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Chronic groin, hip and gluteal pain is a common problem in athletes. Complex anatomy, non-specific presentation and a wide variety of potential causes mean narrowing the differential diagnosis may be difficult.
The experienced practitioner develops the skills to recognise patterns in presentation, which lead the direction of clinical examination. This knowledge base of both basic anatomy and science along with the clinical experience takes a considerable period of time to attain.1
Although some suggest the diagnostic power of history-taking and examination is poor,2 3 there is much evidence that this is due less to the diagnostic power of the test than to the decline in clinical skills in the pursuit of evidence-based medicine.4 5
Changes in medical education over the last decade will produce a new generation of doctors who have less of that knowledge base,6 and are expected to achieve consultant status much more rapidly without the confidence of the professional colleges in the UK7 and already gaining attention in Australia and New Zealand.8 The heavy reliance on problem-based learning techniques may result in less expertise in pattern recognition by future trainees.9
We set out to describe, using a novel educational approach, the many diagnoses in this region. Anatomical reference points identified in our previous work formed a series of triangles as a means of dividing the differential diagnosis and corresponding anatomical structures.10
Since Da Vinci’s Vitruvian Man, humans have superimposed shapes over the human form for the purposes of anatomical description. In our study, we chose a series of triangles, which enables a three-dimensional understanding of this area of the body. These triangles have as their proximal base on easily palpable bony anatomical landmarks and distally share a common apex point mid-thigh. This common point highlights the pathologies “shared” by the triangles and readers should consider all three papers in conjunction in order to appreciate the approach.
Pain-generating structures are categorised according to their relation to these three triangles. The reader is prompted via discriminative questioning and examination to exclude various structures encountered in that area. More distal structures that refer pain to an area on or around a triangle are located at the border of the adjacent triangle. This draws the reader to the appropriate triangle, which deals with the structure appropriately—for example, the hip as a cause of groin pain is located on the lateral border of the groin triangle, so it may be addressed in the greater trochanter triangle.
Proceeding from a pathoanatomical diagnosis to investigate the condition appropriately is explained in a tabular form. An exhaustive list of every examination technique and investigational method would render this system impractical. We present the most evidence-based examinations and investigations. Where doubt arises or personal opinion differs, expert radiological advice is recommended.
This “3G” (groin, gluteal, greater trochanter) approach is aimed at teaching the next generation of specialists and non-specialists along with allied practitioners who may not have the underpinning knowledge to apply a differential diagnosis. For the experienced clinician this method may be usefully employed in the teaching of medical students and trainees under their instruction.
Competing interests: None.
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