Lumbar and Pelvic Counterstrain: Landmarks Before Positions
Locate lumbar and pelvic tender points, compare their positions of ease, and practice counterstrain decisions grounded in anatomy and patient response.
Two tender points near the pelvis can require opposite hip positions. A point just below the PSIS is not treated like one just above it, and a piriformis point is not identified by the word “buttock” alone. Start with the exact landmark, then use the prescribed position as an initial estimate of comfort.
A monitored position of ease, not a stretch
Counterstrain is an indirect, passive approach to a localized tender point associated with somatic dysfunction. The patient remains relaxed while the clinician supports a position that substantially reduces tenderness. The tender point is a monitor for the response, not a structure to crush or massage continuously. A tender point also differs from a myofascial trigger point, which is classically associated with a taut muscular band and a referred pain pattern. A tender point by itself does not establish a specific muscle tear, nerve entrapment, or visceral diagnosis. [1][3]
First identify the point, establish a reproducible baseline tenderness, and explain how the patient will report changes. Traditional instruction seeks approximately 70% reduction before beginning the standard 90-second hold. If baseline tenderness is called ten, the positioning goal is roughly three or less with comparable monitoring pressure. This is a teaching convention, not a validated threshold proving a diagnosis or guaranteeing an outcome. After the hold, the clinician slowly returns the relaxed patient to neutral and reassesses. [1]
Identify a discrete point and record baseline tenderness.
Support the patient in an anatomically appropriate position of ease.
Fine-tune while checking that tenderness substantially decreases.
Maintain the comfortable position for the standard 90 seconds.
Return slowly and passively to neutral, then retest the point and useful function.
The sequence describes supervised clinical technique. The listed angles below are approximate starting positions, not force targets.
If tenderness increases, stop and reassess support, positioning, pressure, and the clinical interpretation. Do not simply press harder until the patient changes the rating. Proposed explanations include changes in neuromuscular reflex activity and pain processing, but an exact muscle-spindle “reset” at 90 seconds is not established physiology. The measured result is the patient's response after the intervention. Prioritizing a dominant or central point can be useful, but treatment order should follow the examination and tolerance rather than a rule that the most painful point always comes first.
Read the anterior pelvis from lateral to medial
Locate the anterior superior iliac spine (ASIS), anterior inferior iliac spine (AIIS), pubic symphysis, and pubic tubercle before assigning names. The ASIS and AIIS are different landmarks. The pubic tubercle is lateral to the symphysis; it is not interchangeable with every point on the pubic ramus. Abdominal or inguinal palpation requires explanation, appropriate draping, consent, and attention to underlying structures. Do not pursue a presumed point through an acutely painful abdomen. [1]
One side, viewed from the front: ASIS toward the midline
Relative position
Common teaching label
Initial positioning theme
Relative positionASIS → about one-third of the distance toward midline
Common teaching labelIliacus, more lateral
Initial positioning themeMarked bilateral hip flexion with external rotation
Relative positionASIS → about two-thirds of the distance toward midline
Common teaching labelPsoas major, more medial
Initial positioning themeBilateral hip flexion and external rotation; ipsilateral lumbar sidebending can refine ease
Relative positionSuperior to the iliopectineal eminence, between AIIS and pubic tubercle
Common teaching labelLow ilium, psoas minor region
Initial positioning themeSubstantial ipsilateral hip flexion, commonly around 100 degrees
Relative positionLateral aspect of pubic tubercle near inguinal ligament attachment
Common teaching labelInguinal, pectineus region
Initial positioning themeBilateral hip and knee flexion with ipsilateral adduction and internal rotation
Fractions start at the ASIS. Two-thirds is closer to the midline than one-third. These surface relationships do not make deep palpation uniquely diagnostic of an individual muscle.
Psoas and iliacus share a hip-flexion role but occupy different anatomical regions. Their similar positions of ease do not erase the distinction between the more medial psoas monitor and more lateral iliacus monitor. Quadriceps or abdominal guarding can interfere with supported hip positioning. Ask the patient to let the clinician carry the weight of the legs; active lifting changes the technique and may reproduce symptoms. [1][3]
A groin provocation test is a different procedure. FADIR means flexion, adduction, and internal rotation; FABER means flexion, abduction, and external rotation. A painful FADIR response can raise concern about hip pathology but does not independently diagnose it. A comfortable counterstrain position is selected to reduce the monitored tenderness. Neither a FABER response nor relief during hip flexion proves an iliacus diagnosis. [5]
Keep anterior lumbar levels and trunk directions separate
Anterior lumbar tender-point numbers do not mean that the point lies directly over that numbered vertebra. In the ATSU convention used here, AL1 is medial to the ASIS, AL2 medial to the AIIS, AL3 lateral to the AIIS, AL4 inferior to the AIIS, and AL5 on the anterior pubic ramus about one centimeter lateral to the symphysis. A point below the AIIS is AL4 in this map, even though an older quiz may have incorrectly placed it on the pubis. [1]
Anterior lumbar positioning refers to lumbar flexion, sidebending, and rotation
Point
Flexion or extension
Sidebending relative to point
Rotation relative to point
PointAL1
Flexion or extensionFlexion
Sidebending relative to pointToward
Rotation relative to pointAway
PointAL2, AL3, AL4
Flexion or extensionFlexion
Sidebending relative to pointAway
Rotation relative to pointToward
PointAL5
Flexion or extensionFlexion
Sidebending relative to pointAway
Rotation relative to pointAway
For a right AL2 point, “away” sidebending means left lumbar sidebending, while “toward” rotation means right lumbar rotation. Those words describe the trunk, not the direction a bent knee or foot happens to point. Hip positioning is a way to introduce the desired lumbar configuration. Monitor the original point throughout fine-tuning rather than substituting a memorized foot position for the tissue response.
