Introduction

The pelvis is the region of the body bound by the innominate bones, sacrum, and coccyx. Within this bony framework lie the contents of the pelvic floor. The pelvic floor is comprised not only of muscular structures, but also all of the structures in the pelvic cavity (Hartman & Sarton, 2014). The muscles of the abdominal–pelvic region serve many roles, including control of the urinary and anal sphincters, sexual arousal and orgasm, support for the pelvic viscera, local spinal stability, and motor control. Muscles contributing to pelvic girdle pain may not be limited to the intrinsic muscles of the pelvic floor.

The American College of Obstetricians and Gynaecologists describes chronic pelvic pain (CPP) as pain located in the pelvis, abdominal wall at or below the umbilicus, lumbar, sacral, and buttock regions (Vercellini et al., 2009). Several pain syndromes are included within the CPP terminology, including bladder pain syndrome, endometriosis pain syndrome, interstitial cystitis, prostatic pain syndrome, dysmenorrhoea, and vulvodynia (Fall et al., 2010). CPP remains a somewhat enigmatic diagnosis. Pastore and Katzman (2012) commented that 40% of all laparoscopies are performed to determine a cause of CPP. Vleeming and colleagues (2008) suggested that, from a biomechanical point of view, there is a connection between chronic sacroiliac dysfunction and CPP, which is evidenced by many patients with SI pain, who also suffer from CPP. In addition, Vleeming and colleagues (2008) reported that the prevalence of pelvic girdle pain in pregnancy is 20%. According to Zondervain and colleagues (2001), the lifetime occurrence of CPP is 33%. In a recent study researchers found a significant relationship between the presence of spine and hip movement diagnoses and pelvic floor muscle diagnoses (Wente & Spitznagle 2017). Cohen and colleagues (2016) described the relationship between pelvic floor muscle dysfunction in males with sexual dysfunction, chronic prostatitis, and CPP. These authors found a significant overlap of signs and symptoms of these disorders with a common thread of muscular dysfunction in the muscles of the pelvic floor, which implies that treating these muscles may result in improved function in men with chronic pelvic pain, chronic prostatitis, and sexual dysfunction (Cohen et al., 2016).

Moreover, pelvic floor muscle dysfunction is associated with impairments of the lumbar spine and hip regions. A functional relationship exists between the pelvic floor, diaphragm and transverse abdominus (Sapsford et al., 2001; Hodges et al., 2014). Smith and colleagues (2006) reported that the association between incontinence and low back pain is greater than the association between low back pain and body mass index. Several studies reported an association between hip pathology, including end-stage hip osteoarthritis and femoroacetabular impingement, and pelvic floor disorders such as vulvodynia and urinary incontinence (Podschun et al., 2013; Baba et al., 2014; Tamaki et al., 2014; Prather & Camacho-Soto 2014; Coady & Futterman, 2015).

Pain from visceral organs is often similar to myofascial pain and described as a poorly localised, dull, aching pain. Both myofascial and visceral pain are known causes of secondary hyperalgesia or referred pain. Of interest is that visceral-induced referred pain can persist even after the dysfunctions or the disease has been resolved. For example, referred pain from kidney stones to the quadratus lumborum muscle may continue to cause low back pain even after the kidney stones are no longer present. Little is known about the referred pain from muscles to the viscera, although there is an established somatovisceral pathway. A study of injections of an acidic saline solution in the gastrocnemius of a rat caused more distention of the colon and increased muscle activity in the ipsilateral external abdominal oblique muscle (Miranda et al., 2004; Peles et al., 2004); however, it is not known whether such patterns are common. Luz and colleagues (2015) found that lamina I of the spinal cord is the first site in the central nervous system in an animal model at which somatic and visceral pathways converge onto individual projection and local circuit neurons, explaining potential somatovisceral interactions. Abdominal and pelvic TrPs may be secondary to visceral disease or dysfunction through a visceral–somatic convergence pathway; however, myofascial impairments, including myofascial trigger points (TrPs), are also common pain contributors to CPP (Pastore & Katzman 2012) and other types of pelvic floor dysfunction (Doggweiler-Wiygul, 2004).

