Downloaded from bjsm.bmj.com on April 27, 2014 - Published by group.bmj.
com
Occasional piece
1
Centre for Health, Exercise and
Sports Medicine, Faculty of
Medicine, Dentistry and Health
Sciences, The University of
Melbourne, Victoria, Australia;
2
Olympic Park Sports Medicine
Centre, Olympic Boulevard,
Melbourne, Australia
Correspondence to:
Dr A Franklyn-Miller, Centre for
Health, Exercise and Sports
Medicine, Faculty of Medicine,
Dentistry and Health Sciences,
The University of Melbourne,
Victoria 3010 Australia;
afranklynmiller@gmail.com
Accepted 23 October 2008
Published Online First
19 November 2008
460
The gluteal triangle: a clinical patho-anatomical
approach to the diagnosis of gluteal pain in athletes
A Franklyn-Miller,1,2 E Falvey,1,2 P McCrory1
ABSTRACT
Gluteal pain is a common presentation in sports medicine.
The aetiology of gluteal pain is varied, it may be referred
from the lower back, mimic other pathology and refer to
the hip or the groin. The complex anatomy of the buttock
and pelvis, variability of presentation and non specific
nature of signs and symptoms make the diagnostic
process difficult. To date the approaches to this problem
have focused on individual pathologies.
The paper proposes a novel educational system based on
patho-anatomic concepts. Anatomical reference points
were selected to form a diagnostic triangle, which
provides the discriminative power to restrict the
differential diagnosis, and form the basis of ensuing
investigation.
This paper forms part of a series addressing the three
dimensional nature of proximal lower limb pathology. The
3G approach (groin, gluteal and greater trochanter
triangles) acknowledges this, permitting the clinician to
move throughout the region, considering pathologies
appropriately. These papers should be read in conjunction
with one another in order to fully understand the
conceptual approach.
Gluteal pain is common in athletes and is often
ascribed to hamstring origin pain however; back
pain may be a source of referred gluteal pain.1
It can be seen how this can present a diagnostic
conundrum. The presentation of gluteal strains,
hamstring tears or sacroiliac joint pathology is
similar and for the clinician, eliciting the significant
features in order to differentiate the diagnosis can
be a challenge.
This paper sets out a method based on patho-
anatomic principles for a systematic examination
of the chronically painful gluteal region and
posterior thigh. This enables the clinician to
discriminate more easily between pathological
conditions and target their management to specific
diagnoses.
THE GLUTEAL TRIANGLE
The 3G point
From anthropometric measurements in previous
cadaveric dissection studies,2 the authors have
defined a new reference point at the apex of the
triangle. This point was termed the ‘‘3G point’’ in
reference to the three-dimensional pathology and
the groin, gluteal and greater trochanteric regions.
The relationship of this point in the posterior
coronal plane is that of, double the distance from
the spinous process of L5 lumbar vertebrae to the
ischial tuberosity, as a continuation of that line to
the femur.
The specific anatomical landmarks and borders
of the gluteal triangle are set out in fig 1:
c Spinous process of L5 lumbar vertebrae
c Lateral edge of greater trochanter
c 3G point
ANATOMICAL RELATIONSHIPS OF THE BORDERS
OF THE GLUTEAL TRIANGLE
Superficially in all cases the skin provides the
surface covering, with epidermis and dermis, with
underlying superficial fat superficial to the fascia.3
Last’s Anatomy was used as the reference text
along with the authors current anatomical work.2 4
The fascia overlying the gluteal triangle is a
continuation of the posterior lumbar fascia, in
which Gluteus maximus is embedded then extend-
ing to join tensor fasciae latae and form the
iliotibial band with a slip insertion into the greater
trochanter. This gives rise to a continuous layer of
fascia which plays a significant role in the
pathology.
SUPERIOR BORDER OF TRIANGLE
c Iliolumbar ligament and fascia
c Gluteus maximus
c Gluteus medius
c Gluteus minimus
The spinous process of L5 lumbar vertebrae was
selected for its ease of location and the associated
lumbar pathology. This is an easily palpable
reference point located at the midline, at a level
just below the line drawn between the posterior
iliac crests. The posterior layer of the thoracolum-
bar fascia makes a major contribution to the
supraspinous and interspinous ligaments in the
lower thoracic spine. Multifidus combines with the
thoracolumbar fascia to form the lumbar supras-
pinous and interspinous ligaments. The spinal
attachments of these ligaments form a dense
connective tissue and support the composition by
both muscle tendon and aponeuroses along the
length of the lumbar spine. Specific attachments at
the L5 spinous process are difficult to differentiate
on palpation. The supraspinous ligament is the
deepest structure with the proximal insertion of
multifidus, erector spinae and thoracolumbar fascia
more superficially.
The line between L5 and the greater trochanter
forms the superior border of the triangle which
corresponds to the medial border of gluteus medius
muscle.2 This fan-shaped muscle arises from the
outer surface of ilium between the posterior and
anterior gluteal lines and converges to form a
tendon, this is attached to the oblique ridge sloping
downwards and forwards on the lateral surface of
Br J Sports Med 2009;43:460–466. doi:10.1136/bjsm.2007.042317
 Downloaded from bjsm.bmj.com on April 27, 2014 - Published by group.bmj.com

