Obturator Internus, Quadratus Femoris and Bursae.
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Therapist guide: Obturator Internus (OI) and Quadratus Femoris (QF) treatment, rehab exercises and more.
Patients with deep gluteal pain near the ischial tuberosity are often told they have a high hamstring issue. Often the hamstring is not involved, but the obturator internus, quadratus femoris or a bursa is. About 20 different bursae have been identified near the hip and pelvis(1), and should always be considered when prescribing exercises.
..the obturator internus tendon makes a right-angled bend over the grooved surface of the ischium, between the ischial spine and tuberosity, and then passes horizontally across the posterior to the hip joint before it inserts into the greater trochanter. Moreover, the obturator internus bursa is located between the obturator internus tendon and the grooved surface of the ischium(1) (anatomy video).
If tendinopathy is suspected but bursitis is also possible, it may be wise to load the tendon without compressing the bursa. Avoiding compression of tendons where they pass over bones during loading is covered in this excellent video from Running Reform.
Obturator internus EMG amplitude was greatest during hip extension, then external rotation then abduction, with minimal to no activation in other directions. Paul Hodges. (2)
Therefore to load the OI tendon with less pressure on the bursa, I shorten the muscle in extension /ext rotation / abduction and apply resistance.
The QF is an easy muscle to treat, but if thigh internal rotation is decreased it is wise to see if doing plank activations immediately increases the lacking ROM.Our approach:
1. Check hip ROM in various amounts of hip flexion.
2. Plank activations if ROM is decreased, if no change do ART of the OI, QF, and more.
3. Isometric – progressing to conc / eccentric loading
4. Check for cross over gait (3) (Shawn Allen of The Gait Guys) to prevent reoccurrence.
Note: Ischiofemoral Impingement (IFI) Syndrome by Roger M. Kerr is worth a read, QF strain can be confused with IFI (4).
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