Clinical relevance of trigger points in syndromes related to the pelvis

Myofascial dysfunction is one of the most common contributing factors to pelvic pain (Itza et al., 2010). Patients with visceral pain and cutaneous hyperalgesia in the abdominal wall are likely to present with abdominal TrPs (Giamberardino et al., 1999; Jarrell, 2011). Close to 90% of patients with interstitial cystitis, pelvic pain, and incontinence present with myofascial pain and TrPs (Wesselman, 2001; Fitzgerald & Kotarinos, 2003; Pastore & Katzman, 2012). Jarrell (2011) described abdominal TrPs in patients with endometriosis. TrPs are also a common finding in patients with provoked vestibulodynia, which is another type of a CPP disorder (Hartman & Sarton, 2014). Moldwin and Fariello (2013) found that TrPs are associated with high tone pelvic floor dysfunction. Men with chronic prostatitis and CPP presented with pain in the scrotal, perineal, inguinal, and bladder areas in 54% of cases, and 88% of the cases had myofascial pain (Zermann et al., 2001). TrPs in the puborectalis, pubococcygeus, and rectus abdominus muscles reproduced penile pain 75% of the time, whereas TrPs in the external oblique elicited suprapubic, groin, and testicular pain in 80% of the cases (Anderson et al., 2009). Another study showed that 78.5% of patients with interstitial cystitis had myofascial pain, and 67.9% of those patients had six or more identifiable TrPs (Bassaly et al., 2010). TrPs were most commonly found in the obturator internus, puborectalis, iliococcygeus muscles, and the arcus tendineus. Farrell and colleagues (2016) studied the effects of physical therapy for chronic scrotal content pain and found that manual physical therapy reduced pain levels in 50% of patients with a complete resolution of pain in 13% of the patients. The number of patients taking pain medication reduced from 73.3% to 44%. Pelvic floor tension and myofascial pain and tenderness are commonly seen with scrotal pain.

Clinical practice guidelines and recent literature support the treatment of TrPs as part of a multidisciplinary approach to treating patients with pelvic floor dysfunction. The European Association of Urology and the Society of Obstetricians and Gynaecologists of Canada recommend that TrPs be considered in the diagnosis of pelvic pain (Jarrell et al., 2005; Fall et al., 2010), which is supported in studies by Jarrell, who demonstrated that abdominal TrPs have a 93% positive predictive value for visceral disease, particularly CPP (Jarrell, 2011; Jarrell et al., 2011). The presence of abdominal TrPs along with abdominal and perineal cutaneous allodynia discriminated visceral from somatic sources of pain (Jarrell et al., 2011). However, of interest is that in spite of the recommendations, obstetrics and gynaecology residency training programs rarely include the examination of the pelvic floor muscles (Bonder et al., 2017). The American Urological Association (2014) lists release of TrPs as a second-line treatment for interstitial cystitis/bladder pain syndrome (IC/BPS), after self-care and patient education (Qaseem et al., 2014), whereas the Canadian Urological Association considers that ‘looking for tenderness, spasm/tight bands, and/or trigger points, is important for both diagnosis and treatment recommendations’ as part of the mandatory physical examination of patients with IC/BPS (Cox et al., 2016). IC/BPS is defined as ‘an unpleasant sensation (pain, pressure, discomfort) perceived to be related to the urinary bladder, associated with lower urinary tract symptoms for more than 6 weeks duration, in the absence of infection or other identifiable causes’.