Occasional piece

Figure 2 The ischial tuberosity clock face. ST, semitendinosus; BF,

biceps femoris; QF, quadratus femoris; P, piriformis; G Med, Gluteus
medius.

Inferiorly, the medial border of the triangle transects the

posterior compartment. The bellies of semimembranosus and
semitendinosus along with biceps femoris are palpable working
Figure 1 The gluteal triangle. G Max, gluteus maximus; G Med, gluteus from medial to lateral. Superiorly, the border follows the line of
medius; P, piriformis; QF, quadratus femoris; SM, semimembranosus; the sacrotuberous ligament, with gluteus maximus palpable
ST, semitendinosus; BF, biceps femoris; VL, vastus lateralis. superficially. The medial line of the triangle also serves to
remind us of the vector of referred pain from the sciatic nerve
the greater trochanter. The posterior border of gluteus medius which is an important differential diagnosis in the buttock.
may merge with piriformis at its insertion. Gluteus maximus
overlies medius and is transected by the superior border of the
LATERAL BORDER
triangle. It arises from the ilium behind the posterior gluteal
line, the iliac crest, the thoracolumbar fascia, and the posterior c Tensor fasciae latae
surfaces of the sacrum, coccyx, and the sacrotuberous ligament c Iliotibial band
and from the fascia covering gluteus medius. The fibres descend
inferolaterally, the deeper fibres inserting into the greater
trochanter whilst the superficial fibres and the upper part of
the muscle end in a tendonous band, passing lateral to the
greater trochanter and inserting into to the iliotibial band.

MEDIAL BORDER
c L5 lumbar vertebrae
c Gluteus maximus
c Sacroiliac joint
c Sacrotuberous ligament
c Ischial tuberosity and common hamstring origin
c Semimembranosus origin
c Gemellus superior, inferior
The medial border runs from the 3G point on the femur to the
spinous process of L5. The mid point of this line is the ischial
tuberosity, which allows for its easy location. The ischial
tuberosity marks the lateral boundary of the pelvic outlet but
also is found at the midpoint of the medial border of the gluteal
triangle. The importance of palpable knowledge here is critical.
From a posterior view, in the 2 o’ clock position is palpable the
origin of semimembranosus and from the 4 o’clock position
round to 7 o’clock, the combined tendonous insertion of the
long head of biceps femoris and semitendinosus. The sacrotu-
berous ligament at 10 o’clock is palpable at the 8 o’clock
position and the insertion of the gemellus at the 7 o’clock
position. Figure 3 Medial to the gluteal triangle.

Br J Sports Med 2009;43:460–466. doi:10.1136/bjsm.2007.042317 461

 Downloaded from bjsm.bmj.com on April 27, 2014 - Published by group.bmj.com

Occasional piece

Figure 4 Superior to the gluteal triangle. Figure 5 Lateral to the gluteal triangle.

c Vastus lateralis
c Biceps femoris
The lateral border of the triangle is marked from the greater
trochanter along the shaft of the femur to the 3G point. The
iliotibial band runs parallel to this border. It blends with the
capsule of the knee joint to attach to Gerdy’s tubercle, the
lateral condyle of the tibia and the head of the fibula. Vastus
lateralis and biceps femoris form the bulk of this muscular
compartment, with the bellies of these muscles the only
palpable structures. The apex of the triangle is at the 3G point
which lies in line with the femur at a point double the distance
from the spinous process of L5 to the ischial tuberosity.
sciatic nerve is sandwiched on its exit from the greater sciatic
foramen by the pririformis muscle superiorly and the gemmulus
inferiorly5 and there has been much variation in anatomy
described potentially infringing on the nerve on its extra pelvic
course.
A PATHO-ANATOMIC APPROACH USING GLUTEAL TRIANGLE
The diagnostic process of history and examination, although
taught as integral to determining the differential diagnosis may

