strain and counterstrain for pelvic pain

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 intervention in the treatment of painful hypertonic
pelvic floor musctes and the joints they influence.
Pelvic floor muscle hv~ertonicitvcan cause musculoskeletal pain and adversely affect the urogenital and colorectal systems they maintain
(ICusunose 1993). This innovative treatment system uses passive body positioning of hypertonic
muscles and dysfunctional joints toward positions of con~fortor tissue ease that compress or
shorten the offending structure. The purpose of
movement toward shortening is to arrest aberrant propriocep tive neuromuscular reflexes that
maintain n~usclehypertonicity, forcing eventual
reduction of neuromuscular tone to tonic levels.
The strain and counterstrain (SCS) technique
is considered to be an indirect manipulative technique, 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 American osteopath Dr. Lawrence Jones in the 1950s.
It is categorized as an "afferent reduction technique" (Wilder 1997) and was originally called
"spontaneous release by positioning" or "positional 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 dysfunction). He was schooled to believe that somehow joints became loclced or subluxed and that
the only way to treat them was to bust them
loose via high-velocity thrust techniques. His results were generally good, but occasionally a patient 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 discovered positional release.
A young man with psoasitis (stooped posture,
unable to come con~pletelyerect, 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 devoted one treatment session to finding a reasonably 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 dramaticafter 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 following the position-of-release treatment, a return to neutral carried out very slowly was important for the outcome of the treatment. If the
patient was returned toward neutral too quickly,
especially in the first 15" of the motion, the benefit from the positioning was lost. Also, after initially 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 inconsistent, 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 correlation 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 pressure, 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 pressure 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 paravertebral musculature or over spinous processes are
especially valuable for diagnosing segmental dysfunction in the vertebral column (Jones 1964,
Wilder 1997).
-
Evaluation with Tender Points
Tender points are not only found over spinous 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 illustration 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 involved 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, gluteals, quadratus femoris, piriformis, obturator internus, and adductor muscles and many others,
indicating local muscle dysfunctions as well as
points that diagnose joint ilial-sacral and sacral-ilia1 motion restrictions, lumbosacral dysfunctions, 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 tender point for changes in tissue tension and the
patient's feedback of either increasing or decreasing sensitivity, the operator is guided to a position of maximum palpatory relaxation beneath
the monitoring finger. A marked and prompt reduction in subjective tenderness ensues. Jones
calls this the "mobile point" Uones 1964, Wilder
1997). It is the point of maximum ease or relaxation 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 multiple 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 positions the patient into a posture of comfort and
relaxation. He may proceed successfully just by
questioning the patient as he probes intermittently while moving toward the position. If he
is correct, the patient can report diminishing tenderness 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 returning to neutral very slowly are the major components of the SCS technique.
A common question is the relationship of SCS
tender points to Travell's trigger points, acupuncture 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 pattern of referral specific for the muscle involved (Korr 1975).
Trigger points are also associated with a taut
band of skeletal muscle that is painful on compression and a local twitch in the muscle fibers
containing the trigger point. A local twitch can
be produced by stimulation, with a snapping palpation 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 exquisitely painful to palpation, patients can react
with a jump sign when they are palpated. This
response is a full-body pain reaction to the palpation 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 designate 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 manifestation of a neuromuscular or musculosl<eletal dysfunction (Wilder 1997). The points are used to
make the diagnosis and to monitor the effectiveness 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.
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 pressure 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).
----.
.
(
\
TFL
+4
,
I1
\
7
,
,2-
..,
,:
,'
i
.
L I S ~- .
ITechniques
The techniques demonstrated in this section emphasize 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 hypertonic dysfunction (dyspareunia, coccydynia,
vaginismus, constipation, etc.) would be broadened 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 diagnosis and as monitoring tools to sense the release
of tone with the treatment technique, but internal palpation will not be presented here (see section 2.1 above).
.
1
/
\
LIFO
L-,'
'..
'.--./
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---
.
.
01
Fig. 2.8 Tender points in the posterior pelvis and
hip. Note: the arrows point in the direction of palpation. 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)
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 thickened and dense and co~nmonlyproduces a burning pain when palpated. Palpate in a posterior direction (Fig. 2.9).
