Complete Jones Counterstrain Tenderpoint Atlas & Positioning

The primary neurophysiological target of Strain-Counterstrain is the muscle spindle (intrafusal fibers innervated by gamma motor neurons and monitored by primary Type Ia and secondary Type II sensory afferents), whereas Muscle Energy Technique (MET) primarily engages the Golgi tendon organ (Type Ib afferents) during post-isometric relaxation. In a somatic dysfunction with an active counterstrain tenderpoint, the muscle housing the tenderpoint is maintained in a shortened, hypertonic state by continuous gamma-loop hyperactivity; the central nervous system erroneously perceives that the shortened muscle is still being stretched because Ia afferent discharge remains elevated.

By passively folding and positioning the patient's body to approximate the bony attachments of the affected muscle—moving into the position of ease (indirect barrier)—the physician mechanically slackens the intrafusal nuclear bag and nuclear chain fibers. This slackening immediately reduces Type Ia afferent discharge toward zero. Holding this shortened position for 90 seconds permits the spinal cord internuncial pool to turn down gamma motor neuron efferent tone (gamma gain) and restores normal intrafusal-to-extrafusal length calibration, accompanied by local nitric oxide release and resolution of tissue edema.

When integrating 1. Intrafusal Muscle Spindle Reset & The Golgi Tendon Organ Differentiator into clinical osteopathic care, the physician always correlates regional palpatory findings—specifically deep paraspinal and myofascial tissue texture changes, bony landmark asymmetry, three-planar motion restriction, and localized tenderness—with the patient's underlying neurophysiologic and biomechanical status. Before initiating treatment, establish a clear baseline assessment of range of motion and pain intensity; during the procedure, maintain continuous palpatory feedback at the target motion segment or tenderpoint fulcrum; and immediately following treatment, re-examine the segment to confirm objective resolution of somatic dysfunction and restoration of balanced physiological motion.

Every counterstrain treatment on COMLEX and OPP practical examinations follows five strict sequential phases: (1) Locate the tenderpoint and establish a baseline pain scale of 10/10 (100% tenderness); (2) Passively guide the patient into the gross position of ease using the regional F/E/S/R heuristic while continuously keeping the monitoring finger on the tenderpoint (monitoring contact is never lifted, though deep probing pressure is softened during the 90-second hold); (3) Fine-tune the mobile point using small adjustments in flexion, extension, sidebending, or rotation until tenderness drops to 3/10 or less (at least a 70% reduction in pain) and palpable tissue tension melts beneath the monitoring finger; (4) Maintain the motionless position for 90 seconds (120 seconds for cranial or chronic recalcitrant rib points); and (5) Slowly and passively return the patient to neutral posture while instructing the patient not to assist.

If the patient actively contracts their muscles during the return to neutral, the sudden alpha-gamma co-activation immediately re-triggers the Ia afferent stretch reflex and spoils the therapeutic reset. Following passive return to neutral, the physician must re-palpate the tenderpoint to verify that tenderness remains at 3/10 or below. Absolute contraindications to counterstrain include an uncooperative patient unable to remain still for 90 seconds, acute unstable fracture, or ligamentous tear at the mobilized joint.

AC1 (Occipitoatlantal / OA): Located on the posterior surface of the ascending ramus of the mandible between the earlobe and the angle of the jaw (palpated by pressing anteriorly against the posterior mandibular border). Because AC1 reflects rotation of the atlas on the occiput, it is treated with R(A) S(A) (primarily Rotation Away up to 90 degrees with slight sidebending away, neutral flexion/extension). AC2 through AC6: Located on the anterior tips of the respective cervical transverse processes (along the posterior border of the sternocleidomastoid muscle); all five points (AC2, AC3, AC4, AC5, AC6) are treated with F S(A) R(A).

AC7 (Clavicular SCM Exception): Located on the superior surface of the medial clavicle just lateral to the clavicular head of the sternocleidomastoid (SCM) insertion. Because the SCM sidebends the neck ipsilaterally and rotates the head contralaterally, shortening the SCM requires F S(T) R(A) (Flexion, Sidebending Toward, Rotation Away). AC8 (Sternal SCM): Located at the medial end of the clavicle / superolateral manubrium at the sternal head of the SCM; treated with F S(A) R(A).