Fitzgerald and colleagues (2013) utilised TrP treatment in addition to other specific manual therapy techniques to treat women with IC/BPS and compared this approach with generalised massage. Their findings demonstrated greater reduction in pain and urinary urgency in the myofascial group. Other studies demonstrated similar results incorporating TrP release into a comprehensive plan to address pelvic floor dysfunction (Weiss, 2001; Anderson et al., 2009). Goldstein and colleagues (2016) recommend physical therapy treatment to the pelvic floor, including internal muscle treatment, for the treatment of vulvodynia. Several studies have confirmed that physical therapy interventions are useful in the treatment of patients with sexual dysfunction such as erectile dysfunction (Lavoisier et al., 2014; Pelayo-Nieto et al., 2015; Yüksela et al., 2015; Bechara et al., 2016; Rudolph et al., 2017).

Pain in the pelvic girdle may be referred from other muscles in the spine and hip regions. Examination of the patient with pain or other symptoms in the pelvis should include an assessment of the lower thoracic and lumbar segments, the sacroiliac and hip joints, and the pubic region. Careful consideration should be given to muscle, fascia, and nerves in addition to the joints of these regions. Muscle or fascia innervated by the 10th thoracic to the sacral segments can refer pain to the lower abdomen, pubic region, groin, buttocks, and ischial tuberosities (Baker, 1993; Brookhoff & Bennett, 2006; Longbottom, 2009). Treatment of TrPs in the pelvic floor muscles as well as the spine, hips, and lower extremities is an integral part of any physical therapy plan of care to address pelvic pain and dysfunction.

Clinical relevance of trigger points in syndromes related to the hip and thigh

Several studies have reported that TrPs in hip muscles such as the gluteus medius or piriformis can be involved in patients with low back pain. Teixera and colleagues (2011) identified the presence of active TrPs in the gluteus medius and the quadratus lumborum muscles in 85.7% of patients suffering from postlaminectomy pain syndrome. Iglesias-Gonzalez and colleagues (2013) found that active TrPs in the gluteus medius and piriformis were present in almost 35% of patients with nonspecific low back pain. TrPs in the gluteus muscles have been identified in 76% of patients with lumbar radiculopathy (Adelmanesh et al., 2015), and their presence has been considered a highly specific indicator of radiculopathy with a specificity of 0.91 and a sensitivity of 0.74 (Adelmanesh et al., 2016).

There is a lack of studies investigating the effects of dry needling (DN) in the hip muscles. Rainey (2013) reported a case report study of a patient with low back pain who received DN into the lumbar multifidus and gluteus maximus and gluteus medius muscles with a positive outcome on pain and related disability. Huguenin and colleagues (2005) observed that DN of the gluteal muscles was effective for decreasing symptoms and tightness in athletes with posterior thigh pain; however, no changes in the straight leg raise test were found. Anandkumar (2017) recently described the positive effects of DN of the quadratus femoris muscle in a case report of a patient with posterior thigh pain managed unsuccessfully with other conventional treatments.

Due to the interregional dependence principle, the hip and the knee are clearly interconnected. In fact, several hip muscles can refer pain to the knee. Roach and colleagues (2013) found an increase in the prevalence of TrPs in the gluteus medius and quadratus lumborum muscles in patients with patellofemoral pain. Additionally, the role of TrPs in knee pain syndromes has been recently confirmed. Torres-Chica and colleagues (2015) observed that the referred pain elicited by active TrPs of the knee muscles reproduced symptoms in individuals with postmeniscectomy knee pain. The review of Dor and Kalichman (2017) concluded that there is preliminary evidence suggesting a potential role of TrPs in knee osteoarthritis, but more research is clearly needed. In fact, one study included in this review found that the higher number of active TrPs was associated with higher intensity of ongoing knee pain in a sample of elder people with knee osteoarthritis (Alburquerque-García et al., 2015). This hypothesis is also supported by a case series showing that the combination of TrP DN and therapeutic exercises was effective for improving pain, range of motion, and related disability in patients who had chronic pain after total knee arthroplasty (Núñez-Cortés et al., 2017). Similarly, Mayoral and colleagues (2013), in a double-blind study, reported that a single DN treatment under anaesthesia reduced pain in the first month in patients receiving a total knee arthroplasty for knee osteoarthritis. The randomised clinical trial conducted by Espi-López and colleagues (2017) showed that the inclusion of three sessions of DN into the vastus medialis and lateralis muscles in a manual therapy and exercise program did not result in improved outcomes for pain and disability in individuals with patellofemoral pain at the 3-month follow-up. It is important to consider that only two muscles received the needling intervention, explaining the lack of effects. In fact, a recent randomised, controlled trial observed that application of DN into TrPs on the vastus medialis combined with a rehabilitation protocol was effective for increasing range of motion and function in subacute patients with surgical reconstruction of complete anterior cruciate ligament rupture (Velázquez-Saornil et al., 2017).