WITHIN THE TRIANGLE

c Gluteus maximus
c Piriformis
c Sciatic nerve
Structures contained within the triangle are the causal agents in
much gluteal pathology, but lie deep to gluteus maximus and
are palpable at best, at their insertion to the greater trochanter.
Piriformis, which arises from the anterior aspect of the sacrum,
between and lateral to the sacral foramina. As the muscle leaves
the pelvis, some slips arise from the pelvic surface of
sacrotuberous ligament. The muscle passes out of the pelvis
through the greater sciatic foramen. Its rounded tendon is
attached to the upper border and medial aspect of the greater
trochanter, close to the insertion of the obturator internus and
the gemellus with which it may be partially conjoined. The
sciatic nerve, from the ventral rami of the fourth lumbar to
third sacral spinal nerves exits the pelvis through the greater
sciatic foramen, deep to piriformis, and descends between the
greater trochanter of the femur and the ischial tuberosity. The Figure 6 Within the gluteal triangle.

462 Br J Sports Med 2009;43:460–466. doi:10.1136/bjsm.2007.042317

 Downloaded from bjsm.bmj.com on April 27, 2014 - Published by group.bmj.com

Occasional piece

be abbreviated, due to time pressures, coaching and manage-

ment pressures,6 or to ward off potential litigation, with a
tendency to rely on investigational studies as an initial
diagnostic step (eg, a magnetic resonance scan to check for an
anterior cruciate ligament rupture), or much earlier than
required.7 8
The authors propose a four step compartmentalisation of the
diagnostic process re-emphasising history and examination and
limiting investigation to the final step as follows:

Step 1: define & align

Define the anatomical points and borders of the triangle on the
patient (L5 spinous process, greater trochanter, ischial tuberos-
ity and 3G point).

Step 2: listen & localise

Listen to the patient’s history and obtain as many localising
factors as possible then pinpoint the pain in relation to the
gluteal triangle.

Step 3: palpate & re-create

Carefully palpate the identified area and determine which
anatomical structures are painful. The use of provocative
examinations to re-create the patient’s pain can be a vital
diagnostic stage, although to describe all of these tests in detail
is beyond the scope of this text, and these have been described
comprehensively elsewhere.9 10

Step 4: alleviate & investigate

Where a number of anatomical structures are in close proximity,
clinical presentations can be very similar. The manner in which
pain can be removed may be very helpful. A decrease in pain
following removal from aggravating activity, or the elimination
of symptoms following guided injection of local anaesthetic into
the structure can be as diagnostic as a positive sign.

THE DIAGNOSTIC TRIANGLE

The step-wise approach using the gluteal triangle is summarised
in tables 1–5. This gives the clinician a guide to the diagnostic
process and pathological cause of the chronic gluteal pain in
relation to the triangle. Each table shows the differential
diagnosis for conditions presenting within that anatomical
area, and the combined sieve represents a comprehensive
assessment of the region. Prior to each table the most common
diagnosis is drawn out but the reader is directed to the table for
a comprehensive differential.
It is recognised that some argue the discriminatory nature of
clinical tests11 but where appropriate, the evidence based
examination of choice is given,10 some tests are widely utilised
in clinical practice with limited or conflicting evidence, as the
best available, and in this case these are included.
MEDIAL
The area lying medial to the line from spinous process of L5
vertebrae to apical point of the gluteal triangle highlights the
sacro-iliac joint (SIJ) and the most common presentation within
this region of the triangle is that of sacro-iliac pain. The SIJ is a
joint with limited mobility, acting as a force transducer and a
shock absorber. This is affected as part of three closed kinematic
chains involving the lumbar spine, sacrum, pelvic girdle and
lower extremities.
Figure 7 Ischial tuberosity.
SUPERIOR
The area lying superior to the line from spinous process of L5
vertebrae to the greater trochanter transects the postural and
locomotor muscles of the gluteals of which the muscle bellies
and insertions are the cause of much pathology located in this
area.
LATERAL
The area lying lateral to the line from greater trochanter to the
3G point on the shaft of the femur highlights the hip and
structures around it as potential origins of pathology in
particular the acetabulum.
WITHIN THE TRIANGLE
Within the space marked by the lines described above, are
contained the lateral rotators of the hip which sit deep to the
gluteal muscles in particular piriformis, but this region is also
transected by the sciatic nerve an important cause of referred
pain.

