT4-6
AR1

 Tender point
⚫ Beneath the clavicle on the first costal
cartilage to the sternum
 Treatment
⚫ Supine
⚫ Mild cervical flexion
⚫ Rotate – toward, markedly
⚫ Sidebend – toward. Greatest force is applied
in sidebending
AR2

 Tender point
1. On second ribs in mid-clavicular line
2.. High in medial axilla
 Treatment
⚫ Same as AR1

 With decreased shoulder abduction,

be sure to check AR1-AR2
AR3 – AR6
 Tender point
⚫ On anterior axillary line inferior rib margins at
corresponding levels
 Treatment
⚫ Sitting
⚫ Flexion – slight, neck and trunk
⚫ Sidebend – toward. This is accomplished by
leaning patient to opposite side with the
patient’s axilla on clinician’s knee (who is
standing behind patient). Sidebend toward by
translating patient’s trunk away from tender
point. If patient’s feed are on plinth on tender
point side, the sidebend can be increased
⚫ Rotate – toward. Let involved side arm hang
behind patient to augment
INT4 – INT6
 Tender point
⚫ On or between costal cartilage just lateral to
sternum at the corresponding level
 Treatment
⚫ Patient seated and leaning toward opposite
side with opposite axilla supported on
clinician’s knee. Clinician standing behind
patient.
⚫ Cervical flexion
⚫ Patient’s feet on table on tender point side
⚫ Trunk flexion
⚫ Sidebend – toward. Created by translating
trunk away
⚫ Rotate – away, by placing patients involved
side arm across front of body
 PR1

Posterior
Ribs – PR2-6

Elevated
Tender
Points
PR1
 Tender point
⚫ Posterolateral aspect of first rib, beneath the
margin of trapezius at side on neck
 Treatment
⚫ Sitting
⚫ Opposite axilla over clinician’s knee, lean
patient mildly toward opposite side, then
position head/neck
⚫ Extension – mild
⚫ Sidebend – away, mild
⚫ Rotate – toward, moderate
PR2 – PR6
 Tender point
⚫ Posteriorly at angle of ribs on superior surface. Adduct
patient’s arm across front of body to move scapula
laterally and allow easier palpation of rib angles
 Treatment
⚫ Sitting
⚫ Axilla on affected side is resting on clinician’s knee.
Lean patient toward tender point side. Opposite arm is
hanging loosely behind patient’s back. Patient’s feet are
on table opposite of tender point side.
⚫ Sidebend – away by translating trunk toward tender
point side.
⚫ Rotate – away
 For 2nd rib, rotate neck away moderately also
 Treat spinal tender points (thoracic) before rib tender
points, even if somewhat more tender
Anterior AbL2

Lumbar AL1

Tender
AL2

Points AL3

AL4

AL5
 AT9-AL1
⚫ Similar procedure for 5 levels
 AL1 & AL 2
⚫ Often involved with patient who can’t stand
upright
 AL3 & AL4
⚫ Virtually no rotation. Sidebend through legs
 AL2 & AL5
⚫ Are the “key” tender ponts in this area
AL1
 Tender point
⚫ Medial to anterior superior iliac spine. ¾”
deep. Push medial to lateral
 Treatment
⚫ Supine with head of table elevated
⚫ Patient’s flexed legs rest on clinician’s thigh
⚫ Clinician on tender point side
⚫ Flexion – marked at level of dysfunction
⚫ Sidebend – mild, toward
⚫ Rotate – knees toward tender point side
AL2
 Tender point
⚫ Medial inferior surface to anterior
inferior iliac spine
 Treatment
⚫ Supine
⚫ Clinician opposite tender point side
⚫ Flexion – patient’s legs flexed 90o
⚫ Rotate – knee away from tender point
60o (markedly)
⚫ Sidebend – away, slightly. Push feet
toward floor
AbL2 (Abdominal
 Tender point
⚫ 5 cm lateral to umbilicus
 Treatment
⚫ Supine
⚫ Clinician on tender point side
⚫ Flexion – more than AL2
⚫ Rotate – knee toward tender point
(60o)
⚫ Sidebend – away. Elevate feet
upwards to create
AL3

 Tender point
⚫ Lateral surface of anterior inferior iliac spine
 Treatment
⚫ Supine
⚫ Clinician opposite tender point side
⚫ Flexion – flex thighs 50o – 90o
⚫ Sidebend – away markedly by pulling feet
toward clinician
⚫ Rotate – slightly to fine tune
AL4