When integrating 1. Anterior Cervical (AC1–AC8) Anatomical Landmarks & Setup Exceptions into clinical osteopathic care, the physician always correlates regional palpatory findings—specifically deep paraspinal and myofascial tissue texture changes, bony landmark asymmetry, three-planar motion restriction, and localized tenderness—with the patient's underlying neurophysiologic and biomechanical status. Before initiating treatment, establish a clear baseline assessment of range of motion and pain intensity; during the procedure, maintain continuous palpatory feedback at the target motion segment or tenderpoint fulcrum; and immediately following treatment, re-examine the segment to confirm objective resolution of somatic dysfunction and restoration of balanced physiological motion.

PC1 — Inion (Flexion Exception): The classical PC1 (Inion) tenderpoint is located on the midline occipital bone 1.5 to 2 cm directly inferior to the external occipital protuberance (inion). Despite being a posterior cervical point, the inion point is treated with pure Cervical Flexion (F) ('chin-to-chest' tuck of the upper cervical spine). Note: A separate PC1 Occiput point located laterally between the inion and mastoid process is treated with E R(A). PC2: Located on the superior tip of the spinous process of C2; treated with E S(A) R(A).

PC3 (Flexion Exception): Located on the inferior tip of the spinous process of C2 (not on C3!). Because it lies inferior to the C2 spinous process, PC3 is treated with F S(A) R(A) (Flexion, Sidebending Away, Rotation Away). PC4 through PC7: Located on the inferior tip of the spinous process of the vertebra ABOVE (i.e., PC4 is on the inferior tip of C3 SP; PC5 is on C4 SP; PC6 is on C5 SP; PC7 is on C6 SP) or over the corresponding articular pillars; all are treated with standard E S(A) R(A). PC8: Located on the inferior tip of the C7 spinous process; treated with E S(A) R(A).

When integrating 2. Posterior Cervical (PC1–PC8) Landmarks & The Inion (PC1) and PC3 Exceptions into clinical osteopathic care, the physician always correlates regional palpatory findings—specifically deep paraspinal and myofascial tissue texture changes, bony landmark asymmetry, three-planar motion restriction, and localized tenderness—with the patient's underlying neurophysiologic and biomechanical status. Before initiating treatment, establish a clear baseline assessment of range of motion and pain intensity; during the procedure, maintain continuous palpatory feedback at the target motion segment or tenderpoint fulcrum; and immediately following treatment, re-examine the segment to confirm objective resolution of somatic dysfunction and restoration of balanced physiological motion.

Anterior Thoracic (AT1–AT6): Located along the anterior midline sternum (AT1 at the suprasternal notch, AT2 at the sternal angle of Louis, AT3–AT6 descending along the sternal body to the xiphisternal junction). Because AT1–AT6 lie directly on the midline, they are treated with pure Thoracic Flexion (F) (with minor fine-tuning in sidebending/rotation as needed). AT7–AT9: Located bilaterally in the interchondral spaces of the 7th, 8th, and 9th costal cartilages near the subcostal margin (AT7 right/left corresponds to epigastric/duodenal viscerosomatics). AT10–AT12: Located in the abdominal rectus sheath lateral to the umbilicus (AT10 at the level of the umbilicus, AT11 1 inch below, AT12 on the inner iliac crest at the midaxillary line). Bilateral lower anterior thoracic points AT7–AT12 are treated with F S(T) R(A).

Posterior Thoracic (PT1–PT12): Located bilaterally on the transverse processes (or interspinous/paraspinal gutter immediately lateral to the spinous processes) of T1 through T12 (accounting for the Rule of Threes where lower thoracic spinous processes project inferiorly). PT1–PT9 are treated with E S(A) R(A) (Extension, Sidebending Away, Rotation Away—typically achieved with the patient prone by raising the ipsilateral or contralateral arm/shoulder to extend and rotate the upper/mid-thoracic spine away from the tenderpoint). PT10–PT12 (the lower three thoracic segments whose facet joints transition toward lumbar sagittal orientation) are treated with E S(T) R(A) (Extension, Sidebending Toward, Rotation Away).

