As a specialist in the pelvic floor, I see pain that resides anywhere from the lower ribs to the knees. We see a lot of patients who develop persistent hip pain, see several physicians, and are referred to a physical therapist. These patients go through months – sometimes years – of physical therapy, joint injections, acupuncture, and massage but continue to suffer from hip pain. Some of these patients end up having surgery, some do not. By the time they find us they feel hopeless, frustrated, and worried they may never get back to the activities they love. What is really going on? The Pelvic Floor musculature is a very important muscle group for stability in the human body. It works in close proximity to the abdominals and deep spinal muscles to provide good trunk stability so that the legs and arms are able to function on a stable base. The Pelvic Floor shares a direct connection to the hip through the Obturator internus muscle. Making it even more important to consider that hip pain or post-surgical pain could be obturator internus pain. The Obturator Internus Muscle in close proximity to the pelvic floor musclesThe Obturator Internus is connected to the pelvic floor through fascial and tendon attachments. It is part of a group of muscles in the deep hip, which externally rotate the hip joint, but also help stabilize the hip joint in single-leg activities like walking, running, and climbing stairs. When the pelvic floor is not functioning at 100%, the obturator internus loses a mechanical advantage affecting the entire hip joint stability and control. The Obturator Internus is a deep muscle, which is best assessed through a vaginal or rectal exam, along with the pelvic floor muscle group. The two go hand in hand. If the pelvic floor is overactive and painful, one or both Obturator Internus muscles are as well. Often the pelvic floor is weak or poorly coordinated, and because of this, the Obturator Internus is overactive in order to over compensate for the weakness. As well, this muscle will become overactive when the gluteal muscles are weak in an attempt to provide some control at the hip and pelvis.. Pain from the Obturator Internus is generally felt at the “Sit Bone” and radiates into the buttock and groin. It is often mistaken for medial hamstring pain. It is often overlooked by physical therapists because it is so deep in the pelvis and hip, and it is not a muscle often readily discussed in PT programs or continuing education courses. Unfortunately because of this, patients end up in several bouts of PT with poor outcomes. What should conservative treatment look like? Often, trigger point release to the Obturator Internus OI muscle, combined with addressing the pelvic floor dysfunction and restoring blood flow and healthy muscle balance to the pelvic girdle will allow for a gradual return to activities like hiking, running, biking, and swimming. Trigger point release can be done vaginally, rectally, or externally with manual palpation of the soft tissue. Another conservative treatment to alleviate pain is using dry needling to the obturator internus muscle. Restoring range of motion and improved motor patterns should be addressed through the correct combination of strengthening and stretching and is individually tailored for each patient. An individual treatment plan is key. You need a physical therapist who will consider you, your muscle patterns, and your activity level and develop a program that fits you. You should be screened for labral tear or other hip pathology as well as pelvic girdle dysfunction like pudendal nerve that could be causing your pain. Every person is different and so are our movement strategies. The way I bend to lift a heavy box, might look just a little different for you. What is important is that we restore mobility within a certain element of stability and alleviate pain! At Foundational Concepts, our physical therapists are specially trained in the pelvic floor. We are able to provide treatment options of pelvic floor physical therapy with screening the rest of your body to alleviate obturator internus pain that many others have missed.
-Sarah Dominguez, PT, MSPT, CLT, WCSDisclaimer: This blog is here for your help. It is the opinion of a Licensed Physical Therapist. If you experience the symptoms addressed you should seek the help of a medical professional who can diagnose and develop a treatment plan that is individualized for you.
Sarah is the proud co-owner of Foundational Concepts, Specialty Physical Therapy which opened in March 2013. Sarah lectures at the University of Missouri Department of PT, University of Kansas Departments of PT and Nurse Midwifery, and at Rockhurst University Department of PT. She is board certified in Women’s Health PT and holds certifications in medical therapeutic yoga, lymphedema therapy and dry needling.
