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Occasional piece Br J Sports Med: first published as 10.1136/bjsm.2007.042317 on 19 November 2008. Downloaded from The gluteal triangle: a clinical patho-anatomical approach to the diagnosis of gluteal in athletes A Franklyn-Miller,1,2 E Falvey,1,2 P McCrory1

1 Centre for Health, Exercise and ABSTRACT The specific anatomical landmarks and borders Sports Medicine, Faculty of Gluteal pain is a common presentation in sports medicine. of the gluteal triangle are set out in fig 1: Medicine, Dentistry and Health c Spinous process of L5 lumbar vertebrae Sciences, The University of The aetiology of gluteal pain is varied, it may be referred Melbourne, Victoria, Australia; from the lower back, mimic other pathology and refer to c Lateral edge of 2 Olympic Park Sports Medicine the or the groin. The complex anatomy of the buttock c 3G point Centre, Olympic Boulevard, and , variability of presentation and non specific Melbourne, Australia nature of signs and symptoms make the diagnostic ANATOMICAL RELATIONSHIPS OF THE BORDERS process difficult. To date the approaches to this problem Correspondence to: OF THE GLUTEAL TRIANGLE Dr A Franklyn-Miller, Centre for have focused on individual pathologies. Superficially in all cases the provides the Health, Exercise and Sports The paper proposes a novel educational system based on Medicine, Faculty of Medicine, surface covering, with and , with patho-anatomic concepts. Anatomical reference points Dentistry and Health Sciences, underlying superficial superficial to the .3 The University of Melbourne, were selected to form a diagnostic triangle, which Last’s Anatomy was used as the reference text Victoria 3010 Australia; provides the discriminative power to restrict the along with the authors current anatomical work.24 [email protected] differential diagnosis, and form the basis of ensuing The fascia overlying the gluteal triangle is a investigation. Accepted 23 October 2008 continuation of the posterior lumbar fascia, in Published Online First This paper forms part of a series addressing the three which is embedded then extend- 19 November 2008 dimensional nature of proximal lower pathology. The ing to join tensor fasciae latae and form the 3G approach (groin, gluteal and greater trochanter iliotibial band with a slip insertion into the greater triangles) acknowledges this, permitting the clinician to trochanter. This gives rise to a continuous layer of Protected by copyright. move throughout the region, considering pathologies fascia which plays a significant role in the appropriately. These papers should be read in conjunction pathology. with one another in order to fully understand the conceptual approach. SUPERIOR BORDER OF TRIANGLE c Iliolumbar and fascia Gluteal pain is common in athletes and is often c Gluteus maximus ascribed to origin pain however; back c 1 pain may be a source of referred gluteal pain. c http://bjsm.bmj.com/ It can be seen how this can present a diagnostic The spinous process of L5 lumbar vertebrae was conundrum. The presentation of gluteal strains, selected for its ease of location and the associated hamstring tears or sacroiliac joint pathology is lumbar pathology. This is an easily palpable similar and for the clinician, eliciting the significant reference point located at the midline, at a level features in order to differentiate the diagnosis can just below the line drawn between the posterior be a challenge. iliac crests. The posterior layer of the thoracolum- This paper sets out a method based on patho- bar fascia makes a major contribution to the on September 4, 2020 at University of Melbourne Library. anatomic principles for a systematic examination supraspinous and interspinous in the of the chronically painful gluteal region and lower thoracic spine. Multifidus combines with the posterior . This enables the clinician to to form the lumbar supras- discriminate more easily between pathological pinous and interspinous ligaments. The spinal conditions and target their management to specific attachments of these ligaments form a dense diagnoses. and support the composition by both muscle and aponeuroses along the length of the lumbar spine. Specific attachments at THE GLUTEAL TRIANGLE the L5 spinous process are difficult to differentiate The 3G point on palpation. The is the From anthropometric measurements in previous deepest structure with the proximal insertion of cadaveric dissection studies,2 the authors have multifidus, erector spinae and thoracolumbar fascia defined a new reference point at the apex of the more superficially. triangle. This point was termed the ‘‘3G point’’ in The line between L5 and the greater trochanter reference to the three-dimensional pathology and forms the superior border of the triangle which the groin, gluteal and greater trochanteric regions. corresponds to the medial border of gluteus medius The relationship of this point in the posterior muscle.2 This fan-shaped muscle arises from the coronal plane is that of, double the distance from outer surface of between the posterior and the spinous process of L5 lumbar vertebrae to the anterior gluteal lines and converges to form a ischial tuberosity, as a continuation of that line to tendon, this is attached to the oblique ridge sloping the . downwards and forwards on the lateral surface of

