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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

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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 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 pain 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 greater trochanter 2 Olympic Park Sports Medicine the hip or the groin. The complex anatomy of the buttock c 3G point Centre, Olympic Boulevard, and pelvis, 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 skin provides the Health, Exercise and Sports The paper proposes a novel educational system based on Medicine, Faculty of Medicine, surface covering, with epidermis and dermis, with patho-anatomic concepts. Anatomical reference points Dentistry and Health Sciences, underlying superficial fat superficial to the fascia.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 Gluteus maximus is embedded then extend- 19 November 2008 dimensional nature of proximal lower limb 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 ligament and fascia Gluteal pain is common in athletes and is often c Gluteus maximus ascribed to hamstring origin pain however; back c Gluteus medius 1 pain may be a source of referred gluteal pain. c Gluteus minimus 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 ligaments in the of the chronically painful gluteal region and lower thoracic spine. Multifidus combines with the posterior thigh. This enables the clinician to thoracolumbar fascia 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. connective tissue and support the composition by both muscle tendon 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 supraspinous ligament 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 ilium 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 femur. 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 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 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 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 c line, the iliac crest, the thoracolumbar fascia, and the posterior 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 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 sciatic nerve 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 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 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.
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