anterior thoracic tender points
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Anterior Thoracic Tender Points: A review and guide

You can really break the anterior thoracic tender points down into two sections:

  1. T1-T6: Located at the midline of the sternum at the corresponding ribs
  2. T7-T12: Located in the abdominal muscle just on each side of center at corresponding spinal level

Lets go into more detail.

Why you should Know Tender Points

The anterior thoracic tender points, and really the tender points in general are one of the topics that helped me score >700 on both the COMLEX Level 1 and COMLEX Level 2.

You see, I barely made it into medical school, but once I got in I was able to get a 4.0 GPA and score 704 on COMLEX Level 1 (97th percentile), and a 779 on the COMLEX Level 2 (98th percentile).

I don’t say this to brag, I just tell you before you get into this article that you are reading an article written by someone who did pretty well on these exams and in Osteopathic medical school in general.

Anterior thoracic tender points can be low hanging fruit on test day, so we will go over some of the basics here.


Tender points, are part of the strain/counterstrain technique in OMM.

Counterstrain is a passive technique (the patient doesn’t do anything), and an indirect technique (away from the restrictive barrier).

An important thing to differentiate from tenderpoints are trigger points.

Trigger points radiate pain, tender points don’t.

Essentially, tenderpoints are small painful nodules that can be located anywhere throughout tendons, ligaments, or muscles.

The basics of strain/counerstrain is to shorten the affected structure and hold it there until a release is felt.

Summary of Anterior Thoracic Tender Points

  • T1-T6: Located midline of the sternum (see image)
  • T7-T12: Most are located in the rectus abdominal muscle (see image)
  • Tx for anterior thoracic tender points: Flex Sidebend toward, Rotate Away
anterior thoracic tender points
A page from the counterstrain guide in the CPM OMM Course.

How it presents in Testing Situations

Typically, the questions you will see on this topic will be very diagnostic and treatment oriented.

Here is a sample of what you can expect:

“A patient presents with pain in his chest. On palpation you note a small nodule of pain that does not radiate pain when pressed, but it is painful to the patient. You also note a lot of hypertonicity in the area. The small nodule is located in the midline of the sternum at the level of the 4th rib attachement.

ACS has been ruled out.

If treating with Counterstrain, what position would you put the patient in?

  1. Extend the patient
  2. Flex the patient
  3. Flex the patient and add sidebending/rotation towards
  4. Rotate the patient

In this scenario flexing the patient would be the answer.

The point here is that even though these are simple topics, they are presented in complicated patient scenarios. So, be ready to have to evaluate these topics in a diagnostic and treatment based question.

  • Know the location of tender points
  • Know the treatment for them
  • Counterstrain Technique
  • Find tender point
  • Ensure it doesn’t radiate pain
  • YOU shorten the affected structure (I go over this in more detail in CPM OMM)
  • Hold for 90 seconds
  • Achieve at least 70% reduction in pain

This is an important process and one that I cover in great detail in the CPM OMM course. I also cover all the OMM topics in test relevant fashion. I don’t regurgitate your OMM class to you, you will be ready for OMM questions on tests at the end of CPM OMM.

Check it out below.

Tips to get answers right

  • Focus on treatment set up
  • Focus on diagnosing

It is very rare that these questions are simple first order recall questions, so be ready to know some details about strain/counterstrain and the anterior thoracic tender points to get the answer right.

Also, focus on the process of strain/counterstain, know the amount reduction and the time you have to hold the shortened position for.

Concluding this summary of Anterior Thoracic Tender Points

Alright, we all get it. Some aspects of OMM just feel like test fodder.

In all honesty, this is one of those topics that is super useful clinically, and can be helpful to patients because it does work.

It is taken to the next level on tests because they get so specific, truth be told all you need to do is shorten the structure until you get 70% or more reduction in pain, then hold for 90 seconds and that’s it. The details are so unimportant for real life.

The details are great for test questions though, so be sure to know them

If you found this article helpful, then be sure to check out CPM  OMM. I teach more OMM in similar fashion in that short course.

Other Common Questions

Which Counterstrain points do you treat first?

In the simplest term, treat the most tender one first.

A lot of the time the patient will get relief in other areas of tender points if you treat the most tender one first.

What are counterstrain points?

Counterstrain points is just another name for the tender points that this article covers. It is essentially all the same.

Counterstrain and tenderpoints are the same.

Counterstrain is the technique to treat the tenderpoints, but just lump them together so it is one less thing to remember.

What is counterstrain technique?

The counterstrain technique is used to shorten an affected structure that has a tender point in it. This helps to “reset” if you will the neuromuscular attachments and resolve the tender point and relieve a patients pain.

Is counterstrain indirect?

Counterstrain is a indirect and passive technique.

Indirect just means that it is away from the barrier or towards the position of comfort.

How long is Counterstrain held for?

90 seconds. It used to be different for ribs, but now it is 90 seconds across the board.

Hold counterstrain for 90 seconds.

Don’t forget this.

What is the goal of Counterstrain?

The achieve relief in the patients pain.

It basically restores balance to the lymphatic, neuro, and muscular system and allows the small “clog” in the fascia to be released and restored to its neutral position.

I hope this has been helpful to you.

The goal of this article is to give you what you need to answer basic strain/counterstrain questions.

Thanks for reading

Sean Kiesel, DO, MBA

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