Obturator syndrome: some nasty groin pain

I was joking with a colleague that there are some "sexy muscles" that seem to be popular from time to time, but the one I'm about to blog about is definitely not in that category. Which is unfortunate because it can be an absolute source of misery.

The obturator externus, later referred to as OE is a muscle that is deep in the groin, connecting the anterior inferior part of the pubis to the inside of the upper femur. It's involved in a combination of adduction stability of the leg (and thus can be injured in sharp abduction sprains), with lesser degrees of rotation and flexion. It's not easy to palpate unless you know exactly how to locate certain origin and attachment landmarks, and it connects different parts of our anatomy that make it involved in activities of the leg, trunk and pelvic floor at the same time. The pain pattern usually involves the inside upper thigh, groin, but can also radiate to the perineum and lower abdomen. Mechanism of injury include leg abduction and flexion sprain, slip and trip injuries, weightlifting injuries, and more repetitive type overload injuries such as anterior position of pregnancy and long-distance running.

The reason that the OE is worth talking about is that it can be a source of continued pain even when other parts of an injury have resolved. I have encountered that in many cases where we successfully treated and rehabed sacroiliac and upper thigh injuries for example, but the patient continued to have some very pinpoint groin pain that continue to prevent them from resuming their previous activities. It's often an area that the patients are hesitant to talk about because it will radiate into the genital and pelvic floor area, as well as deep in the inside of the thigh, both areas the patients don't necessarily like to have examined. And an area that many health care providers don’t like to dig in.

Treating and resolving an OE painful syndrome can be a game changer for patient. I'm grateful for my ART training 15 years ago to give me the confidence to properly locate the muscle and perform the appropriate myofascial release on it. The OE responds surprisingly quickly to therapy, usually clearing up within 2 or 3 treatments. It's a little tricky to stretch at home unless you know how to combine the 3 motions to isolate it. I have found my best results with the modified unilateral elevated cobbler with some butterfly flexion.

What causes groin pain ?

It's a question that comes up periodically and since there is no easy answer that I can give to patient during a routine appointment slot, I decided to put my thoughts in writing so I can refer patients to it as a conversation starter.

The groin is a small piece of the body's real estate, that we tend to think of as private, but that can really control your life if it starts acting up.

It's a body area that is the intersection of several structures that can be pain producing, and you need a little bit of attentive detective work to determine the source of the problem.

The main structures that can be involved in producing groin pain:

– referred pain from the middle lumbar area, especially L2 and L3 segments. These would be things like a lumbar disc herniation causing pain to radiate along these dermatomes, or significant bony spurs. The lower lumbar segments such as L4 5 and L5 S1 definitely take the lines shares in terms of referred this pain, so that sometimes we tend to forget that mid lumbar areas can also be a source of referred pain. Patients with groin pain referred from these mid lumbar segments tend to have pain that is aggravated by lumbar movement.

– Referred pain from myofascial structures in the deep hip flexors, especially if involving some peripheral compression of the anterior peripheral nerves that exit that those levels: the femoral nerve, the ilio inguinal nerve, and the lateral femoral continues nerve. This pain can be really tricky to assess, since it will not readily show up on advanced imaging like MRI. During physical examination, deep lateral palpation of those structures can usually be pretty revealing, and the fact that very often activities involving hip flexion can be very triggering.

– The hip joint, or more precisely the acetabular femoral joint (AF joint) . This is the ball and socket joint between the socket in the pelvis (acetabulum) , and the femoral head. This is not usually a joint that is subject to primary misalignments due to its ball and socket nature, although it certainly can, but is subject to articular cartilage degeneration, and tearing and catching of the cartilage rim also known as the labrum. There are specific orthopedic testing that can help isolate the AF joint is the source of the problem, and in addition pain from imaging as well as advanced imaging like MRI can be very diagnostic of the problem starting in that structure. From a history standpoint, patient will often report the sensation of catching or clicking, and pain triggered by hip movement rather than lumbar movement.

– The sacroiliac joint. The sacroiliac is a rather large vertical/horizontal articulation at the base of the sacrum, and the anterior portion of the sacroiliac joint can refer pain to the groin. This would happen with misalignment of the sacroiliac joint internally, that will be often associated with deep pain in the buttocks, difficulty with flexibility in the affected side of the pelvis, and standing with a toe out position on the affected side.

So groin pain can come from many different sources, but it should not be a mystery and a good physical examination can usually point the patient and the treating doctor into the right direction.

How to use orthotics in sandals?

It's a seasonal subject I find myself discussing a lot, as our most dedicated orthotics users are finding it cumbersome to keep their toes covered in sweltering conditions this year.

Orthotics can definitely be worn in sandals as long as you find the right sandal: it needs to have a deep enough removable footbed, and in most instances for patients with pronation, and adequate support along the medial ankle.

I keep a running list of the most common brands and models, which I'll happily email to patient's who requested. Since women's fashion is subject to an notoriously high turnaround, I do not post on the website for fear I would forget to update it periodically.

In the meantime, you can see in the video how easily and orthotic can be fitted in a good sandal.

https://www.youtube.com/watch?v=IjK0GV62QHM&t=5s

Wearing sandals that fit heel lifts and orthotics

This blog entry may seem a little untimely since this cool morning hints of fall, which will eventually retire our sandals. However this is also the time of the year when high-quality sandals come on sale, and a good opportunity to stock up for the winter vacation and the following summer. By now most of my patients seem to understand that they can continue wearing their orthotics in the summer by fitting them in orthotic compatible sandals. I keep a document with a list of some common brands and model that fit the bill, (although in the fashion world I'm constantly reminded that I have to update it). What has not always been made clear is that you can actually wear an orthotic combined with a heel lift or medial pronation wedge in a sandal as well, if you know what shoe to look for. That particular sandal will need to have a heel cup instead of an open back with a simple strap. There are several models on the market, they are often found under the definition of a Roman sandal or fishermen sandal (although the example listed below is actually not tagged as such on the website). Our orthotic compatible sandal document has a subset of models with heel cups. The shoe industry has really stepped up to the plate in the last few years by offering routinely models that are orthotic compatibles, broadening the choices to remain well supported with your custom appliances year-round.

Squatting exercises for knee problems

I frequently run into patients who tell me they have had to give up squatting exercises because of aggravated knee pain. This is extremely unfortunate since squatting is 1 of the best exercises to functionally engage the core, upper gluteal areas, lower back, and squats mimics the type of strength and stability posture we need for real-life activities.

It's all the more unfortunate since there is a pretty easy alternative to do a squat without causing me pain. Notice that you can use a ball of any size including something pretty small or even a foam roller, unlike the large ball that I use for the demonstration video.

https://www.youtube.com/watch?v=1zpZeza8lKU