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Obturator Neuropathy

From WikiSM
(Redirected from Obturator Nerve Injury)

Other Names

  • Obturator Nerve Injury
  • Obturator Neuropathy
  • Obturator Nerve Entrapment
  • Obturator Nerve Palsy
  • Obturator nerve compression
  • Obturator neuritis
  • Obturator canal syndrome
  • Obturator neuralgia
  • Obturator nerve dysfunction
  • Obturator nerve lesion

Background

  • This page refers to entrapment neuropathy and other presentations of pathology associated with the Obturator Nerve

History

  • First case series published by Bradhsaw in 1997[1]

Epidemiology

  • Rare clinical condition poorly described in the literature
  • Limited to case reports and case series

Introduction

The course of the obturator nerve[2]
Anatomy of Obturator Nerve[3]
Schematic drawing of the obturator nerve pathway in the pelvis. Mass effect on the nerve commonly occurs around the obturator canal or as the nerve enters the thigh[4]
Global representation of potential entrapment areas of the obturator nerve and anatomical variations prevalence[5]

General

  • Obturator neuropathy is a rare clinical condition most commonly associated with surgery, hemorrhage or neoplasm
  • Patients present with with pain and parasthesia in the groin and thigh
  • It is a difficult clinical presentation to evaluate and diagnose
  • Patients can often be treated conservatively unless their is a clear mass effect cause

Etiology

  • Rarely injured in isolation
    • Often associated with surgery, hemorrhage or compression by a tumor[6]
    • Sports related injuries are far less common
  • Cases described in athletes
    • One athlete had fascial entrapment of the nerve as it enters the thigh[1]

Anatomy of the Obturator Nerve

  • Motor: Medial Compartment of the Thigh
  • Sensory: Cutaneous innervation of the medial thigh
  • Anatomic Course
    • Formed from the Lumbar Plexus, anterior divisions of L2, L3, L4
    • Descends through the psoas major emerging medially
    • Travels posterior to common iliac artery towards the obturator foramen
    • Enters the medial thigh through the obturator canal
    • Here it divides into the anterior and posterior branch
  • Anterior division
    • Anterior to adductor brevis
    • Descends in a plane between adductor longus, adductor brevis
    • Supplies motor fibers to adductor longus, adductor brevis, gracilis
    • Can supply pectineus
    • Pierces the fascia lata, becomes cutaneous branch of the obturator nerve
  • Posterior division
    • Posterior to adductor brevis
    • Pierces the obturator externus, then descends down between adductor brevis and magnus
    • Innervates obturator externus and adductor magnus

Risk Factors

General

  • Pelvic surgery (especially pelvic lymph node dissection)
  • Anatomical variations
  • Space-occupying lesions
  • Trauma

Sport Specific activities

  • Sports involving repetitive hip adduction or chronic groin stress

Differential Diagnosis

Differential Diagnosis Groin Pain

Clinical Features

Pain distribution in a patient with compressive obturator neuropathy[7]

History

  • Most commonly presents with altered sensation in the medial thigh[8]
  • Includes parasthesia, sensory loss and pain
  • Groin and medial thigh pain was cited as the most common symptom in another study[9]
  • The pain may be a deep ache in the adductor region, can extend into medial thigh as far down as the knee
  • Pain is often worse with movements such as extension or lateral leg movement[10]
  • Sensation along the medial thigh can be diminished, very rarely it can extend down to the calf[11]

Physical Exam

  • Motor strength is usually diminshed on the affected side
  • In chronic cases, muscle wasting may be observed
  • Loss of adduction and internal rotation
  • Gait exam: hip is externally rotated and abnormally abducted, which results in a circumducting, wide based gait[12]
  • Loss of Hip Adductor Tendon Reflex can occur but must be compared to asymptomatic leg

Special Tests

  • Needs to be updated

Evaluation

Obturator neuropathy. Hip arthrogram (a) showing liquid distension of the obturator externus bursa (arrow) and MR of the Hip AX T2 FS (b) showing liquid distention of the obturator externus bursa (asterisk) dislocating the obturator nerve (yellow arrow)[13]
Adductor muscle atrophy on the right (blue) compared to the left (red)[14]
Nerve conduction of the right obturator nerve. (A) The stimulation was performed 1.5 cm inferior and 1.5 cm lateral to the pubic tubercle site, and recording was performed at the midpoint of the right medial thigh. (B) Compound muscle action potentials of both obturator nerves showed a difference in amplitude (left side: 2.7 mV vs. right side: 0.3 mV) and onset latency (left side: 3.2 ms vs. right side: 2.2 ms).[15]

Radiographs

MRI

  • Has been used to detect the distribution of local anesthetic during a 3 in 1 block[16]
  • Can be used to evaluate baseline anatomy, exclude other cause of groin pain
  • Atrophy of muscle groups can suggest denervation, nerve entrapment
  • Can not evaluate the nerve proper

CT

  • May be useful to evaluate mass lesions

Ultrasound

  • Role not well defined
  • May be useful toe valuate mass lesions

Bone Scintigraphy

  • Can mild ipsilateral increase in uptake in the region of the pubic ramus

Electromyography (EMG)

  • Probably the best study to evaluate the obturator nerve
  • Bradshaw showed denervation in the short and long adductor muscles
  • Other authors have found important denervation findings (fibrillation potentials or high-amplitude, long-duration complex motor unit potentials)[17]