Most common complaints. Deep achy posterior
lumbar, sacroiliac, and buttock pain; also medial
knee pain.
lliacus (IL)
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 posterior-lateral direction, feeling for aberrant tone
(Fig. 2.10).
Most common complaints. Sacroiliac pain extending down along the medial buttocl<s. Diffuse
lumbar ache. Increased symptoms with prolonged standing or walking.
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.
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. Finetune the position, adjusting hip flexion and rotation to find the mobile point.
Fig. 2.9a, b Tender point anterior fifth lumbar (AL5).
Fig. Z.lOa, b Tender point iliacus (IL).
Low Ilium Sacroiliac (LISI;
Correlates with
Posterior Innominate Rotation)
Most common complaints. Deep ache in the posterior lumbars, sacroiliac, and posterior lateral
hip.
Tender point location. On the superior surface of
the lateral ramus of the pubic bone, approximately 2 cm lateral to the pubic symphysis. Palpation is directed inferiorly (Fig. 2.1 l ) .
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 maintained with mild pressure on the front of the
shin.
'I
Fig. 2.11a, b Tender point low ilium sacroiliac (LISI).
I
Low Ilium with Flare-Out (LIFO)
Tender point location. Found on the inferior
medial surface of the descending ramus of the
pubic bone. Palpate in a superolateral direction
along the length of ramus from just below the
pubic symphysis to just above the ischial tuberosities (Fig. 2.12).
Fig. 2.12a. b Tender point low ilium with flare-out (LIFO).
Most common complaints. Deep ache in buttocl<s
and posterior lateral hip.
Treatment position. The patient lies supine. The
hip is flexed and the knee is allowed to flop laterally, with the foot being kept on the midline,
producing abduction and external rotation of
the femur. Fine-tune the position primarily with
flexion.
H
Inguinal (ING)
Te~ltlerpoint 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).
Most common complaints. Groin pain, medial
thigh pain, and anterior-medial knee pain.
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. Finetune the position with rotation.
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 posteromedial 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).
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 rnedial thigh pain to the knee.
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).
Fig. 2.15a, b Tender points adductors (ADD).
High Ilium Sacroiliac
(HISI; Correlates with
Anterior Innominate Rotation)
Most common complaint. This is a common dysfunction that produces a sharp, localized pain i l l
the area of the tender point.
Tender point location. Approximately 3 crn lateral to the posterior superior iliac spine (PSIS).
Palpation is directed rnedially to the lateral surface of the PSIS (Fig. 2.16).
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.
I
Fig. 2.16a, b Tender point high ilium sacroiliac
(HIS]).
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 sacral edge. 2) A second point found on the ischial
tuberosities can diagnose adductor magnus dysfunction. 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 011the opposite side from the tender point. The affected hip is extended and adducted across the opposite leg. Fine-tune with abduction and adduction until relaxation is felt.
Fig. 2.17a, b Tender point high ilium with flare-out (HIFO).
Midpole Sacroiliac (MPSI; Correlates
with In-Flare Dysfunction)
Most colnlnon complaints. Sacroiliac pain, buttack pain, dysmenorrhea.
Tender point location. Found in the middle of
Treatment position. The patient lies prone. The
each buttoclc, sometimes in a small depression.
Palpation is superficial in a medial direction.
The buttock should be seen rising like an accordion in the middle as the operator's palpating
fingers travel 3-4 cm medially (Fig. 2.18).
Fig. 2.18a. b Tender point midpole sacroiliac (MPSI).
affected hip is abducted. Fine-tune the position
usually with slight hip flexion and external rotac:~..
LIUII.
Note: Decreased cramping is noticed in patients
with dysmenorrhea by the second menstruation.
=
Piriformis (PIR)
Tender point location. 1 ) Found in the mid-belly
of the piriformis muscle between the lateral sacrum and the greater trochanter of the hip. Palpate in an anterior direction. 2) The second tender point is found over the posterior, lateral,
and superior aspect of the greater trochanter. Palpate in an anterior-medial direction (Fig. 2.19).
Most common complaints. Buttoclc pain, trochanter pain, sciatica.