Br J Sports Med 2009;43:460–466. doi:10.1136/bjsm.2007.042317 463

 Downloaded from bjsm.bmj.com on April 27, 2014 - Published by group.bmj.com

Occasional piece

Table 1 Patho-anatomic approach: medial to gluteal triangle (diagnoses appear in order of frequency in an athletic population)
Define
and align Pathology Listen and localise Palpate and recreate Alleviate and investigate

Medial to Sacro-iliac joint pain
triangle
Spondyloarthritides
Sacral stress fracture
Obturator nerve entrapment
Posterior compartment
syndrome
I. Acute
II. Chronic
Superior gluteal artery
entrapment/endo fibrosis
Hamstring syndrome
CRP, C-reactive protein; EMG, electromyography; MRI, magnetic resonance imaging; SIJ, sacro-iliac joint pain; FABER, Flexion, Abduction, External rotation.
Pain in lumbar spine and gluteal region
Systemic symptoms include morning
stiffness, improvement with moderate
activity, diffuse buttock pain. Past medical
history ie, psoriasis
Vague incapacitating gluteal pain, pelvic
anteversion, Insufficiency vs fatigue. Leg
length discrepancy
Medial thigh pain on exercise relieved by
rest
Associated with avulsion fracture. Sudden
tearing pain gradual worsening over
24 hours
Insidious onset prevents completion of
training with relief with rest
Claudicant gluteal pain on exercise relieved
by rest. Smoking
Pain worse on sitting and localised to ischial Tenderness over ischial tuberosity, Puranen-Orava MRI29
tuberosity during and after exercise
Axial femoral compression test with sustained Plain film, guided local anaesthetic
pressure12 has highest specificity,13 but thigh injection to SIJ14
thrust greater inter-tester reliability10 Computerised tomography
Limited range of movement, general tenderness to HLA-B27,CRP,15 plain x rays, MRI
palpation. Asymmetrical poly-arthropathy with scan back, bone scan
tendency toward axial spine and large joints
Tests poorly discriminative. Pain on percussion16 Plain film, bone scan,17
FABER, Gaenslen’s and Spring tests for SIJ MRI18
dysfunction all may be +ve
Adductor weakness, superficial dysesthesia/ EMG of obturator innervated
hyperaesthesia of mid-medial thigh19 muscles20 Guided local anaesthetic
injection to obturator foramen21
Tense swelling and firm feel to posterior Compartment pressure studies usual,
compartment of thigh, tender ischial tuberosity22 23 but MRI24 25 better in this area
Exercise related gluteal pain26 Pre/post exercise ankle-brachial
index, duplex ultrasound scan /
angiography27
test28

Table 2 Patho-anatomic approach: superior to gluteal triangle (diagnoses appear in order of frequency in an athletic population)
Define and
align Pathology Listen and localise Palpate and recreate Alleviate and investigate

Superior to Myofascial pain Hamstring/gluteal tightness, poorly localised Tender ‘‘trigger’’ points palpable within Dry needling effective in relieving trigger
triangle pain muscle.30 31 points30
Gluteus medius Weakness or pain in stance phase of walking Trendelenberg test 72% sensitive , 76% Ultrasound scan34
tendonopathy and /or running33 specificity33 MRI
Iliolumbar ligament pain Lumbar ache, worse on exercise, Due to anatomy may mimic SIJ pain35 36 Responds to dry needling if palpable trigger
may have trigger points points30
MRI, magnetic resonance imaging; SIJ, sacro-iliac joint pain,

Table 3 Patho-anatomic approach: lateral to gluteal triangle (diagnoses appear in order of frequency in an athletic population)
Define and
align Pathology Listen and localise Palpate and recreate Alleviate and investigate

Lateral to Trochanteric bursitis
triangle
Tensor fasciae latae/Iliotibial
band syndrome
Femoral-acetabular
I. Acetabular/labral
II. Degenerative
Stress fracture neck of femur
Lateral cutaneous nerve
entrapment
ASIS, anterior superior iliac spine; MRI, magnetic resonance imaging.
Pain getting up off bed or painful on lying Tenderness directly superior and over Ultrasound scan +/2 local anaesthetic
on floor37 greater trochanter injection38
‘‘Snapping’’ of hip, sharp burning pain Recreate snapping,39 Ultrasound scan34
lateral thigh worsens with exercise Ober’s test41
Mechanical symptoms, clicking +/2 Impingement test41 MRI, magnetic resonance arthrogram42
locking
Night pain, restriction in daily living Limited range of movement,43 pain on Plain film x ray, MRI18
weight bearing.
Female, change in volume of training Hop test,44 Fulcrum test45 Plain film
Osteopenia Bone Scan17, MRI18
Exercise induced para/hyperaesthesia Reproduction of symptoms on Relief of pain by local anaesthetic47
pressure inferior to ASIS46 Nerve conduction studies