Hamstrings injuries also represent a significant problem for the population. Some case reports have observed that the combination of DN with eccentric exercises of the lower extremity was effective for pain and function outcomes for the treatment of hamstring tendinopathy (Jayaseelan et al., 2014) or hamstring strain (Dembowski et al., 2013). However, these results were not replicated in posterior clinical trials. Geist and colleagues (2016) analysed the effects of DN into a sample of asymptomatic individuals with hamstring extensibility deficits and observed that DN did not result in increased extensibility beyond that of stretching alone. It should be noted that the authors did not mention TrPs in the hamstring muscles. (Geist et al., 2016). Similarly, Mason and colleagues (2016) also did not observe any significant effect on hamstring range of motion after application of two session of DN compared with sham needling in a young active population with nontraumatic knee pain.

Dry needling of the abdominal, hip, pelvis, and thigh muscles

Some of the muscles on the hip and pelvis are covered in other chapters. The abdominal muscles are discussed in Chapter 10. The referred pain patterns are mostly based on the descriptions by Simons and colleagues (1999), with substitutions and additions by Dalmau-Carola (2005) and Longbottom (2009).

Hip Muscles

Gluteus maximus muscle

• •  Anatomy: The gluteus maximus muscle originates at the posterior aspect of the ilium, the lower part of the sacrum and coccyx inferior and lateral across the greater trochanter to the iliotibial band of the tensor fascia lata and the gluteal tuberosity. Of importance is that there are extensive connections between the gluteus maximus muscle, the latissimus dorsi muscle, and the thoracolumbar fascia (Carvalhais et al., 2013). Lieberman and colleagues (2006) found that more cranial fibres of the muscle terminate in a thick laminar tendon, which inserts into the iliotibial band. Recent research confirms that the iliotibial band is, in fact, a reinforcement of the fascia lata (Fairclough et al., 2006; Stecco et al., 2008) and, as such, can be viewed as a tendon of insertion of the gluteus maximus muscle, which may explain the functional force relationship between the thoracolumbar fascia and the knee (Stecco et al., 2013).
  
• •  Function: The gluteus maximus muscle is a hip extensor, lateral rotator and contributes to stabilisation of the iliotibial tract.
  
• •  Innervation: Inferior gluteal nerve from L5, S1, and S2.
  
• •  Referred pain: Pain referral is along the inferior or inferior-lateral aspect of the sacrum, the gluteal fold, or insertion along the iliotibial tract. TrPs in the gluteus maximus muscle can imitate sacroiliac pain.
  
• •  Needling technique: Position the patient in the sidelying with the affected side up and a pillow placed between the knees. The muscle is needled with flat palpation towards the TrP (Fig. 11.1). Strong depression of the subcutaneous tissue is required to reduce the distance from the skin to the muscle.

• •  Precautions: Avoid needling the sciatic nerve. The depth of penetration is dependent on the amount of adipose tissue.

Gluteus medius muscle

• •  Anatomy: The gluteus medius muscle is found between the gluteus maximus and the tensor fascia latae. It originates between the posterior and anterior gluteal lines of the ilium and inserts with two distinct and consistent insertions onto the lateral border of the greater trochanter (Robertson et al., 2008). A bursa lies under the tendinous portion over the surface of the trochanter. In the region of overlap between the gluteus medius and gluteus minimus muscles, the individual muscles cannot be identified with palpation.
  