Treatment positions. 1 ) The patient lies prone.
The affected hip is flexed approximately 90" off
the edge of the table and abducted from moderate to marked while resting on the operator's
thigh. Fine-tune the position with flexion, abduction, and hip rotation by drawing the foot medially 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).
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).
Most common complaints. Sharp pain over the
top of the iliac crest, pain in the buttoclcs, and sacral 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)
Tender point location. Found on the inner surface of ;he obturator membrane and rim of the
obturator foramen. It can be found by pushing
cephalad from the medial side of the ischial
tuberosity and then pushing laterally into the
obturator membrane (Fig. 2.21).
Most common complaints. Deep ache in ipsilatera1 hip, coccyx pain, posterior thigh pain.
Treatment position. The patient lies prone. The
knee on the affected side is flexed to 90" and
the foot is then allowed to flop medially to produce marked external rotation of the hip. Finetune 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. Palpate in a cephalad and lateral direction, starting
2 c m 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 symphysis. 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 common, 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 lumbar, sacroiliac. buttoclz, and hip pain. Lateral
Fig. 2.23a, b
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.
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).
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 tender 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.
Most common complaints. Sacroiliac and coccyx
pain.
i
I
i
\.('-.
\,
,
'~
//
\i
6.
\
\
Fig. 2.24a, b Tender point posterior first sacral
(PSI).
b
1;
Sacrum
=
Posterior Second Sacral (PSZ)
and Posterior Third Sacral (PS3)
Tender point locations. Found midline on the sacrum between the first and second sacral spines
and the second and third sacral spines. Both are
com~nontender points, but are frequently missed
because the gaps between the spines are small.
The tip of an index finger has to be used to palpate these points (Fig. 2.25).
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 extension, following the line of the sacrum. This will
create an anterior pressure over the sacral apex
in midline, producing rotation around a transverse axis. Fine-tune by slowly twisting the hand
i n a clocl<wise and counterclocl<wisedirection.
Fig. 2.25a, b Tender points posterior second
sacral (PS2) and posterior third sacral (PS3).
-
Sacrum
Posterior Fourth Sacral (PS4)
Tender point location. Found midline on the sacrum 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<wiseand counterclocl<wisedirection.
/1
-
,--
!
,
I
,'
\
1
I
i
I
ii
t
/
\'
.........
Fig. 2.26a, b Tender point fourth sacral (PS4).
\
'
f
b
/'
'
/' .
Sacrum
Coccyx (CYX)
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.
Fig. 2.27a, b Tender point fifth sacral (PS5).
,-%,
-
\'
Fig. 2.28a. b Tender point coccyx (CYX).
Tender point location. Follow the coccyx as distally 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 extension, 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.
I
Sacrum
I
Case studv 1
References
M. 6.. a 38-year-old woman, presented with pelvic floor pain of 5 years' duration. The diagnosis
at the initial evaluation was a history of endometriosis, which had been confirmed by laparoscopic 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 constant, 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 internus, and right mid-pole sacroiliac were found
and treated. After the second treatment, the
patient was subjectively pain-free. Three follow-up treatments over a 6-week period resulted in long-term pain relief and discontinuation 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 straincounterstrain. Boise, ID: Jones Strain-Counterstrain. 1995.
I<orr IM. Proprioceptors and somatic dysfunction.
J Am Osteopath Assoc 1975; 74:638-50.
I<usunoseR. Strain and counterstrain. In: Basmajian
JV, Nyberg R, eds. Rational manual therapies. Baltimore: 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 dysfunction: 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 varicosity. She underwent surgery for resection of
the offending structure. During the procedure,
the surgeon dissected the round ligament and attempted to evaluate the right inguinal canal.
After surgery, the patient experienced a worsening of the symptoms. These changes had remained constant until the time of her initial evaluation. She had tried multiple interventions for
the pain, including physical therapy, massage
therapy, and acupuncture. At the initial evaluation, the patient was found to have scarring in
the region of the right labium in the form of
thick, fibrous connective tissue. Extreme tenderness 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 techniques for these tender points. A follow-up evaluation showed almost complete absence of right labial tenderness, and the patient reported complete cessation of the sharp labial pain symptoms.