Anterior Rib Tenderpoints (AR1–AR10) — Depressed Rib Dysfunctions: An anterior rib tenderpoint corresponds clinically to a depressed rib (exhalation somatic dysfunction) held inferiorly by hypertonic intercostal or anterior chest wall musculature. AR1 is located where the 1st rib cartilage meets the manubrium immediately beneath the clavicle; AR2 is located in the 2nd intercostal space at the midclavicular line (MCL); and AR3–AR10 are located along the anterior axillary line (AAL) on the respective rib shafts. All anterior rib tenderpoints (AR1–AR10) are treated with the seated or supine patient placed in F S(T) R(T) (Flexion, Sidebending Toward, Rotation Toward the tenderpoint).

Posterior Rib Tenderpoints (PR1–PR12) — Elevated Rib Dysfunctions: A posterior rib tenderpoint corresponds clinically to an elevated rib (inhalation somatic dysfunction). PR1 is located in the trapezius ridge just anterior to the angle of the 1st rib at the base of the neck, and PR2–PR12 are located on the posterior rib angles laterally along the erector spinae / iliocostalis border. All posterior rib tenderpoints (PR1–PR12) are treated in F S(A) R(A) (Flexion, Sidebending Away, Rotation Away from the tenderpoint).

When integrating 2. Anterior Rib (AR1–AR10, Depressed Rib) vs. Posterior Rib (PR1–PR12, Elevated Rib) into clinical osteopathic care, the physician always correlates regional palpatory findings—specifically deep paraspinal and myofascial tissue texture changes, bony landmark asymmetry, three-planar motion restriction, and localized tenderness—with the patient's underlying neurophysiologic and biomechanical status. Before initiating treatment, establish a clear baseline assessment of range of motion and pain intensity; during the procedure, maintain continuous palpatory feedback at the target motion segment or tenderpoint fulcrum; and immediately following treatment, re-examine the segment to confirm objective resolution of somatic dysfunction and restoration of balanced physiological motion.

Anterior Lumbar Landmarks (AL1–AL5): AL1 is located just medial to the Anterior Superior Iliac Spine (ASIS); AL2 is located on the medial surface of the Anterior Inferior Iliac Spine (AIIS); AL3 is located on the lateral surface of the AIIS; AL4 is located on the inferior tip of the AIIS; and AL5 is located on the anterior surface of the pubic ramus approximately 1 cm lateral to the pubic symphysis. With the patient supine, the physician flexes both hips and knees to 90 degrees so that moving the knees/ankles sidebends and rotates the lumbar pelvis: AL1 is treated with F S(A) R(T), whereas AL2, AL3, AL4, and AL5 are all treated with F S(T) R(A) (note: rotating the pelvis away means pulling the knees toward the physician and pushing the ankles away when standing on the side of the tenderpoint).

Posterior Lumbar Landmarks (PL1–PL5 & Upper/Lower Pole L5): PL1–PL5 are located on the transverse processes / paraspinal musculature between the spinous processes of L1–L5. Notice the split between PL3 Lateral (located in the gluteal mass 3 inches lateral to the PSIS and 1 inch superior). Standard PL1, PL2, and PL3 (medial) are treated with E S(A) R(A), whereas PL3 (lateral), PL4, and PL5 are treated with E S(T) R(A). Furthermore, L5 has two midline/paramidline special points: Upper Pole L5 (superior aspect of the L5 spinous process or 1 inch medial and superior to the PSIS) is treated with E S(T) R(T), whereas Lower Pole L5 (inferior aspect of the L5 spinous process) is the ONLY posterior lumbar point treated with FLEXION: F S(T) R(A)!

Iliacus Tenderpoint: Located deep in the iliac fossa approximately one-quarter of the distance from the ASIS toward the umbilicus (pressing posterolaterally against the inner table of the ilium). Because the iliacus flexes and externally rotates the hip, the classic treatment setup is the bilateral 'Frog-Leg' position: extreme Hip Flexion (90–130 degrees), Abduction, and External Rotation — F Abd ER (with the ankles crossed). Psoas Major Tenderpoint: Located deeper and more medially than the iliacus (roughly two-thirds of the way from the ASIS to the umbilicus, lateral to the rectus abdominis); treated with bilateral hip flexion, sidebending toward, and rotation away: F S(T) R(A).