• •  Function: The gluteus medius muscle is the main hip abductor and medial rotator. Insufficiency of the gluteus medius muscle results in a positive Trendelenburg test. Commonly, the gluteus medius muscle becomes insufficient when active TrPs are present in the quadratus lumborum muscle. The gluteus medius muscle activation patterns may be useful in identifying patients at risk for developing low back pain (Nelson-Wong et al., 2008).
  
• •  Innervation: Superior gluteal nerve from L4, L5, and S1.
  
• •  Referred pain: TrPs may be found throughout the entire muscle with referral to the sacroiliac joint, gluteal and lumbosacral regions, and along the iliotibial band, gluteal region, posterior thigh, and posterior lower leg. It is not possible to separate the referred pain patterns from the gluteus minimus muscle in the area where the two muscles overlap.
  
• •  Needling technique: The patient is in the sidelying position with a pillow between the knees. The muscle is needled with flat palpation along the contour of the iliac crest towards the TrP. Strong depression of the subcutaneous tissue is required to reduce the distance from the skin to the muscle. Needle contact at the periosteum of the ilium is common (Fig. 11.2).

• •  Precautions: There are deep branches of the superior gluteal vessels and nerve between the gluteus medius and minimus muscles, but these cannot be always be avoided. The depth of penetration is dependent on the amount of adipose tissue.

Gluteus minimus muscle

• •  Anatomy: The gluteus minimus muscle is found deep to the gluteus medius muscle. It originates between the anterior and inferior gluteal lines of the anterior aspect of the ilium and inserts on the anterior aspect of the greater trochanter. It also has a bursa between the tendon and the insertion at the greater trochanter.
  
• •  Function: The gluteus minimus muscle is a hip abductor and medial rotator. Insufficiency of this muscle along with the gluteus medius results in a positive Trendelenburg test. The muscle supports the body in single leg stance with the tensor fascia latae.
  
• •  Innervation: Superior gluteal nerve from L4, L5, and S1.
  
• •  Referred pain: Referred pain from the gluteus minimus muscle is into the iliotibial band, gluteal region, posterior thigh, and posterior one-third of the lower leg. It is not possible to separate referred pain patterns from the gluteus medius muscle in the area where the two muscles overlap.
  
• •  Needling technique: The patient is in the sidelying position with a pillow between the knees. The muscle is needled with flat palpation along the contour of the iliac crest towards the TrP. Strong depression of the subcutaneous tissue is required to reduce the distance from the skin to the muscle. Needle contact at the periosteum is common (Fig. 11.3).

• •  Precautions: There are deep branches of the superior gluteal vessels and nerve between the gluteus medius and minimus muscles, but these cannot be always be avoided. The depth of penetration is dependent on the amount of adipose tissue.

Tensor fascia latae muscle

• •  Anatomy: The tensor fascia latae muscle originates from the anterior outer aspect of the iliac crest and the anterior superior iliac spine (ASIS), between the gluteus medius and sartorius, and from the deep surface of the fascia latae. It inserts between the two layers of the iliotibial band of the fascia latae of the middle and upper thirds of the thigh.
  
• •  Function: Via the iliotibial band, the tensor fascia latae muscle contributes to knee extension, lateral rotation of the leg, knee flexion, hip abduction, and medial hip rotation. Its main functions are pelvic stabilisation and posture control.
  
• •  Innervation: Superior gluteal nerve from L4, L5, and S1.
  
• •  Referred pain: The referred pain from the tensor fascia latae muscle travels along the iliotibial band, gluteal region, and posterior lateral thigh.
  
• •  Needling technique: The patient is supine or in the sidelying position with a pillow between the knees. The muscle is needled with flat palpation towards the TrP (Fig. 11.4).