ISCHIAL TUBEROSITY INTRA-ABDOMINAL PATHOLOGY

The significant point at the midline of the medial triangle is the
ischial tuberosity. The anatomy of the insertions and relations
here has been discussed above but are highlighted again in the
associated figure. The high incidence of hamstring strains and
their causation of long periods of absence from sport and
frequent recurrence rates make them particularly significant in
causes of gluteal pain.57
A cause of gluteal pain which has not been discussed in this
article is that of intra-abdominal causes. Endometriosis is
known to widely radiate pain and the gluteal region is not
immune. Vascular causes such as abdominal aortic aneurysm
can present as gluteal pain, alongside rarer vascular insufficien-
cies such as Leriche syndrome or common iliac stenosis.61
Colo-rectal pathology can present with referred pain and

464 Br J Sports Med 2009;43:460–466. doi:10.1136/bjsm.2007.042317

 Downloaded from bjsm.bmj.com on April 27, 2014 - Published by group.bmj.com

Occasional piece

Table 4 Patho-anatomic approach: Within the gluteal triangle (diagnoses appear in order of frequency in an athletic population)
Define and
align Pathology Listen and localise Palpate and recreate Alleviate and investigate

Within the Acute/chronic disc Lumbar back pain , +/2 radiation to back ‘‘Lasègue’’ straight leg raise (sensitivity 72–97% Fluroscopic guided nerve root
triangle prolapse of leg specificity 11–66%)48 ‘‘Braggards’’ sign (94% +ve)49 injection50, Magnetic resonance
imaging
Lumbar facet joint Revels criteria51 lumbar back pain radiation Pain on palpation of facet joint and worse in extension10 Fluroscopic guided facet joint injection51
to buttock
Piriformis Hamstring origin pain with gradual rather Tenderness over sciatic notch and aggravated by Ultrasound scan54
tendonopathy than sudden onset and/or sciatic referred flexion, adduction, and internal rotation (Lasègue sign)
pain of the hip52 also FAIR test,53 Pace test10
Pelvic floor Post pregnancy, perineal trauma, cyclists Coccygeus and levator ani along with the conjoint Urine examination, pelvic manometry,
dysfunction bellies of pubococcygeus often ignored attachments to MRI of pelvic floor musculature, EMG
pelvis can give cause to gluteal pain54
Circumflex femoral Hamstring origin pain with gradual onset Tenderness and pain on resisted flexion56 without Venography, duplex ultrasound/MRI
vein thrombosis and deep vein thrombosis risk factors muscle weakness
EMG, electromyography; FAIR, Flexion, Abduction, Internal rotation; MRI, magnetic resonance imaging.

Table 5 Problem based approach: Ischial tuberosity (diagnoses appear in order of frequency in an athletic population)
Define and
align Pathology Listen and localise Palpate and recreate Alleviate and investigate

Ischial Hamstring origin tendonopathy Sudden pain in buttock/posterior thigh. Walking Tenderness of muscle belly or tendon MRI57 58
tuberosity painful.57 from common origin
Proximal hamstring tear Sudden pain on acceleration or deceleration, localised Tenderness, palpable haematoma or Ultrasound scan,34 MRI57
to hamstring muscle belly. Weakness, stiffness defect in muscle
Ischial bursitis Pain on sitting, worsens on movement. Likely to be co- Tenderness of ischial tuberosity37 Ultrasound scan38guided local
existent injury with hamstring injury anaesthetic injection34
Ischial tuberosity apophysitis/ Shooting pain following high energy kick or change of Bogginess of ischial tuberosity Plain film60
avulsion fracture direction. tenderness to palpation59
Stress fracture of pubic ramus Gradual onset, change in training load Pain standing on one leg and Hop Plain film, bone scan17 MRI18
test,40 associated deep buttock pain
MRI, magnetic resonance imaging.