 Tender point
⚫ Inferior surfaced of anterior inferior
iliac spine
 Treatment
⚫ Same as AL3 with fine tuning
AL5

 Tender point
⚫ Anterior surface of pubic bone, 1.5 cm lateral
to pubic symphysis
 Treatment
⚫ Supine
⚫ Clinician on tender point side
⚫ Flexion – flex thighs 60o – 135o
⚫ Sidebend – away, slightly
⚫ Rotate – knees toward side of tender point
 PL1
QL
PLRL2
PL2

PL3

Posterior PL4 UPL5 PL3 (Iliac)

PL5

Lumbar
Tender PL4 (Iliac)

Points
LPL5
PL3 (Iliac)
 Tender point
⚫ 3 cm below margin of ilium and about 7 cm
lateral to posterior superior iliac spine
 Treatment
⚫ Prone
⚫ Clinician on side opposite tender point
⚫ Extension – lift leg on affected side and
support on clinician’s thigh
⚫ Adduct – mild
⚫ Rotate – full external. The higher the hand
placement o the thigh by the operator, the
greater the external rotation created
PL4 (Iliac)

 Tender point
⚫ 4 cm below margin of ilium and just posterior
to the border of the tensor fascia lata
 Treatment
⚫ Prone
⚫ Clinician on side opposite the tender point
⚫ Extension – same as PL3
⚫ Adduct – slight
⚫ Rotate – moderate external rotation
UPL5 (Upper Pole)
 Tender point
⚫ Superior medial surface of the posterior superior iliac
spine.
⚫ Apply pressure caudad and lateral toward posterior
superior iliac spine (45o angle)
 Treatment
⚫ Prone
⚫ Clinician on side opposite tender point
⚫ Extension – via leg. Major movement required
⚫ Adduct – very slight
⚫ Rotate – mild external rotation
LPL5 (Lower Pole)
 Tender point
1. 2 cm below posterior superior iliac spine in
small saddle between posterior superior iliac
spine and posterior inferior iliac spine
2. on sacral promontory in midline
 Treatment
⚫ Prone
⚫ Clinician seated on tender point side
⚫ Leg on tender point side is dropped off table
and resting on clinician’s thigh. Patient’s hip
flexed approximately 90o patient’s pelvis is
rotated posteriorly and hip adducted slightly by
pressure at the knee
⚫ Flexion – hip 90o
⚫ Adduction – slight
⚫ Rotation – pelvis rotate posteriorly
QL (Quadratus Lumborum)
 Tender point
1. On the lateral tips of the transverse processes of L2-4
2. In the angle between the transverse process of L1 and
the 12th rib
 Treatment
⚫ Prone
⚫ Sidebend trunk toward tender point side
⚫ Sidebend legs toward tender point side
⚫ Abduct and extend hip of (on tender point side) and rest
on clinician’s thigh
⚫ Gently hike hip and fine tune with mild rotation (internal
or external
⚫ Extension –hip, mild
⚫ Abduction – hip, moderate
⚫ Rotate – fine tune, mild
 May complain of
⚫ Lateral trunk shift
⚫ Decreased sidebend away
⚫ Pain with prolonged sitting
⚫ Pain rolling in bed
PLRL2 (Posterior Flexed L2)
(Psoas Major Muscle)
 Tender point
⚫ Over the posterior aspect of transverse process of L2
 Treatment
⚫ Prone
⚫ Clinician sits on same side as tender point
⚫ Flexion – hip off edge of table to 90o and support
patient’s knee on clinician’s thigh
⚫ Abduction – hip, slight to nont
⚫ Rotation – fine tune by using clincian’s t high to direct
a force up the shaft of femur to rotate pelvis
 Vertical lumbar pain on tender point
side
 Difficulty finding comfortable sleep
position
 Restless leg syndrome
 IL

ALT

AMT

Anterior LISI

Pelvis / Hip ADD

LIFO
ING

Tender
Points
GMi/TFL
LISI (Low Ilium – Sacoiliac)
 Tender point
⚫ On superior surface of lateral ramus of
pubic bone. 2 cm lateal to pubic
symphysis
⚫ Push cadad
 Treatment
⚫ Supine
⚫ Flexion – 90o to 110o of hip on tender
point side
⚫ Sidebend – none
⚫ Rotate – none
LIFO (Low Ilium – Flareout)
 Tender point
⚫ Inferior medial surface of the descending
ramus of the pubic bone (start palpation at
ischial tuberosity)
 Treatment
⚫ Supine
⚫ Flexion –patient’s thigh
⚫ Abduct femur moderately to accentuate the
low flareout
⚫ Rotate femur externally – markedly by
pushing the foot toward the midline

