Strain-Counterstrain: A Gentle Approach to Pain Relief and Enhanced Functionality (Expanded)

Strain-Counterstrain—also known as Positional Release Therapy or Tender Point Therapy—is a non-invasive manual technique used by healthcare professionals to address pain and dysfunction caused by muscle and joint strains. Its success is rooted in a deep understanding of the underlying physiology of the osteopathic somatic lesion and the neuromuscular reflexes that govern tissue tone. I wrote on this subject a couple years ago but I wanted to go a little more in depth into its mechanisms. Also I love the this style of treatment and use it frequently to reduce acute or chronic pains, tennis elbow, golfers elbow etc. This article explains the multifaceted physiological principles—from joint capsule innervation and mechanoreceptors to muscle spindle function and the alpha‑gamma coactivation loop—and illustrates how these concepts underpin the clinical efficacy of strain-counterstrain in relieving some of the most pervasive forms of human pain.

The Osteopathic Somatic Lesion

Before the technique can be mastered, it is essential to understand the physiology behind the creation of the osteopathic somatic lesion. These lesions manifest as:

Tissue Texture Changes and Asymmetry: Variations in tissue quality that indicate underlying dysfunction.
Altered Range of Motion: Limitations in movement of certain muscles and joints due to neuromuscular imbalance.
Tenderness on Palpation: Focal hypersensitivity that pinpoints areas of somatic dysfunction.

These physical manifestations are the outward signs of an internal problem—a malfunctioning neuromuscular reflex. This “false” strain signal causes continuous muscle tension where none should exist, laying the groundwork for chronic, often rheumatic, pain.

Joint Capsule Innervation and Mechanoreceptors

Understanding the innervation of the joint capsule is critical to grasping how somatic dysfunction develops and is maintained. Neurohistologic studies have revealed various receptors that work together:

Mechanoreceptors

Type I Receptors:
- Morphology & Function: Thinly encapsulated, slow-adapting receptors with small myelinated nerve fibers. They produce tonic reflexogenic effects on neck, limb, jaw, and eye muscles, contribute to postural and kinesthetic sensation, and help suppress pain.
- Location: Superficial layers of the fibrous capsule.
Type II Receptors:
- Morphology & Function: Thickly encapsulated, rapidly adapting receptors with medium myelinated fibers. They act as dynamic mechanoreceptors that produce phasic reflexogenic effects and suppress nociceptive input.
- Location: Deeper layers of the joint capsule and articular fat pads.
Type III Receptors:
- Morphology & Function: Fusiform corpuscles with large myelinated nerve fibers. They are high threshold and very slow adapting, functioning similarly to Golgi receptors with an inhibitory effect on motor neurons.
- Location: Ligaments and tendons.

Nociceptors (Type IV Receptors)

Characteristics: High threshold, non-adapting three-dimensional plexuses of unmyelinated fibers that detect constant pressure, chemical irritation, or inflammatory changes.
Role in Pain: They register actual tissue damage and, when overstimulated, override the pain-dampening effects of mechanoreceptors. In the dorsal horn, interneurons release enkephalins—endogenous opioids that help inhibit nociceptive signals, though high-intensity nociceptor input can still result in pain perception.

This balanced interaction between mechanoreceptors and nociceptors at the joint capsule level sets the stage for the neuromuscular feedback that strain-counterstrain seeks to modulate.

Muscle Fiber Physiology and Neurologic Wiring

Slow Twitch vs. Fast Twitch Muscle Fibers

Muscles consist of two primary fiber types:

Slow Twitch (Type I) Fibers:
- Characteristics: Tonic, oxidative, and resistant to fatigue. They have a high density of muscle spindles and extensive capillary beds, being innervated by alpha‑2 fibers.
- Clinical Implication: These fibers, essential for maintaining posture, tend to shorten in response to chronic irritation, contributing to the formation of tender points.
Fast Twitch (Type II) Fibers:
- Characteristics: Phasic, glycolytic, and capable of rapid contractions but fatigue quickly. They are innervated by alpha‑1 fibers and contain relatively fewer muscle spindles.
- Clinical Implication: In cases of somatic dysfunction, these fibers may present as weakened on exertion.

The differing responses of these muscle fibers to stress and strain are integral to understanding how strain-counterstrain works—by addressing both the shortened, tense postural muscles and the weakened phasic muscles through precise positional adjustments.

Muscle Spindle Function and Alpha‑Gamma Coactivation

The Muscle Spindle Apparatus

Muscle spindles are sensory organs embedded within skeletal muscles, predominantly among slow twitch fibers. They consist of:

Intrafusal Fibers:
- Function: These fibers detect changes in muscle length and the rate of stretch. They are innervated by annulospiral (Ia afferents) and flower-spray (II afferents) endings.
Extrafusal Fibers:
- Function: The contractile fibers responsible for generating force.

Alpha‑Gamma Coactivation

This mechanism involves:

Alpha Motor Neurons: Stimulating the extrafusal fibers to generate movement.
Gamma Motor Neurons: Simultaneously adjusting the sensitivity of the intrafusal fibers, ensuring that muscle spindles provide accurate feedback even during contraction.

Under normal conditions, the alpha‑gamma coactivation loop maintains proper muscle tone and stretch reflex. However, in cases of strain or injury, an overactive gamma system can produce an exaggerated response—leading to heightened muscle spindle sensitivity, continuous muscle contraction, and chronic pain.

