HIP

Hip Int 2015; 25 (5): 424-427

DOI: 10.5301/hipint.5000249

ISSN 1120-7000 ORIGINAL ARTICLE

The anatomy and function of the obturator externus

Ravindra Gudena, Abdullah Alzahrani, Pamela Railton, James Powell, Reinhold Ganz

Orthopaedic Trauma and Lower Extremity Reconstruction, University of Calgary, Calgary, Alberta - Canada

Abstract
There is limited knowledge regarding the anatomic relationships and functional anatomy of the Obturator Externus
muscle (OE). It is described as a muscle which originates from the external bony margin of the obturator foramen
with a cylindrical tendon which passes like a sling under the femoral neck and inserts in the trochanteric fossa. The
primary aim of this study is to describe the OE morphology and its anatomic relationship to the acetabulum. A sec-
ondary aim is to postulate its action. Eighteen fresh human cadaveric hips were dissected to investigate the anatomy
of the OE. A plastic model of the pelvis and femur was used to create a string model based on a technique previously
described by Beck et al. The plastic model was used to determine the function of the OE.
We conclude that the Obturator externus muscle helps to stabilise the head of the femur in the socket. The me-
chanical model demonstrated that the primary action of the obturator externus muscle was to externally rotate
the femur when the hip was in neutral position and flexed at 90°. Its secondary function was as an adductor when
the hip was in flexion.
Keywords: Obturator externus, Muscle, Hip, Femur

Introduction ship to the acetabulum. A string model of the OE as described

Knowledge of the functional anatomy and the anatomic
relationship of the obturator externus muscle (OE) is limited.
It is described as a muscle which originates from the exter-
nal bony margin of the obturator foramen and the obtura-
tor membrane with a cylindrical tendon passing like a sling
under the femoral neck and inserting into the trochanteric
fossa. Solomon et al in their anatomical study explored the
function of the obturator externus as a hip stabiliser follow-
ing total hip replacement (1). The function of the OE has not
been assessed in detail. The OE is considered to be a short ex-
ternal rotator which has a function of external rotation of the
hip. Our interest in this muscle was stimulated by noting the
different course of this muscle compared to the other short
external rotators. We believe it has different functions de-
pendent upon the position of the hip joint. Recently several
reports were published regarding the obturator externus bur-
sa and impingement syndrome after total hip replacement,
which is of interest with regard to the OE anatomical relation
with the hip joint/acetabulum (2-4). The purpose of the study
is to describe the OE morphology and its anatomic relation-
Accepted: March 11, 2015
Published online: April 27, 2015
Corresponding author:
James Powell
Clinical Associate Professor of Surgery
Orthopaedic Trauma and Lower Extremity Reconstruction
3134 Hospital Drive N.W
Calgary, Alberta, T2N 5A1, Canada
jnpowellemail@yahoo.ca
previously was used to investigate the potential function (5).
Methodology
IRB approval (E-23715) was obtained from the University
of Calgary Medical Bioethics for the study. In total, 22 fresh
human cadaver hips were used in this study. In 4 specimens
the exposure of the muscle was sub-optimal and those speci-
mens were discarded. Therefore, 18 hip specimens were in-
cluded in this study (11 females and 7 males, 76 ± 6 years
old, obtained from the Anatomy Lab-Health Sciences Centre
at University of Calgary).
The initial dissection was carried out through an anterior
approach in the supine position with the dissection extended
to the adductor compartment. The adductor muscles were
detached from their origin. The OE was exposed up to the in-
ferior margin of the acetabulum. The origin and its anatomic
relationships were noted. The lengths of the muscular and
tendinous portions were noted as was the direction of the
fibres. The cadaver was then placed in the lateral position
and the dissection was continued through the posterior ap-
proach. The short external rotators were carefully dissected.
The short external rotators were identified individually and
the OE tendon insertion was noted. An arthrotomy was per-
formed and at this stage a sequential release of the piriformis
and the conjoint tendon was performed. The OE function as a
hip stabiliser was assessed.
The plastic model of the pelvis and femur was used to
create a string model of OE based on an investigation of
the gluteus minimus previously described (5). Based on the
anatomy the muscle was divided into 5 equal sectors, with
sector 1 being the most superior part of the muscle origin.

