Obturator Internus- A Deep Dive on Pelvic Pain
Here at Recharged PT, we talk about the anatomy of the pelvic floor extensively – and often. In the past, we have covered how the pelvic floor works in tandem with the diaphragm to create a “soda can” of pressure in the abdomen; how too tight or too loose pelvic floor muscles affect your body; and how even other parts of your body can affect the pelvic floor – and vice versa.
Today, we are going to revisit a topic we have covered in the past with a little bit more detail. We’ve gotten a lot more questions about a certain muscle in particular recently – and how it can affect your pelvic floor symptoms and subsequent treatment. The obturator internus (OI) is a sneaky little muscle that sits deep in the back of the pelvis. Although it is small, do not underestimate its power. Although not directly part of the levator ani (the deepest layer of the pelvic muscle layers), the obturator can in fact be palpated by your pelvic floor PT during your manual examination. Furthermore, the levator ani muscle group originates in part from the OI fascia.
The OI starts on the inside of the lower pelvic bone (superior pubic rami), turns at a 90 degree angle and inserts onto the greater trochanter of the femur. Because of that sharp turn, the obturator internus is uniquely vulnerable from a biomechanical standpoint. The OI helps externally rotate (roll out) the hip, abduct (move out to the side) the hip, and provide pelvic stability as a whole in conjunction with other muscles deep in the pelvic girdle called the deep hip rotators.
As with any other muscle, the obturator internus can be tight and weak or lengthened and weak. There are multiple stressors that may contribute to OI dysfunction. These include:
Mechanical stressors that tighten an already tight muscle (e.g., clamshells or fire hydrants)
Prolonged sitting
Tightness or involvement of the piriformis (another deep hip rotator)
A history of low back or hip pathology
Compensation for tight or weak PFM
Pregnancy, complications during labor or postpartum
Symptoms of OI dysfunction include:
Difficulty pinpointing the pain. Often OI pain is diffuse and can refer anywhere from the ischial tuberosities (“sit” bones) up into the mid glute and side of the hip. It often feels deep.
Urinary or bowel frequency, urgency or overflow because of the pudendal nerve (which runs close to the OI).
Pain with sex.
Significant tenderness to palpate with your PFPT performs your manual examination.
Pain with prolonged sitting or exercises that shorten the OI further.
Pain with hip internal rotation, which stretches the OI.
So how is OI dysfunction diagnosed? In addition to the above symptoms, your PFPT will take a throughout history prior to the examination. They will also perform a comprehensive evaluation of your PFM, back and hips to establish the mechanical relationship between each and pinpoint where the impairments may be coming from.
Once the (dys)function of the OI has been established by your practitioner, there are certain things we need to do to get that pain cleaned up. For an OI that is too tight, you will want to avoid the exercises or activities (temporarily) that may flare it up (e.g. clamshells, fire hydrants, sitting too long, stretching into hip internal rotation). You may want to decrease the amount of hip abduction or external rotation particularly performed with the hip extended (behind you). This is when the OI is especially active. A couple of examples to avoid here would include hip thrusts with a band or bridges.
There is then a specific progression we can use to get the OI to “let go,” get more “buy in” from the pelvic floor muscles, and decrease how cranky this muscle is. It is a great idea to start with passive stretching, like a gentle pigeon pose. Then you can move on iliacus pullbucks with adduction. This exercise starts getting the adductors (inner thigh) muscles to turn on while encouraging the femoral head to translate farther back into the socket. Adductors often tend to be underactive and weak in the wake of OI dysfunction. Any exercises that encourage hip flexion and adduction are ideal in this phase. After that, we will start to eccentrically lengthen the OI and other deep hip rotators. This includes exercises like a lunge with rotation into hip internal rotation, side lunges, or a staggered hip hinge into rotation. The final phase of OI rehab is to start concentrically strengthening the muscle directly with an internal rotation bias: a split stance dead lift with a dumbbell on the same side, for example. After this, we go into external rotation bias (e.g., the exercises we needed to avoid in the beginning): clamshells, fire hydrants, bridges or hip thrusts with a band.
Of course, this will be part of a larger treatment plan designed by your PFPT to address all the impairments you may have. However, getting the obturator internus cleaned up and happy will make a lot of difference overall: particularly when it comes to back and hip pain, PFM muscle function, and moving better throughout the world!
<3 Recharged Performance Therapy
(321) 802-1630
https://www.rechargedperformancetherapy.com
References
Tuttle LJ, DeLozier ER, Harter KA, Johnson SA, Plotts CN, Swartz JL. The role of the obturator internus muscle in pelvic floor function. Journal of Women's Health Physical Therapy. 2016 Jan 1;40(1):15-9.
https://www.physio-pedia.com/Obturator_Internus
Duvall, Sarah (2025). Anatomy. Pregnancy and Postpartum Corrective Exercise Specialist 3.0. https://www.coreexercisesolutions.com/pces/
https://pelvicpainrehab.com/blog/obturator-internus-a-treatable-but-often-overlooked-little-beast/