Nociceptive Input and the Positive Feedback Loop

Nociceptors, with their high thresholds and sensitivity to chemical and mechanical stimuli, play a pivotal role in muscle tone regulation:

Initiation of Malfunction: A seemingly minor strain—whether from a misstep or a slight overexertion—can trigger nociceptors. This starts a cascade in which increased gamma motor neuron firing further heightens muscle spindle tension.
Feedback Loop: The resultant increase in Ia and II afferent firing enhances alpha motor neuron activity, causing excessive extrafusal muscle contraction. This process, if unchecked, evolves into chronic somatic dysfunction.
Spinal Modulation: Interneurons in the dorsal horn, through the release of enkephalins, attempt to dampen this nociceptive input. Yet, when the nociceptive signal is robust, pain is still perceived via the spinothalamic tract and limbic system.

Strain-counterstrain interrupts this positive feedback cycle by “resetting” the aberrant neuromuscular signals through carefully adjusted body positioning.

Autonomic Nervous System Regulation

The autonomic nervous system (ANS) plays a crucial role in muscle tone regulation:

Sympathetic Overdrive: Chronic muscle strain and pain often lead to heightened sympathetic activity (the “fight or flight” response), which increases muscle tension.
Parasympathetic Activation: The gentle nature of strain-counterstrain encourages parasympathetic responses (the “rest and digest” state), reducing inflammation, improving circulation, and promoting overall tissue healing.

Clinical Application: Rheumatic Pain and the Power of Tender Points

Despite the sophisticated diseases described in osteopathic literature, it is estimated that two-thirds of all human body pain is due to a poorly understood malady—rheumatic pain. This pain is almost universal, chronic, and is rarely cured or correctly diagnosed by modern medicine alone. The reason is that rheumatic pain is not primarily a medical problem but a physical one—a malfunctioning neuromuscular reflex that continually reports strain where none exists.

The Counterstrain Approach to Rheumatic Pain

The solution lies in a simple, yet precise, body stretch:

Maximum Comfort Stretch: The muscle in apparent strain is gently stretched into a position of maximum comfort. This brief adjustment—held for only 90 seconds—reverses the false strain signal.
Immediate and Lasting Relief: After the 90-second hold, the body is slowly returned to a neutral position. The relief is immediate, and if the patient cooperates by avoiding reintroducing painful positions in the ensuing weeks, the cure can be long-lasting.

The Role of Tender Points

Tender points are the focal areas of hypersensitivity that:

Provide Diagnostic Clues: These small, subcutaneous spots (often about four times more tender than normal tissue) are critical in identifying the precise location of somatic dysfunction.
Guide Treatment: A skilled practitioner uses these points to monitor changes in tissue tension as the body is repositioned. Remarkably, many of these tender points can be found both on the posterior and anterior aspects of the body.
Technique and Success Rate:
- A novice can begin to succeed by trying different positions and asking for patient feedback on comfort.
- An experienced practitioner, adept at palpating subtle changes (sometimes as little as a two-degree positional shift), can relieve up to 95% of body pain.
- With consistent treatment and patient cooperation—namely, strict avoidance of painful positions—the permanent resolution of symptoms has been reported in as many as 85% of cases.

Developing Palpatory Skill

A major component of successful strain-counterstrain is the development of sensitive palpatory skills:

Learning Curve: Beginners may find the subtle changes in tissue tension intimidating. However, with dedicated practice (even as much as eight hours a day over two years), almost anyone can learn to feel these changes.
Patient Feedback: Early in the learning process, practitioners can rely on direct patient feedback (“Do you still hurt?”) to guide them to the correct position. Over time, refined tactile sensitivity allows for rapid and accurate identification of tender points.
Three Simple Rules:
1. Passively stretch the affected joint into its position of greatest comfort.
2. Slowly return the patient to a neutral position—ensuring that pain does not reoccur.
3. Avoid any sudden repositioning; if pain returns, back off slightly, wait, and proceed slowly.

These principles not only ensure the safety of the treatment but also build the practitioner’s confidence and skill, allowing them to eventually perform the method even when patients verbally express discomfort.

Integration: How Strain-Counterstrain Restores Balance

By synthesizing detailed neuromuscular physiology with precise manual techniques, strain-counterstrain achieves the following:

Interrupts the Malfunctioning Reflex: By repositioning the muscle into its ideal state of comfort, the aberrant alpha‑gamma coactivation is normalized.
Reduces Nociceptive Feedback: The gentle stretch minimizes overactive nociceptor signals, thereby breaking the cycle of chronic pain.
Restores Autonomic Balance: The therapy shifts the ANS from a sympathetic-dominant state to one that favors healing and relaxation.
Resets Tissue Tone: Through consistent application and careful monitoring of tender points, the method gradually resolves somatic dysfunction, leading to enduring relief.

Strain-Counterstrain is far more than a simple manual adjustment—it is a comprehensive, science-based approach that addresses the root causes of chronic, often rheumatic, pain. By understanding and modulating the complex interplay between mechanoreceptors, nociceptors, muscle spindles, and autonomic regulation, clinicians can “turn off” a malfunctioning neuromuscular reflex that perpetuates pain. The practical skills of palpation, patient feedback, and precise positioning converge to relieve pain rapidly and, with dedicated practice and patient cooperation, even produce lasting cures. This method offers a holistic, non-invasive pathway to restoring natural tissue function and achieving long-term well-being.

Lawrence Jones wrote in regards to this modality to treat and this is paraphrased that unless the facilitated segment or tenderpoint is reduced it will only lead to further degenerative changes along that nerve root. So if you have migraines, chronic tendinopathy, chronic pain syndromes, carpal tunnel syndrome, cubital tunnel syndrome, recurring ankle sprains etc. Please seek out someone knowledgeable in this practice or reach out to me.