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Gudena et al 425

Fig. 2 - OE fibres reinforce posterior capsule in left hip.

Fig. 1 - The OE is passing inferior to the femoral neck in right hip.

The excursion of various parts of the muscle was noted after

positioning the hip joint in different positions. Each sector
was represented by a non-stretchable line which was firmly
fixed both at its origin and insertion and directed by eyelets
along the muscle pathway.
The hip was positioned in full extension, neutral and 90°
of flexion and the excursion distance measured in internal
and external rotation. The excursion distances of abduction
and adduction with internal and external rotation were also
noted. There were 3 measurements taken at each position
and the mean values were calculated. Shortening of the
string was interpreted as contraction and elongation as the
ability to resist that particular movement.

Results
The OE muscle originated from the external bony mar-
gin of the obturator foramen in clockwise direction from
12 o’clock around to the10 o’clock position (right hip viewed
from the front) and a few fibres arose from the obturator
membrane (Fig. 1). It formed a musculo-tendinous junction
at the level of femoral neck. The fibres passed laterally along
the inferior margin of the acetabulum acting like a sling at the
inferior part of the neck (Fig. 1). The muscle inserted as a cy-
lindrical tendon into the trochanteric fossa with some fibres
extending towards the piriformis fossa. The fibres originating
from the superior margin of the obturator foramen twisted
at the insertion site inserting postero-inferiorly and the fibres
originating from the inferior margin inserted antero-superi- Fig. 3 - OE bursa at the inferior part on the neck in left hip.
orly (Fig. 2).
After positioning the hip in flexion, it was observed that
the fibres originating from the superior part of the obturator rotation brings the muscle very close to the caudal border of
foramen are more relaxed compared to the fibres originating the acetabulum. Transecting the transverse acetabular liga-
from the inferior margin. All the fibres are straight with the ment brings the OE muscle into direct contact to the inferior
hip at 90º of flexion and externally rotated. The mean mus- margin of the acetabulum. With the hip in a neutral position
cular length of the tendon is 12.6 cm and it is more muscular the tendon is away from the inferior margin of acetabulum.
than tendinous. There are distinctive fibres reinforcing the A bursa with bursal fluid was noted between the muscle and
posterior hip capsule (Fig. 2). the transverse acetabular ligament in 6 of the specimens
The OE runs closely to the inferior margin of the acetab- (Fig. 3). Methylene blue test confirmed that the bursa is com-
ulum (Fig. 1). Positioning the hip in abduction and external municated with the hip joint in all 6 specimens.