Piriformis Tenderpoint: Located in the belly of the piriformis muscle at the midpoint of a line connecting the Inferior Lateral Angle (ILA) of the sacrum (or coccyx/S2–S4) to the greater trochanter of the femur. With the patient prone, the physician brings the ipsilateral leg off the side of the table into Hip Flexion (90–135 degrees), Abduction, and External/Internal Rotation fine-tuning — F Abd ER/IR. Inguinal Ligament (Internal Oblique / Pectineus) Point: Located on the superior pubic ramus near the insertion of the inguinal ligament at the pubic tubercle; treated with hip Flexion, Adduction, and Internal Rotation — F Add IR (crossing the ipsilateral thigh over the contralateral thigh).

When integrating 2. Iliacus ('Frog-Leg'), Psoas, Piriformis & Inguinal Ligament Counterstrain Setups into clinical osteopathic care, the physician always correlates regional palpatory findings—specifically deep paraspinal and myofascial tissue texture changes, bony landmark asymmetry, three-planar motion restriction, and localized tenderness—with the patient's underlying neurophysiologic and biomechanical status. Before initiating treatment, establish a clear baseline assessment of range of motion and pain intensity; during the procedure, maintain continuous palpatory feedback at the target motion segment or tenderpoint fulcrum; and immediately following treatment, re-examine the segment to confirm objective resolution of somatic dysfunction and restoration of balanced physiological motion.

The ten posterior sacral tenderpoints consist of six midline points (PS1, PS2, PS3, PS4, PS5, plus PS1-2) along the median sacral crest and four bilateral lateral points (PS1 Lateral / Cephalad Sulcus and PS5 Lateral / Caudad ILA). The biomechanics follow a simple see-saw leverage rule across the middle transverse sacral axis at S2: to treat a cephalad/superior sacral tenderpoint (PS1, PS2, or PS1 Lateral), apply anterior downward pressure on the CAUDAD sacral apex (S4/ILA) so that the sacral base rocks posteriorly (counternutation) and slackens the superior sacral tissues!

Conversely, to treat a caudad/inferior sacral tenderpoint (PS4, PS5, or PS5 Lateral at the ILA), apply anterior downward pressure on the CEPHALAD sacral base (S1/S2) so that the sacral base nutates anteriorly and the inferior apex rocks posteriorly! Specifically: PS1 (midline S1) is treated by pressing anteriorly on the midline sacral apex (S4/S5); PS5 (midline S5) is treated by pressing anteriorly on the midline sacral base (S1); PS3 (midline S3) is treated by pressing anteriorly on S2; PS1 Lateral (sacral sulcus) is treated by pressing anteriorly on the ipsilateral ILA; and PS5 Lateral (ILA) is treated by pressing anteriorly on the contralateral or ipsilateral sacral base (S1).

When integrating 1. Posterior Sacral Tenderpoints (PS1–PS5): Rocking the Sacral Base vs. Sacral Apex into clinical osteopathic care, the physician always correlates regional palpatory findings—specifically deep paraspinal and myofascial tissue texture changes, bony landmark asymmetry, three-planar motion restriction, and localized tenderness—with the patient's underlying neurophysiologic and biomechanical status. Before initiating treatment, establish a clear baseline assessment of range of motion and pain intensity; during the procedure, maintain continuous palpatory feedback at the target motion segment or tenderpoint fulcrum; and immediately following treatment, re-examine the segment to confirm objective resolution of somatic dysfunction and restoration of balanced physiological motion.

High Ilium Sacroiliac (HISS) Tenderpoint: Located on the superior/lateral aspect of the posterior iliac crest approximately 2 to 3 cm lateral to the Posterior Superior Iliac Spine (PSIS), where the gluteus medius and iliolumbar/posterior SI fibers attach. With the patient prone, the HISS tenderpoint is treated with passive ipsilateral hip Extension, Abduction, and External Rotation (E Abd ER) (or slight internal rotation fine-tuning), which approximates the posterior iliac crest toward the sacrum and greater trochanter.

Low Ilium Sacroiliac (LSI) / Mid-Pole Sacroiliac Tenderpoint: Located on the inferior slope of the PSIS along the lateral margin of the sacrum. In contrast to HISS, the Low Ilium point is treated by bringing the prone patient's ipsilateral thigh off the side of the table into Hip Flexion, Abduction, and External Rotation (F Abd ER) (similar to the piriformis setup) or Extension with Adduction depending on the fiber vector.