 Treat LIFO before LISI

AMT (Anterior Medial Trochanter)
(Rectus Femoris)
 Tender point
⚫ 1 cm lateral to the anterior inferior iliac
spine (AIIS)
 Treatment
⚫ Supine
⚫ Flex hip 130o
⚫ Abduct – none
⚫ Rotate – none
ALT (Anterior Lateral Trochanter)
(Sartorius)
 Tender point
⚫ 2 cm lateral to AIIS. Flex the hip to
find this tender point
 Treatment
⚫ Supine
⚫ Flex hip 90o
⚫ Abduct – moderate
⚫ Rotate – external, little or none
IL (Iliacus)

 Tender point
⚫ Anterior and deep in iliac fossa (push
posterior and medial)
 Treatment
⚫ Supine
⚫ Patient’s ankles supported on
clinician’s thigh. Extreme flexion of
hips and external rotation of both
femurs. Full abduction
ING (Inguinal Ligament)
 Hip internal rotator dysfunction
 Tender point
⚫ Lateral surface of pubic bone just below the inguinal
ligament attachment. Push medial
 Treatment
⚫ Supine
⚫ Clinician stands on tender point side
⚫ Flexion – flex hip 90o and rest on clinician’s thigh. Move
the leg on the tender point side under opposite leg of
patient. This produces crossing of knees and thighs
⚫ Adduction of femur
⚫ Rotate – internal rotation of femur

 Groin pain
ADD (Adductor)

 Tender point
1. Origin of adductors to pubic bone
2. Occasionally in muscle belly
 Treatment
⚫ Supine
⚫ Adduction – marked
⚫ Cross leg of tender point side in front of
opposite leg
⚫ Flexion – slight
GMi (Gluteus Minimus)
 Tender point
⚫ Anterior border of gluteus minimus
muscle. Superior and anterior to the
greater trochanter. Push posterior and
medical above greater trochanter
 Treatment
⚫ Supine
⚫ Flexion – hip to 90o
⚫ Abduction – slight
⚫ Rotate – marked internal
TFL (Tensor Fascia Lata)
 Tender point
⚫ Belly of TFL muscle approximately 6
cm cephalad and anterior to the
greater trochanter
 Treatment
⚫ Supine
⚫ Flexion – hip 90o-100o
⚫ Abduction – hip, slight
⚫ Rotation – draw foot laterally to create
internal rotation of hip
SAR (Sartorius)
(Connection with RK Technique)
 Tender point
⚫ 1. Proximal tendon 2 cm lateral from anterior
inferior iliac spine
⚫ 2. Mid belly of muscle
⚫ 3. Distal sartorius on medial side of knee (RK)
 Treatment
⚫ Supine
⚫ Flexion – hip and knee 90o
⚫ Abduction – hip, moderate
⚫ Rotation – external, moderate
 HISI

PLT

Posterior MPSI

Pelvis / Hip
Tender HFO-SI
PMT
GM

Points PIR

LT
HISI (High Ilium – Sacroiliac)

 Common
 Tender point
⚫ 3 cm lateral to the posterior superior
iliac spine
 Treatment
⚫ Prone
⚫ Extension – hip, supported on
clinician’s thigh
⚫ Abduct - slight
HFO-SI (High Flare-Out Sacroiliac)
 May be associated with coccygodynia
 Tender point
⚫ 1. 4 cm below and slightly medial to PSIS in
the area of the inferior lateral angles of the
sacrum
⚫ Occasionally on the ischial tuberosity
 Treatment
⚫ Prone
⚫ Clinician on side opposite tender pont
⚫ Raise leg on the tender point side high
enough to clear opposite leg and adduct
across, scissoring the legs
⚫ Correction is by increasing/accentuating the
high ilium and flareout. Occasionally, the
opposite leg is extended mildly and adducted
MPSI (Mid-Pole Sacoiliac)
 Ilium flare in - superiorly
 Tender point
⚫ Middle of the buttocks in slight depression
⚫ Direct palpating finger medially (located
medial to piriformis)
 Treatment
⚫ Prone
⚫ Extension – slight, occasionally slight flexion
⚫ Abduction – moderate, major component