460 Br J Sports Med 2009;43:460–466. doi:10.1136/bjsm.2007.042317 Occasional piece Br J Sports Med: first published as 10.1136/bjsm.2007.042317 on 19 November 2008. Downloaded from

Figure 2 The ischial tuberosity clock . ST, semitendinosus; BF, 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 , with gluteus maximus palpable Protected by copyright. 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 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 c line, the , the thoracolumbar fascia, and the posterior Tensor fasciae latae surfaces of the , coccyx, and the sacrotuberous ligament c Iliotibial band and from the fascia covering gluteus medius. The fibres descend http://bjsm.bmj.com/ 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 on September 4, 2020 at University of Melbourne Library. 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 Occasional piece Br J Sports Med: first published as 10.1136/bjsm.2007.042317 on 19 November 2008. Downloaded from Protected by copyright.

Figure 4 Superior to the gluteal triangle. Figure 5 Lateral to the gluteal triangle. c Vastus lateralis is sandwiched on its exit from the greater sciatic c Biceps femoris foramen by the pririformis muscle superiorly and the gemmulus The lateral border of the triangle is marked from the greater inferiorly5 and there has been much variation in anatomy trochanter along the shaft of the femur to the 3G point. The described potentially infringing on the nerve on its extra pelvic iliotibial band runs parallel to this border. It blends with the course. http://bjsm.bmj.com/ capsule of the 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 A PATHO-ANATOMIC APPROACH USING GLUTEAL TRIANGLE compartment, with the bellies of these muscles the only The diagnostic process of history and examination, although palpable structures. The apex of the triangle is at the 3G point taught as integral to determining the differential diagnosis may which lies in line with the femur at a point double the distance

from the spinous process of L5 to the ischial tuberosity. on September 4, 2020 at University of Melbourne Library.

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 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 Occasional piece Br J Sports Med: first published as 10.1136/bjsm.2007.042317 on 19 November 2008. Downloaded from 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.78 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 Protected by copyright. comprehensively elsewhere.910

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 http://bjsm.bmj.com/ the structure can be as diagnostic as a positive sign.

THE DIAGNOSTIC TRIANGLE The step-wise approach using the gluteal triangle is summarised Figure 7 Ischial tuberosity. 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 on September 4, 2020 at University of Melbourne Library. diagnosis for conditions presenting within that anatomical SUPERIOR area, and the combined sieve represents a comprehensive The area lying superior to the line from spinous process of L5 assessment of the region. Prior to each table the most common vertebrae to the greater trochanter transects the postural and diagnosis is drawn out but the reader is directed to the table for locomotor muscles of the gluteals of which the muscle bellies a comprehensive differential. and insertions are the cause of much pathology located in this It is recognised that some argue the discriminatory nature of area. 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 LATERAL best available, and in this case these are included. 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 MEDIAL particular the acetabulum. 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 WITHIN THE TRIANGLE this region of the triangle is that of sacro-iliac pain. The SIJ is a Within the space marked by the lines described above, are joint with limited mobility, acting as a force transducer and a contained the lateral rotators of the hip which sit deep to the shock absorber. This is affected as part of three closed kinematic in particular piriformis, but this region is also chains involving the lumbar spine, sacrum, pelvic girdle and transected by the sciatic nerve an important cause of referred lower extremities. pain.