Posterior lumbar points require a second distinction: midline versus lateral. Midline points on the spinous processes generally begin with extension alone. Lateral points at the inferolateral spinous-process or transverse-process region commonly use extension, sidebending away, and rotation toward the point in the ATSU teaching map. It is inaccurate to assign extension with both sidebending and rotation away to all posterior lumbar points. The precise point and atlas convention must be stated. [2]
Use the PSIS, sacral angle, and trochanter as separate references
The posterior superior iliac spine (PSIS), inferior lateral angle of the sacrum (ILA), and greater trochanter form three distinct reference regions. Identify them before comparing upper and lower PL5, piriformis, and sacroiliac points. The superior-medial and inferior aspects of the PSIS are especially easy to conflate. A small change in the monitor location can change the initial hip position substantially. [2]
Posterior map and its important exceptions
Point and region
Initial position of ease
Discriminating relationship
Point and regionUpper PL5, superomedial PSIS
Initial position of easeProne hip extension with slight adduction
Discriminating relationshipIntroduces lumbar extension, sidebending away, and rotation toward
Point and regionLower PL5, inferior PSIS
Initial position of easeProne supported hip flexion near 90 degrees, adduction, internal rotation
Discriminating relationshipA posterior point that uses flexion
Point and regionPiriformis, between sacral ILA region and greater trochanter
Initial position of easeSupported hip flexion, commonly near 120 degrees, abduction, external rotation
Discriminating relationshipUsually more lateral than a sacral-margin monitor
Point and regionHigh ilium sacroiliac, HISI, lateral to PSIS
Initial position of easeHip extension with slight abduction
Discriminating relationshipGluteus maximus attachment region
Point and regionMiddle pole sacroiliac, MPSI or FOSI, lateral to ILA
Initial position of easeHip abduction with a small flexion or extension adjustment
Discriminating relationshipNot the midpoint toward the greater trochanter
Point and regionHigh ilium flare out, HIFO, lateral coccygeal region
Initial position of easeHip extension and adduction; external rotation may refine ease
Discriminating relationshipDo not infer hip abduction from the words “flare out”
The sciatic nerve usually passes inferior to piriformis as it exits the pelvis, with anatomical variants. [6] Buttock pain with posterior thigh symptoms warrants assessment beyond the tender point. A negative straight-leg raise does not eliminate all lumbar or neurologic causes, and improved tenderness does not prove that sciatic entrapment was corrected. New weakness, sensory loss, or bowel or bladder symptoms require a different diagnostic priority.
Lateral PL3 and PL4 monitor gluteus medius regions: PL3 is commonly described about halfway from the PSIS toward the posterior tensor fasciae latae region near the iliac crest; PL4 is nearer the posterior tensor fasciae latae region. Both can begin with hip extension, abduction, and external rotation. These labels should not be confused with a midline L3 or L4 spinous-process point. [2]
Resolve nearby points without inventing a recipe
Quadratus lumborum spans the iliac crest, lumbar transverse processes, and twelfth rib region. Common monitors are near these attachments. A taught starting position uses hip extension, abduction, and external rotation, with the lumbar response monitored rather than the hip forced. The twelfth-rib or iliac-crest landmark distinguishes this region from the PSIS-based upper PL5 point. [3]
ATSU also distinguishes lateral trochanteric and posterolateral trochanteric points. A lateral monitor roughly twelve centimeters below the greater trochanter over the iliotibial-band region can use abduction with slight flexion. A posterolateral monitor at the superolateral posterior greater trochanter uses extension, slight abduction, and marked external rotation as tolerated. A location described simultaneously as “below the greater trochanter” and “medial to the ischial tuberosity” cannot be treated as an unambiguous single coordinate. [1]
Older low-ilium flare and posteromedial-trochanteric labels vary across teaching materials. The conflicting coordinates and opposite directions in the original material are not sufficient to define a safe additional point. For an adductor-region monitor, use an explicitly identified pubic attachment and an established atlas description, such as supported adduction with small rotational adjustments. Do not infer a mirrored inflare or outflare technique from the name. A tenderness response can help refine an identified position; it cannot repair an uncertain anatomical label.
Counterstrain is gentle in intent but requires positioning that may be inappropriate after trauma, with instability, or with surgical hip precautions. Follow the actual postoperative restrictions. An inability to relax or to communicate a reliable tenderness change may require adaptation, an interpreter, or another approach; a language difference alone is not a contraindication. End with reassessment of pain and a relevant task such as sitting, standing, or walking. If the response is absent or worse, revisit the diagnosis and technique instead of presenting the 90-second hold as guaranteed treatment.
Choose from the landmark and the response
These cases use the ATSU point convention unless another source is named. Trunk rotation and hip rotation are stated separately.
Case 1
Show answer and explanations for case 1
A. Ask for a maximal contraction against resistance. (Why this does not fit)
That changes an indirect passive approach into an active effort and may reproduce pain.
B. Increase pressure until the point becomes painful again. (Why this does not fit)
The point monitors comfort; provoking greater pain is not the treatment objective.
C. Rapidly return to neutral as soon as tenderness decreases. (Why this does not fit)
The standard sequence includes the hold and a slow passive return.
D. Maintain the comfortable position for approximately 90 seconds. (Best answer)
The positioning response meets the traditional reduction goal before the hold begins.
Takeaway: Find substantial ease before beginning the standard hold.