© 2015 The Authors. Published by Wichtig Publishing

426
Fig. 4 - OE function simulated using a string model.
The function of the OE was simulated using a string mod-
el (Fig. 4), positioning the hip in different positions. Flexion
and external rotation of the hip caused shortening of the
strings, indicating a primary function of external rotation.
Internal rotation elongated the strings resisting the move-
ment in this position. This also confirms the role of the hip
stabiliser function of the OE in flexion and internal rotation.
With the hip in extension there is very limited excursion,
suggesting the OE muscle does not function as an external
rotator in this position. The contractions of all the sectors
are nearly similar with the hip in flexion. While moving the
hip from abduction to adduction sectors III - V shortened
and sectors I and II elongated (Figs. 5-7).
Discussion
Current knowledge regarding the functional anatomy of
the OE muscle is limited. It’s different course and innervation
by the posterior branch of the obturator nerve compared to
the other short external rotators suggested it may serve a dif-
ferent role (6, 7).
In this study, we explored the special characteristics of the
OE muscle including its role as hip stabiliser, anatomic rela-
tions and significance and the function of the muscle.
The fibres reinforcing the posterior capsule are noted
in 13 out of 18 specimens. This has special implications in
providing hip stability. Solomon et al explored the role of
the short external rotators in hip stability following a total
hip replacement through a posterior approach. They noted
The anatomy and function of the obturator externus
Fig. 5 - Hip in 90 degree flexion with different degrees of internal
and external rotation.
Fig. 6 - Hip in neutral position.
that preservation of the piriformis and the external obtu-
rator reduces the risk of dislocation (1). We found similar
findings in our study using native cadaver hips. The dissec-
tions were done through the posterior approach of the hip
joint. We preserved the piriformis, and obturator externus
and hip joint stability assessed for posterior dislocation and
noted to be stable even at 90 degree flexion and internal
rotation. In another specimen we followed the similar steps
as above and released the OE insertion which made the hip
joint prone to dislocation. We noted that the OE with its
fibres which reinforce the posterior capsule acts as a hip
stabiliser.
Recently several reports have been published which de-
scribe OE bursa and obturator impingement syndrome. In
these dissections, an OE bursa with bursal fluid was pres-
ent between the transverse acetabular ligament and the
OE muscle in 6 of the 18 specimens. There is evidence of
© 2015 The Authors. Published by Wichtig Publishing
Gudena et al
Fig. 7 - Hip in extension.
extensive osteoarthritic changes in all these 6 specimens
and no arthritic changes noted in the rest of the specimens
suggesting that the bursa is present in diseased hips rather
than normal hips. This corresponds to the findings reported
by Kassarjian et al (4). In their study they looked into 200
consecutive hip MR arthrograms and noted 11 cases of OE
bursa. All these patients had intra-articular disease dem-
onstrated by a labral tear and arthritis. Robinson et al (8)
noted an OE bursa in their series of patients with histopath-
ologically confirmed pathological hips. Their reports and our
study suggest that OE bursa is prevalent in hips with intra
articular pathology.
Recent reports have also described OE impingement syn-
drome following total hip arthroplasty. In our dissections we
noted a close relationship between the musculo-tendinous
part of the OE muscle and the inferior margin of the acetabu-
lum. Releasing the inferior hip capsule did not bring the OE
muscle closer to the caudal border of the acetabulum. How-
ever releasing the transverse acetabular ligament did bring
the OE muscle in contact with the acetabulum. This is more
pronounced while the hip is in the flexed position. While
performing a total hip arthroplasty, an acetabular cup posi-
tion protruding beyond the caudal rim can risk pathological
contact of the OE muscle and can cause impingement. Re-
leasing the OE insertion attachment to the posterior capsule
decreased the risk of impingement.
The string model helped to assess the function of the
OE muscle. Stretching of the string in hip flexion and exter-
nal rotation suggests that the primary function is that of an
external rotator. We also noted a similar function with the
hip in the neutral position (acts as an external rotator both
in flexion and neutral position). The OE muscle doesn’t act as
an external rotator in hip extension. Shortening of the string
in adduction suggests that the OE muscle acts as an adductor
with the hip in the neutral position.
© 2015 The Authors. Published by Wichtig Publishing
427
It was also noted that the course of the muscle helps to
stabilise the head of the femur in the socket. It also protects
the femoral neck as it acts as a suspension sling. We conclude
that the primary action of the OE is external rotation in flex-
ion and the neutral position and its secondary function is as
an adductor in flexion.
Gauthier et al demonstrated that the obturator externus
protects the deep branch of the medial femoral circumflex
vessel from stretch or disruption. In their dissections, the in-
tegrity of the artery was protected as long as the tendon of
the obturator externus was intact, even after release of all
other rotators and a circumferential capsulotomy (9).
This study has a number of limitations. A small number of
specimens were examined. The cadaveric material was gen-
erally from an older population. The string model is a simple
representation of the anatomical specimens and it does not
replicate muscle contraction and relaxation.
Our study describes the functional anatomy of the OE
muscle and its importance as a hip stabiliser. It also described
the anatomical relation to the caudal margin of the acetab-
ulum and describes the OE bursa. Findings from our study
adds to the current knowledge about the obturator externus
muscle.
Disclosures
Financial support: None.
Conflict of interest: None.
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