When integrating 2. High Ilium Sacroiliac (HISS) & Low Ilium Sacroiliac (LSI) Tenderpoints into clinical osteopathic care, the physician always correlates regional palpatory findings—specifically deep paraspinal and myofascial tissue texture changes, bony landmark asymmetry, three-planar motion restriction, and localized tenderness—with the patient's underlying neurophysiologic and biomechanical status. Before initiating treatment, establish a clear baseline assessment of range of motion and pain intensity; during the procedure, maintain continuous palpatory feedback at the target motion segment or tenderpoint fulcrum; and immediately following treatment, re-examine the segment to confirm objective resolution of somatic dysfunction and restoration of balanced physiological motion.

Rotator Cuff Tenderpoints: Both Supraspinatus (in the supraspinous fossa above the scapular spine) and Infraspinatus (in the infraspinous fossa below the scapular spine) are treated in the exact same 'Salute / Statue of Liberty' position: Shoulder Flexion (90–120 degrees), Abduction (45–90 degrees), and External Rotation — F Abd ER. Conversely, the Subscapularis tenderpoint (palpated on the anterior surface of the scapula via the posterior axillary fold with the arm abducted) is treated by placing the arm behind the back in Extension, Adduction, and Internal Rotation — E Add IR. Biceps Brachii: The Long Head of Biceps (in the bicipital groove) is treated with Shoulder Flexion, elbow flexion, and forearm Supination, whereas the Short Head of Biceps (inferolateral to the coracoid process) adds Shoulder Adduction.

Elbow Tenderpoints (RAD vs. COR): The Radial Head (Lateral Epicondylitis / Supinator / RAD) tenderpoint is located over the anterolateral radial head/supinator belly and is treated with full Elbow Extension, Forearm Supination, and Valgus/Abduction stress — E Sup Abd ('RAD = Extend & Supinate'). Conversely, the Coronoid (Medial Epicondylitis / Pronator Teres / COR) tenderpoint is located over the coronoid process of the ulna / pronator teres and is treated with Elbow Flexion, Forearm Pronation, and Adduction — F Pro Add.

When integrating 1. Upper Extremity Counterstrain: Rotator Cuff, Biceps & Elbow (Radial Head vs. Coronoid) into clinical osteopathic care, the physician always correlates regional palpatory findings—specifically deep paraspinal and myofascial tissue texture changes, bony landmark asymmetry, three-planar motion restriction, and localized tenderness—with the patient's underlying neurophysiologic and biomechanical status. Before initiating treatment, establish a clear baseline assessment of range of motion and pain intensity; during the procedure, maintain continuous palpatory feedback at the target motion segment or tenderpoint fulcrum; and immediately following treatment, re-examine the segment to confirm objective resolution of somatic dysfunction and restoration of balanced physiological motion.

Popliteus Tenderpoint: Located in the posterior popliteal space just inferior to the joint line on the proximal posteromedial tibia. Because the popliteus muscle flexes the knee and internally rotates the tibia (unlocking the extended knee), it is treated with the prone patient's knee in slight Flexion (20–30 degrees) with Internal Rotation of the tibia (and posterior translation/adduction of the distal tibia). Medial vs. Lateral Hamstring/Meniscus: The Medial Meniscus (MM) / Medial Hamstring point is treated with Knee Flexion, Internal Rotation of the tibia, and Adduction (Varus), whereas the Lateral Meniscus (LM) / Lateral Hamstring (Biceps Femoris) point is treated with Knee Flexion, External Rotation of the tibia, and Abduction (Valgus). The Patellar Tendon (Extension Knee) point is treated with Knee Extension and superior patellar shear.

Ankle Counterstrain Points: The Lateral Ankle (LA / Anterior Talofibular Ligament — ATFL) tenderpoint (located 1–2 cm anterior/inferior to the lateral malleolus in the sinus tarsi following a classic inversion ankle sprain) is treated by folding the foot around the lateral malleolus into Eversion (Abduction + External Rotation / Pronation)! Conversely, the Medial Ankle (MA / Deltoid Ligament / Tibialis Posterior) tenderpoint (inferior to the medial malleolus) is treated with Inversion (Adduction + Internal Rotation / Supination). Finally, the Flexion Ankle (FA / Tibialis Anterior) point on the anterior talocrural joint is treated with extreme Dorsiflexion, while the Extension Ankle (EA / Gastrocnemius-Soleus / Achilles) point in the calf/calcaneal tendon is treated with extreme Plantarflexion and knee flexion.