inflammatory bowel disease is seen inn association with the 2. Franklyn-Miller A, Falvey E, McCrory P, et al. Landmarks for the 3G approach: groin,
gluteal and greater trochanter triangles: a patho-anatomical method in sports
spondyloarthritidies. Malignancy either of the pelvis or of soft medicine. Eur J Anat 2008;12:81–8.
tissues cannot be ignored and must be excluded but is beyond 3. Last R, Suinnatamby C. Last’s anatomy: regional and applied. 10th Edition ed.
the scope of this diagnostic sieve which restricts itself London: Churchill Livingstone 1999.
4. Franklyn-Miller A, Falvey E, McCrory P, et al. The morphology of the deep fascia of
necessarily to musculoskeletal diagnoses. the lower limb. submitted to J Bodyw, Mov Ther.
5. Windisch G, Braun EM, Anderhuber F. Piriformis muscle: clinical anatomy and
consideration of the piriformis Syndrome. Surg Radiol Anat 2007;29:37–45.
CONCLUSION 6. Anderson LC, Gerrard DF. Ethical issues concerning New Zealand sports doctors.
This paper presents a method of teaching the causes of chronic J Med Ethics. 2005;31:88–92.
pain in the gluteal region and posterior thigh. This also serves as 7. Iglehart JK. The new era of medical imaging—progress and pitfalls. N Engl J Med
2006;354:2822–8.
a means of making the differential diagnosis through history, 8. Bowen JL. Educational strategies to promote clinical diagnostic reasoning.
appropriate discriminative diagnostic examination and ulti- N Engl J Med 2006;355:2217–25.
mately, we accept in many cases, directed investigation. 9. Bruckner P, Khan KM. Clinical sports medicine. 3rd ed. Australia: McGraw-Hill 2007.
10. Malanga G, Nadler S. Musculoskeletal physical examination. An evidence-based
This paper is but a part of the 3G approach to proximal lower approach. 1st ed. Philadelphia: Elsevier Mosby 2006.
limb pain, and for a comprehensive approach, should be read in 11. Hancock MJ, Maher CG, Latimer J, et al. Systematic review of tests to identify the
conjunction with the groin and greater trochanter 3G compa- disc, SIJ or facet joint as the source of low back pain. Eur Spine J 2007;16:1539–50.
nion papers. 12. Solonen KA. The sacroiliac joint in the light of anatomical, roentgenological and
clinical studies. Acta Orthop Scand Suppl 1957;27:1–127.
In delivering this as a diagnostic tool we recognise that 13. Laslett M, Williams M. The reliability of selected pain provocation tests for sacroiliac
experience, expertise and a thorough knowledge of the anatomy joint pathology. Spine 1994;19:1243–9.
of the area cannot be supplanted but may help narrow the 14. Boswell MV, Shah RV, Everett CR, et al. Interventional techniques in the
management of chronic spinal pain: evidence-based practice guidelines. Pain
differential diagnosis, to the benefit of patient and clinician. Physician 2005;8:1–47.
15. Warrell D, Cox TM, Firth J, Benz E, Isner-Horobeti M. Oxford textbook of medicine.
Acknowledgements: Thanks to the medical illustrator Dr Levent Efe for the high Oxford University Press 2004.
standard of illustrations. 16. Lourie H. Spontaneous osteoporotic fracture of the sacrum. An unrecognized
syndrome of the elderly. JAMA 1982;248:715–7.
Funding: AFM was supported by an educational grant from RS Scan Lab UK. EF was 17. Ryan PJ, Fogelman I. The role of nuclear medicine in orthopaedics. Nucl Med
supported by the Irish Centre for Arthritis Research and Education (ICARE). Commun 1994;15:341–60.
Competing interests: None. 18. Berger FH, de Jonge MC, Maas M. Stress fractures in the lower extremity. The
importance of increasing awareness amongst radiologists. Eur J Radiol 2007;62:16–
26.
19. Bradshaw C, McCrory P. Obturator nerve entrapment. Clin J Sport Med
REFERENCES 1997;7:217–19.
1. Lawrence JP, Greene HS, Grauer JN. Back pain in athletes. J Am Acad Orthop Surg 20. Delagi EF PA. Anatomic guide for the electromyographer. 2nd ed. Springfield:
2006;14:726–35. Charles C Thomas Publishers, 1980.