Obturator Nerve Block

  • Has been described in the literature using both ultrasound and fluoroscopy
  • Theoretically, should reproduce the patients weakness, especially after excercise

Classification

  • Not applicable

Management

Transducer and needle position for short axis in plane Obturator Nerve Injection[18]

Nonoperative

Operative

  • Indications
    • Mass effect from hemorrhage or neoplasm?
    • Resistance to conservative therapy with EMG or nerve block documented findings
  • Technique
    • Surgical decompression of the obturator nerve

Rehab and Return to Play

Rehabilitation

  • There is no consensus rehabilitation program
  • Early phase: gentle range of motion, isometic exercises and symptom management[19]
  • Intermediate phase: progression to resistance training, proprioceptive exercise, sport specific training
  • Advanced phase: Restore sport-specific skills, cardiovascular conditioning, and functional testing

Return to Play/ Work

  • Expected return to sport around 3-6 weeks
  • General RTP critieria
    • Restoration of anatomical and functional healing
    • Full sport-specific skill performance
    • Absence of undue risk to the athlete or others

Prognosis and Complications

Prognosis

  • Time from onset
    • Patients with acute onset have good recovery with conservative management
    • Patients with chronic neuropathy have less chance for improvement, worse outcomes
  • Surgical management
    • Surgical decompression of the anterior division of the obturator nerve has produced favorable results[1]

Complications

  • Persistent adductor muscle weakness
  • Chronic pain
  • Gait instabilit
  • Permanent disability

See Also

References

  1. ↑ 1.0 1.1 1.2 Bradshaw, C., et al. "Obturator neuropathy: a cause of chronic groin pain in athletes." Am J Sports Med 25 (1997): 402-8.
  2. ↑ Craig, Anita. "Nerve compression/entrapment sites of the lower limb." Nerves and nerve injuries. Academic Press, 2015. 755-770.
  3. ↑ Kati, Bulent, and Murat Izgi. "A nightmare during endoscopic bladder tumor resection; obturator reflex." (2017).
  4. ↑ Leão, Renata Vidal, et al. "Magnetic Resonance Imaging of Hip Neuropathies: Beyond the Sciatica: A Practical Approach." Current Radiology Reports 5.8 (2017): 36.
  5. ↑ Prudhon, J., et al. "Variations of the obturator nerve and implications in obturator nerve entrapment treatment: An anatomical study." Surgical and Radiologic Anatomy 45.10 (2023): 1227-1232.
  6. ↑ Pavlov, Helene, et al. "Stress fractures of the pubic ramus. A report of twelve cases." JBJS 64.7 (1982): 1020-1025.
  7. ↑ Trescot, Andrea M., and Helen W. Karl. "Obturator nerve entrapment: lower extremity." Peripheral Nerve Entrapments: Clinical Diagnosis and Management. Cham: Springer International Publishing, 2016. 699-712.
  8. ↑ Stewart, John D. "Focal peripheral neuropathies." (No Title) (1993).
  9. ↑ Sorenson, Eric J., Joseph J. Chen, and Jasper R. Daube. "Obturator neuropathy: causes and outcome." Muscle & nerve 25.4 (2002): 605-607.
  10. ↑ Busis, N. A. "Entrapment and other focal neuropathies." Neurol Clin 17.3 (1999): 633-53.
  11. ↑ Dawson DM, Hallet M, Wilbourn AJ. Miscellaneous uncommon syndromes of the lower extremity. In: Entrapment neuropathies. 3rd ed. Philadelphia: Lippincott-Raven; 1988, p. 369–79.
  12. ↑ Mumenthaler M, Schliack H. Lesions of individual nerves of the lower limb plexus and the lower extremity. In: Peripheral nerve lesions. Diagnosis and therapy. New York: Thieme Medical Publishers; 1991, p. 297–343.
  13. ↑ Leão, Renata Vidal, et al. "Magnetic Resonance Imaging of Hip Neuropathies: Beyond the Sciatica: A Practical Approach." Current Radiology Reports 5.8 (2017): 36.
  14. ↑ Case courtesy of Bouhouche Abdeldjalil, Radiopaedia.org, rID: 173225
  15. ↑ Chang, Min Cheol, et al. "Obturator nerve injury diagnosed by nerve conduction: a case report." Annals of Palliative Medicine 10.6 (2021): 7069072-7067072.
  16. ↑ Marhofer, Peter, et al. "Magnetic resonance imaging of the distribution of local anesthetic during the three-in-one block." Anesthesia & Analgesia 90.1 (2000): 119-124.
  17. ↑ Kimura, Jun, and Jeffrey A. Strakowski. Electrodiagnosis in diseases of nerve and muscle: principles and practice. Oxford university press, 2025.
  18. ↑ Malanga, Gerard A., and Kenneth R. Mautner. "Atlas of ultrasound-guided musculoskeletal injections." (No Title) (2014)
  19. ↑ Herring, Stanley A., et al. "Initial assessment and management of select musculoskeletal injuries: a team physician consensus statement." Current Sports Medicine Reports 23.3 (2024): 86-104.
Created by:
John Kiel on 14 June 2019 08:39:00
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Last edited:
16 October 2025 01:08:07
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