• •  Precautions: None

Iliacus muscle

• •  Anatomy: The iliacus muscle originates from the upper two-thirds of the inner surface of the iliac fossa, inner lip of the iliac crest, the iliolumbar and ventral sacroiliac ligaments, and the upper surface of the lateral portion of the sacrum. It comes forward as far as the anterior superior and anterior inferior iliac spines. Many of the fibres of the iliacus muscle join the psoas major tendon, and together they insert into the lesser trochanter of the femur. Some fibres also attach to the femur and in front of the trochanter. The muscle also receives some fibres from the upper portion of the hip joint capsule (Standring, 2015). Anatomical variations have been reported for the iliacus muscle. Jelev and colleagues (2005) as well as D’Costa and associates (2008) reported the presence of an accessory iliacus muscle, covered by a separate fascia, which attached at the middle third of the iliac crest and inserted on the lesser trochanter with the iliopsoas tendon. Rao and colleagues (2008) reported another variation of the iliacus muscle: two defined variant muscles, an iliacus minimus and an accessory slip of the iliacus muscle, were identified on one side; on the contralateral side, an additional single slip of the iliacus muscle fused with the iliopsoas tendon distally. Fabrizio (2011) reported a variation that originated from the superior–lateral aspect of the iliac fascia and travelled nearly horizontally to insert into the psoas major muscle, forming a blended iliacus–psoas muscle. Another variation, reported by Aleksandrova and colleagues (2013), described slips missing from the middle and anterior parts of the muscle (due to not developing). The posterior portion of the muscle started unusually high from the iliolumbar ligament. There are also reported variations of the iliopsoas tendon at the level of the hip joint. Philippon and colleagues (2014) examined 52 cadavers and found that in only 28% of the specimens were the tendons single banded. Sixty-four percent of the specimens featured double banded tendons, and 7.5% were triple banded.
  
• •  Function: One of the primary functions of the muscle is flexion of the hip. When acting from below and contracting bilaterally, the iliacus muscles and the psoas major muscle are able to bend the trunk and pelvis forward against resistance, as when performing a sit-up (Standring, 2015).
  
• •  Innervation: Branches from the femoral nerve in the pelvic region (L2-L3). The accessory iliacus muscle is innervated by the L4 root of the femoral nerve when present (D’Costa et al., 2008).
  
• •  Referred pain: The iliacus muscle refers pain to the sacroiliac region and may continue to include the sacrum and proximal medial buttock. It frequently includes the pelvic floor, groin, and upper anteromedial aspect of the thigh on the same side and should be considered with all pelvic floor pain and dysfunction. The attachment of the iliopsoas muscle (mostly iliacus fibres) on the lesser trochanter of the femur may refer pain both to the back and anteriorly to the thigh. Pain referral to the medial knee has been reported in the literature (Cummings, 2003) and frequently observed in clinical practice.
  
• •  Needling technique: The iliacus muscle should be approached from below the iliac crest with the patient in the sidelying position. Wrap the fingers of the nonneedling hand around the iliac crest and ‘hook on’ to the bone. Insert the needle approximately 5 mm from the bone into the abdominal external oblique muscle. Direct the needle towards the ilium and stay close to the inner surface of the ilium to avoid penetrating the abdominal contents. This approach may not be possible in obese individuals (Fig. 11.5).

• •  Precautions: To avoid penetration of the peritoneum, direct the needle towards the inside surface of the ilium.

Obturator internus muscle

• •  Anatomy: The obturator internus muscle has a broad attachment to the anterior lateral wall of the inner pelvic brim, the rim of the obturator foramen, and the obturator membrane, covering most of the obturator foramen. The pelvic surface of the obturator internus and its fascia form the anterior lateral wall of the true pelvis. The muscle exits the pelvis through the lesser sciatic foramen, then makes a right angle turn, posterior to the hip joint capsule, attaching to the anterior medial surface of the greater trochanter in close proximity to the gemelli muscles.
  
• •  Function: The primary function of the obturator internus muscle is commonly described as lateral or external rotation of the hip joint when the thigh is extended and hip abduction when the hip is flexed to 90 degrees (Travell & Simons, 1992). However, a recent study showed that the muscle consistently showed increased electromyographic activity with hip extension first, followed by external rotation and abduction (Hodges et al., 2014).
  