Br J Sports Med 2009;43:460–466. doi:10.1136/bjsm.2007.042317 465

 Downloaded from bjsm.bmj.com on April 27, 2014 - Published by group.bmj.com
Occasional piece
21. Magora F, Rozin R, Ben-Menachem Y, et al. Obturator nerve block: an evaluation of
technique. Br J Anaesth 1969;41:695–8.
22. Oseto MC, Edwards JZ, Acus RW 3rd. Posterior thigh compartment syndrome
associated with hamstring avulsion and chronic anticoagulation therapy. Orthopedics
2004;27:229–30.
23. Kwong Y, Patel J, Ramanathan EB. Spontaneous complete hamstring avulsion
causing posterior thigh compartment syndrome. Br J Sports Med 2006;40:723–4;
discussion 4.
24. Brandser EA, el-Khoury GY, Kathol MH, et al. Hamstring injuries: radiographic,
conventional tomographic, CT, and MR imaging characteristics. Radiology
1995;197:257–62.
25. Orava S, Laakko E, Mattila K, et al. Chronic compartment syndrome of the
quadriceps femoris muscle in athletes. Diagnosis, imaging and treatment with
fasciotomy. Ann Chir Gynaecol 1998;87:53–8.
26. Batt M, Baque J, Bouillanne PJ, et al. Percutaneous angioplasty of the superior
gluteal artery for buttock claudication: a report of seven cases and literature review.
J Vasc Surg 2006 May;43:987–91.
27. Berthelot JM, Pillet JC, Mitard D, et al. Buttock claudication disclosing a thrombosis
of the superior left gluteal artery: Report of a case diagnosed by a selective
arteriography of the iliac artery, and cured by per-cutaneous stenting. Joint Bone
Spine 2007;74:289–91.
28. Puranen J, Orava S. The hamstring syndrome. A new diagnosis of gluteal sciatic
pain. The American journal of sports medicine 1988;16:517–21.
29. Orava S. Hamstring syndrome. Oper Tech Sports Med 1997;5:143.
30. Lavelle ED, Lavelle W, Smith HS. Myofascial trigger points. Med Clin North Am
2007;91:229–39.
31. Njoo KH, Van der Does E. The occurrence and inter-rater reliability of myofascial
trigger points in the quadratus lumborum and gluteus medius: a prospective study in
non-specific low back pain patients and controls in general practice. Pain
1994;58:317–23.
32. Ozcakar L, Erol O, Kaymak B, et al. An underdiagnosed hip pathology: apropos of
two cases with gluteus medius tendon tears. Clin Rheumatol 2004;23:464–6.
33. Bird P, Oakley S, Shnier R, et al. Prospective evaluation of magnetic resonance
imaging and physical examination findings in patient with trochanteric pain syndrome.
Arthritis Rheum 2001;44:2138–45.
34. Allen GM, Wilson DJ. Ultrasound in sports medicine--a critical evaluation. Eur J Radiol
2007;62:79–85.
35. Aihara T, Takahashi K, Yamagata M, et al. Biomechanical functions of the iliolumbar
ligament in L5 spondylolysis. J Orthop Sci 2000;5:238–42.
36. Pool-Goudzwaard A, Hoek van Dijke G, Mulder P, et al. The iliolumbar ligament: its
influence on stability of the sacroiliac joint. Clin Biomech (Bristol, Avon)2003;18:99–
105.
37. Paluska SA. An overview of hip injuries in running. Sports Med 2005;35:991–1014.
38. Walker P, Kannangara S, Bruce WJ, et al. Lateral hip pain: does imaging predict
response to localized injection? Clin Orthop Relat Res 2007;457:144–9.
39. Brignall CG, Brown RM, Stainsby GD. Fibrosis of the gluteus maximus as a cause of
snapping hip. A case report. J Bone Joint Surg Am 1993;75:909–10.
40. Malanga GAN, S F. Physical examination of the hip. Muscloskeletal physical
examination, an evidence-based approach. Philadelphia, PA: Elsevier Mosby,
2006:251–79.
41. Ganz R, Parvizi J, Beck M, et al. Femoroacetabular impingement: a cause for
osteoarthritis of the hip. Clin Orthop Relat Res 2003;(417):112–20.
466
42. Leunig M, Podeszwa D, Beck M, et al. Magnetic resonance arthrography of labral
disorders in hips with dysplasia and impingement. Clin Orthop Relat Res
2004;(418):74–80.
43. Birrell F, Croft P, Cooper C, et al. Predicting radiographic hip osteoarthritis from
range of movement. Rheumatology (Oxford) 2001;40:506–12.
44. Monteleone GP, Jr. Stress fractures in the athlete. The Orthopedic clinics of North
America 1995;26:423–32.
45. Johnson AW, Weiss CB Jr, Wheeler DL. Stress fractures of the femoral shaft in