 Helpful with dysmenorrhea, may decrease

cramping intensity by 50-60%
PIR (Piriformis)
 Tender point
⚫ In the muscle belly, 8 cm medial and slightly cephalad
to the greater trochanter
 Treatment
1. Similar to LP5
⚫ Prone
⚫ Clinician seated on tender point side
⚫ Leg on tender point side suspended off side of table
with patient’s anterior aspect on ankle resting on
operator’s thigh
⚫ Flexion – 120o at hip
⚫ Abduct –moderate, horizontally
⚫ rotate – usually internal
⚫ Piriformis – muscle belly
2. Occasionally will clear with the posterior lateral
trochanter technique (easier)
⚫ Piriformis - tendon
PLT (Posterior Lateral Trochanter)
 Hip external rotator dysfunction
 Tender point
⚫ Posterosuperior lateral surface of greater
trochaner
⚫ Tender point is near the insertion of the piriformis
muscle
⚫ Push anterior and medial
 Treatment
⚫ Prone
⚫ Clinician on tender point side
⚫ Extension – hip, support thigh on clinician’s knee
⚫ Abduction – slight
⚫ Rotate – marked external
PMT (Posterior Medial Trochanter)

 Tender point
⚫ On a line from the lateral inferior surface of
ischial tuberosity to the medial aspect of the
posterior surface of the femur
 Treatment
⚫ Prone
⚫ Clinician on side opposite tender point
⚫ Clinician pins patient’s ankle in his/her axilla
⚫ Extension – hip, moderate
⚫ Adduction – marked
⚫ Rotate – marked external
LT (Lateral Trochanter (LT)
 Tender point
⚫ 12 cm below greater trochanter on
lateral side of the shaft of the femur.
Push medially
 Treatment
⚫ Prone
⚫ Flexion – hip, minimal
⚫ Abduction – hip
⚫ Rotate – hip, internal or external,
slight
GM (Gluteus Medius)
 Tender point
⚫ On a line 1 cm below the iliac crest
⚫ Follow medial to lateral with palpation
 Treatment
⚫ Prone
⚫ Clinician on tender point side
⚫ Extension – hip, clinician places knee
under patient’s thigh
⚫ Abduction – hip, moderate
⚫ Rotate – marked, internal
 S1 S1

Sacral
Tender S2

Points S3

S5 S5
S4
PS1
 Backward sacral torsion dysfunction
 Tender point
⚫ 1.5 cm medial to inferior aspect of PSIS
bilaterally
 Treatment
⚫ Prone
⚫ Apply a downward pressure (toward table)
on the opposite corner of the sacrum from
which the tender point is found to produce
rotation around an oblique axis
⚫ Twist heel of hand for subtle fine
tuning/rotation
PS2
 Sacral extension dysfunction
 Tender point
⚫ Midline on sacrum between the first and
second spinous tubercles
 Treatment
⚫ Prone
⚫ Apply a downward pressure to the apex of
the sacrum in midline to produce rotation
around a transverse axis
⚫ Twist heel of hand for subtle fine
tuning/rotation
PS3

 Sacral extension dysfunction

 Tender point
⚫ Midline on sacrum between the
second and third spinous tubercles
 Treatment
⚫ Prone
⚫ Apply a downward pressure to the
apex of the sacrum in midline
⚫ Twist heel of hand for subtle fine
tuning/rotation
PS4
 Sacral flexion dysfunction
 Tender point
⚫ Midline on sacrum just above sacral
hiatus
⚫ Approach inferior to superior
 Treatment
⚫ Prone
⚫ Apply a downward pressure to the
sacral base in midline
⚫ Twist heel of hand for subtle fine
tuning/rotation
PS5
 Forward sacral torsion dysfunction
 Tender point
⚫ 1 cm medial and 1 cm superior to the inferior
lateral angles bilaterally
 Treatment
⚫ Prone
⚫ Apply a downward pressure to the opposite
corner of the sacrum from where the tender
point is found
⚫ Twist heel of hand for subtle fine
tuning/rotation
CYX (Coccyx Point)

 Coccygodynia
 Tender point
⚫ Either side of tip of coccyx
 Treatment
⚫ Prone
⚫ Apply a downward pressure to the
apex of the sacrum
⚫ Rotate sacrum toward side of tender
point (95%). Rotate away from the
side of tender point (5%)