Table 1 Patho-anatomic approach: medial to gluteal triangle (diagnoses appear in order of frequency in an athletic population)
Define and alignPathologyListen and localisePalpate and recreateAlleviate and investigate
Medial to triangleSacro-iliac joint painPain in lumbar spine and gluteal regionAxial femoral compression test with sustained pressure12 has highest specificity,13 but thigh thrust greater inter-tester reliability10Plain film, guided local anaesthetic injection to SIJ14Computerised tomography
SpondyloarthritidesSystemic symptoms include morning stiffness, improvement with moderate activity, diffuse buttock pain. Past medical history ie, psoriasisLimited range of movement, general tenderness to palpation. Asymmetrical poly-arthropathy with tendency toward axial spine and large jointsHLA-B27,CRP,15 plain x rays, MRI scan back, bone scan
Sacral stress fractureVague incapacitating gluteal pain, pelvic anteversion, Insufficiency vs fatigue. Leg length discrepancyTests poorly discriminative. Pain on percussion16 FABER, Gaenslen’s and Spring tests for SIJ dysfunction all may be +vePlain film, bone scan,17MRI18
Obturator nerve entrapmentMedial thigh pain on exercise relieved by restAdductor weakness, superficial dysesthesia/hyperaesthesia of mid-medial thigh19EMG of obturator innervated muscles20 Guided local anaesthetic injection to obturator foramen21
Posterior compartment syndromeAssociated with avulsion fracture. Sudden tearing pain gradual worsening over 24 hoursTense swelling and firm feel to posterior compartment of thigh, tender ischial tuberosity22 23Compartment pressure studies usual, but MRI24 25 better in this area
I. Acute
II. ChronicInsidious onset prevents completion of training with relief with rest
Superior gluteal artery entrapment/endo fibrosisClaudicant gluteal pain on exercise relieved by rest. SmokingExercise related gluteal pain26Pre/post exercise ankle-brachial index, duplex ultrasound scan /angiography27
Hamstring syndromePain worse on sitting and localised to ischial tuberosity during and after exerciseTenderness over ischial tuberosity, Puranen-Orava test28MRI29
  • CRP, C-reactive protein; EMG, electromyography; MRI, magnetic resonance imaging; SIJ, sacro-iliac joint pain; FABER, Flexion, Abduction, External rotation.