Medicine (MD/DO)
Osteopathic Manipulative Medicine by TrueLearn
Treatment Modalities
Counterstrain Overview

Master Counterstrain Overview with Picmonic for Medicine

With Picmonic, facts become pictures. We've taken what the science shows - image mnemonics work - but we've boosted the effectiveness by building and associating memorable characters, interesting audio stories, and built-in quizzing.

Counterstrain Overview

Recommended Picmonics

picmonic thumbnail
Muscle Energy
picmonic thumbnail
High-Velocity, Low-Amplitude Thrust (HVLA)
picmonic thumbnail
Myofascial Release and Soft Tissue
picmonic thumbnail
Zink's Common Compensatory Pattern
picmonic thumbnail
Myofascial Trigger Points

Counterstrain Overview

Counterstrain is an indirect and passive technique invented by Lawrence Jones, DO to treat somatic dysfunctions associated with a tender point. It is an indirect, passive technique. The pain from tender points is thought to be due to inappropriate proprioceptive firing. Counterstrain follows a regular procedure consisting of first identifying the tender point. The patient is then asked to rate their pain on a pain scale. They are then passively placed into a position of ease for 90 seconds. At this point, a therapeutic pulse, or fasciculation, may be observed. Patients are then slowly returned to normal position and reassessed for pain.

Counterstrain is an indirect technique, meaning the physician positions the patient’s dysfunction towards a point of ease, away from the restrictive barrier.


Counterstrain is a passive technique, meaning the forces used during treatment come from the physician. The patient is instructed to remain relaxed and to refrain from muscle contraction during treatment.

Inappropriate Proprioception
Inappropriate Propeller-scepter

The predominant theory on the pathophysiology of counterstrain points involves inappropriate proprioceptive firing. Overload of a muscle (the agonist) causes reflexive and defensive contraction. When stretched, the agonist muscle’s spindle fibers sense the strain, and the alpha neurons defensively contract the agonist. The opposing muscle (the antagonist) will be stretched and may then reflexively contract, resulting in a “counter strain”. The counterstrain technique is meant to reset muscle proprioception.

Tender Point
Tenderizer Point

The physician finds a discrete point of tissue texture change in myofascial tissue that is locally tender. Tender points are hypersensitive but do not radiate pain to other areas of the body. Tender points are usually found in muscle, most often the muscle belly or tendinous attachment, but may also be found in other fascial tissues. Tender points are found in consistent locations from person to person.

Pain Scale
Pain-bolt Scale

When palpating a tender point, the physician should establish a pain scale with the patient, such as 0 (not tender) to 10 (severely tender). The physician then tells the patient to consider the pain from the tender point a 10, in order to accurately measure pain reduction. Some prefer to use a percentage scale. For example, pre-treatment pain may be rated as 100%, and complete elimination of tenderness would be 0%.

Maximum Comfort
Maximum Comforter

After establishing a pain scale, the physician places the patient in a position of maximum comfort. This means that palpation of the tender point causes pain rated as 3 or less on the pain scale, or at least a 70% improvement.

90 Seconds
90 Second-timer

The physician holds the patient in the position of maximum comfort for 90 seconds while the patient remains relaxed. This amount of time is sufficient to treat most tender points. A notable exception is the treatment of rib tender points, which should be held for 120 seconds.

Therapeutic Pulse
Feeling Pulsing Sensation

During the 90-second hold, the physician may palpate a pulsing sensation in the tender point being treated. This is not necessary for treatment success but usually indicates an adequate response to treatment. This should not be confused with the “local twitch response” observed in myofascial trigger points.

Slowly Return to Neutral
Slowly Returning to Neutral

After 90 seconds, the physician slowly returns the patient to neutral, or pre-treatment position. It is important for the patient to remain relaxed during this step.


After returning the patient to neutral, the physician reassesses the tender point and any associated somatic dysfunction.


Take the Counterstrain Overview Quiz

Picmonic's rapid review multiple-choice quiz allows you to assess your knowledge.

It's worth every penny

Our Story Mnemonics Increase Mastery and Retention

Memorize facts with phonetic mnemonics

Unforgettable characters with concise but impactful videos (2-4 min each)

Memorize facts with phonetic mnemonics

Ace Your Medicine (MD/DO) Classes & Exams with Picmonic:

Over 1,890,000 students use Picmonic’s picture mnemonics to improve knowledge, retention, and exam performance.

Choose the #1 Medicine (MD/DO) student study app.

Picmonic for Medicine (MD/DO) covers information that is relevant to your entire Medicine (MD/DO) education. Whether you’re studying for your classes or getting ready to conquer the USMLE Step 1, USMLE Step 2 CK, COMLEX Level 1, or COMLEX Level 2, we’re here to help.

Works better than traditional Medicine (MD/DO) flashcards.

Research shows that students who use Picmonic see a 331% improvement in memory retention and a 50% improvement in test scores.