athletes—more common than expected. A new clinical test. Am J Sports Med
1994;22:248–56.
46. Seror P, Seror R. Meralgia paresthetica: clinical and electrophysiological diagnosis in
120 cases. Muscle & nerve 2006;33:650–4.
47. Rab M, Ebmer And J, Dellon AL. Anatomic variability of the ilioinguinal and
genitofemoral nerve: implications for the treatment of groin pain. Plast Reconstr Surg
2001;108:1618–23.
48. Andersson G, Deyo R. History and examination in patients with herniated lumbar
discs. Spine 1996;21(Suppl 24):10–8S.
49. Stankovic R, Johnell O, Maly P, et al. Use of lumbar extension, slump test, physical
and neurological examination in the evaluation of patients with suspected
herniatednucleus pulposus;a prospective clincal study. Man Ther 1999;4:25–32.
50. Manchikanti L, Cash KA, Pampati V, et al. Evaluation of fluoroscopically guided
caudal epidural injections. Pain Physician 2004;7:81–92.
51. Revel M, Poiraudeau S, Auleley GR, et al. Capacity of the clinical picture to
characterize low back pain relieved by facet joint anesthesia. Proposed criteria to
identify patients with painful facet joints. Spine 199815;23:1972–6; discussion 7.
52. Beatty RA. The piriformis muscle syndrome: a simple diagnostic maneuver.
Neurosurgery 1994;34:512–4; discussion 4.
53. Solheim L, Siewars P, Paus B. The Piriformis muscle syndrome; sciatic nerve
entrapment treated with section of the piriformis muscle. Acta Orthp Scand
1981;52:73–5.
54. Smith J, Hurdle MF, Locketz AJ, et al. Ultrasound-guided piriformis injection:
technique description and verification. Arch Phys Med Rehabil 2006;87:1664–7.
55. Hetrick DC, Ciol MA, Rothman I, et al. Musculoskeletal dysfunction in men with
chronic pelvic pain syndrome type III: a case-control study. J Urol 2003;170:828–31.
56. Papastergiou S, Koukoulias N, Tsitouridis I, et al. Circumflex femoral vein
thrombosis misinterpreted as acute hamstring strain. Br J Sports Med 2007;41:
460–1.
57. Verrall GM, Slavotinek JP, Barnes PG, et al. Diagnostic and prognostic value of
clinical findings in 83 athletes with posterior thigh injury: comparison of clinical
findings with magnetic resonance imaging documentation of hamstring muscle strain.
Am J Sports Med 2003;31:969–73.
58. Askling CM, Tengvar M, Saartok T, et al. Acute first-time hamstring strains during
high-speed running: a longitudinal study including clinical and magnetic resonance
imaging findings. Am J Sports Med 2007;35:197–206.
59. Rossi F, Dragoni S. Acute avulsion fractures of the pelvis in adolescent competitive
athletes: prevalence, location and sports distribution of 203 cases collected. Skeletal
Radiol 2001;30:127–31.
60. Clanton TO, Coupe KJ. Hamstring strains in athletes: diagnosis and treatment. J Am
Acad Orthop Surg 1998;6:237–48.
61. Lequesne M, Zaoui A. [Misleading ‘‘hip’’ or buttock pain: proximal arteritis or lumbar
spinal stenosis?]. Presse Med 2006;35:663–8.
Br J Sports Med 2009;43:460–466. doi:10.1136/bjsm.2007.042317
 Downloaded from bjsm.bmj.com on April 27, 2014 - Published by group.bmj.com

The gluteal triangle: a clinical

patho-anatomical approach to the diagnosis
of gluteal pain in athletes
A Franklyn-Miller, E Falvey and P McCrory

Br J Sports Med 2009 43: 460-466 originally published online

November 19, 2008
doi: 10.1136/bjsm.2007.042317

Updated information and services can be found at:

http://bjsm.bmj.com/content/43/6/460.full.html

These include:
References This article cites 8 articles, 3 of which can be accessed free at:
http://bjsm.bmj.com/content/43/6/460.full.html#ref-list-1

Article cited in:

http://bjsm.bmj.com/content/43/6/460.full.html#related-urls

Email alerting Receive free email alerts when new articles cite this article. Sign up in
service the box at the top right corner of the online article.

Notes

To request permissions go to:

http://group.bmj.com/group/rights-licensing/permissions

To order reprints go to:

http://journals.bmj.com/cgi/reprintform

To subscribe to BMJ go to:

http://group.bmj.com/subscribe/