• •  Innervation: The muscle is supplied by the nerve to the obturator internus from L5 and S1.
  
• •  Referred pain: The obturator internus muscle refers pain to the vagina, anococcygeal region, and the posterior thigh. The patient may also have a perception of fullness in the rectum.
  
• •  Needling technique: The patient is positioned in sidelying on the involved side with hip and knee flexion and a pillow between the knees. Palpate the muscle along the ischial tuberosity. Place the fingers medially around the bony prominence and then angle the needle perpendicular to the muscle surface with a slight anterior superior angle directly into the TrP (Fig. 11.6). An alternate approach is to palpate the TrP along the internal portion of the obturator internus muscle through intrarectal palpation and angle the needle towards the palpating finger (Fig. 11.7). The external portion of the muscle may be needled medial to the greater trochanter with the other hip lateral rotators.

• •  Precautions: Avoid needling towards the pudendal or Alcock canal containing the pudendal and obturator nerve and vessels.

Obturator externus/gemellus inferior and superior muscles

• •  Anatomy: The obturator externus muscle is a flat triangular muscle that covers the external surface of the obturator membrane and adjacent bone of the ischial and pubic rami laterally and upward to the trochanteric fossa of the femur. The superior gemellus muscle originates at the spine of the ischium and inferior from the ischial tuberosity. Collectively they insert into the medial surface of the greater trochanter of the femur. Functionally, the gemelli muscles can be considered to be part of the obturator internus muscle, and these muscles may actually be fused together (Honma et al., 1998) (Fig. 11.8).

• •  Function: The obturator externus muscle is often described as an external rotator of the hip along with the gemelli muscles, obturator internus, and quadratus femoris muscles; however, a recent biomechanical study showed that the obturator externus muscle is a primary flexor and adductor of the extended hip (Vaarbakken et al., 2015). It is actually not clear to what degree the obturator externus muscles contribute to external rotation and stability of the hip.
  
• •  Innervation: The obturator externus muscle is innervated by the posterior branch of the obturator nerve from L3-L4, the gemellus superior muscle by branches of the obturator internus nerve form L5-S2, and the gemellus inferior muscle by branches of the quadratus femoris nerve from L4-S1.
  
• •  Referred pain: Referred pain patterns from this muscle are not described in detail but are generally thought to include the proximal posterior thigh, hip, and groin and a sciatic-type referral pattern.
  
• •  Needling technique: The patient is positioned in the sidelying position with the involved side up and a pillow between the knees. Palpate the muscle just medial to the greater trochanter. Insert the needle perpendicular to the muscle surface directly towards the TrP. The obturator externus muscle is found deeper and more posterior to the trochanter (Fig. 11.9).

• •  Precautions: Avoid needling the sciatic nerve.

Quadratus femoris muscle

• •  Anatomy: The quadratus femoris muscle is a flat quadrilateral muscle that originates at the upper part of the external aspect of the ischial tuberosity and inserts above the middle of the trochanteric crest of the femur.
  
• •  Function: As is the case with the obturator externus and gemelli muscles, the quadratus femoris muscle is generally considered to be an external rotator of the hip. However, a recent biomechanical study showed that the quadratus femoris muscle is primarily an extensor of the flexed hip (Vaarbakken et al., 2015). During the late swing phase in running, the quadratus femoris muscle plays a synergistic role with other posterior thigh muscles to control deceleration of the lower extremity (Semciw et al., 2015).
  
• •  Innervation: Branches from the quadratus femoris nerve from L5 and S1.
  
• •  Referred pain: Referred pain patterns from this muscle are not described in detail but are generally thought to include the proximal posterior thigh, hip, and groin, along with a sciatic-type referral pattern.
  
• •  Needling technique: The patient is positioned comfortably in the prone or sidelying position. Palpate the greater trochanter and the ischial tuberosity. The needle can be inserted perpendicular to the muscle surface at the trochanter Dry needling of trigger points or just medial to the ischial tuberosity running parallel to the sciatic nerve directly towards the TrP (Fig. 11.10).

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