Br J Sports Med 2009;43:460–466. doi:10.1136/bjsm.2007.042317 463 Occasional piece Br J Sports Med: first published as 10.1136/bjsm.2007.042317 on 19 November 2008. Downloaded from

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 Pain in lumbar spine and gluteal region Axial femoral compression test with sustained Plain film, guided local anaesthetic triangle pressure12 has highest specificity,13 but thigh injection to SIJ14 10 thrust greater inter-tester reliability Computerised tomography Spondyloarthritides Systemic symptoms include morning Limited range of movement, general tenderness to HLA-B27,CRP,15 plain x rays, MRI stiffness, improvement with moderate palpation. Asymmetrical poly-arthropathy with scan back, scan activity, diffuse buttock pain. Past medical tendency toward axial spine and large joints history ie, psoriasis Sacral stress fracture Vague incapacitating gluteal pain, pelvic Tests poorly discriminative. Pain on percussion16 Plain film, bone scan,17 anteversion, Insufficiency vs fatigue. Leg FABER, Gaenslen’s and Spring tests for SIJ MRI18 length discrepancy dysfunction all may be +ve entrapment Medial thigh pain on exercise relieved by Adductor weakness, superficial dysesthesia/ EMG of obturator innervated rest hyperaesthesia of mid-medial thigh19 muscles20 Guided local anaesthetic injection to obturator foramen21 Posterior compartment Associated with avulsion fracture. Sudden Tense swelling and firm feel to posterior Compartment pressure studies usual, syndrome tearing pain gradual worsening over compartment of thigh, tender ischial tuberosity22 23 but MRI24 25 better in this area I. Acute 24 hours II. Chronic Insidious onset prevents completion of training with relief with rest Superior gluteal Claudicant gluteal pain on exercise relieved Exercise related gluteal pain26 Pre/post exercise -brachial entrapment/endo by rest. Smoking index, duplex scan / angiography27 Hamstring syndrome Pain worse on sitting and localised to ischial Tenderness over ischial tuberosity, Puranen-Orava MRI29 tuberosity during and after exercise test28 CRP, C-reactive protein; EMG, ; MRI, magnetic resonance imaging; SIJ, sacro-iliac joint pain; FABER, Flexion, Abduction, External rotation.

Table 2 Patho-anatomic approach: superior to gluteal triangle (diagnoses appear in order of frequency in an athletic population) Protected by copyright. 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 33 33 tendonopathy and /or running specificity 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, http://bjsm.bmj.com/

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 Pain getting up off bed or painful on lying Tenderness directly superior and over Ultrasound scan +/2 local anaesthetic triangle on floor37 greater trochanter injection38 on September 4, 2020 at University of Melbourne Library. Tensor fasciae latae/Iliotibial ‘‘Snapping’’ of hip, sharp burning pain Recreate snapping,39 Ultrasound scan34 band syndrome lateral thigh worsens with exercise Ober’s test41 Femoral-acetabular Mechanical symptoms, clicking +/2 Impingement test41 MRI, magnetic resonance arthrogram42 I. Acetabular/labral locking II. Degenerative Night pain, restriction in daily living Limited range of movement,43 pain on Plain film x ray, MRI18 weight bearing. Stress fracture of femur Female, change in volume of training Hop test,44 Fulcrum test45 Plain film Osteopenia Bone Scan17, MRI18 Lateral cutaneous nerve Exercise induced para/hyperaesthesia Reproduction of symptoms on Relief of pain by local anaesthetic47 entrapment pressure inferior to ASIS46 Nerve conduction studies ASIS, anterior superior iliac spine; MRI, magnetic resonance imaging.

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

464 Br J Sports Med 2009;43:460–466. doi:10.1136/bjsm.2007.042317 Occasional piece Br J Sports Med: first published as 10.1136/bjsm.2007.042317 on 19 November 2008. Downloaded from

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 ‘‘Lase`gue’’ 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 (Lase`gue sign) pain of the hip52 also FAIR test,53 Pace test10 Post , 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 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 Protected by copyright. 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.

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