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 triangle	Sacro-iliac joint pain	Pain in lumbar spine and gluteal region	Axial femoral compression test with sustained pressure12 has highest specificity,13 but thigh thrust greater inter-tester reliability10	Plain film, guided local anaesthetic injection to SIJ14Computerised tomography
	Spondyloarthritides	Systemic symptoms include morning stiffness, improvement with moderate activity, diffuse buttock pain. Past medical history ie, psoriasis	Limited range of movement, general tenderness to palpation. Asymmetrical poly-arthropathy with tendency toward axial spine and large joints	HLA-B27,CRP,15 plain x rays, MRI scan back, bone scan
	Sacral stress fracture	Vague incapacitating gluteal pain, pelvic anteversion, Insufficiency vs fatigue. Leg length discrepancy	Tests poorly discriminative. Pain on percussion16 FABER, Gaenslen’s and Spring tests for SIJ dysfunction all may be +ve	Plain film, bone scan,17MRI18
	Obturator nerve entrapment	Medial thigh pain on exercise relieved by rest	Adductor weakness, superficial dysesthesia/hyperaesthesia of mid-medial thigh19	EMG of obturator innervated muscles20 Guided local anaesthetic injection to obturator foramen21
	Posterior compartment syndrome	Associated with avulsion fracture. Sudden tearing pain gradual worsening over 24 hours	Tense swelling and firm feel to posterior compartment of thigh, tender ischial tuberosity22 23	Compartment pressure studies usual, but MRI24 25 better in this area
	I. Acute
	II. Chronic	Insidious onset prevents completion of training with relief with rest
	Superior gluteal artery entrapment/endo fibrosis	Claudicant gluteal pain on exercise relieved by rest. Smoking	Exercise related gluteal pain26	Pre/post exercise ankle-brachial index, duplex ultrasound scan /angiography27
	Hamstring syndrome	Pain worse on sitting and localised to ischial tuberosity during and after exercise	Tenderness over ischial tuberosity, Puranen-Orava test28	MRI29

CRP, C-reactive protein; EMG, electromyography; MRI, magnetic resonance imaging; SIJ, sacro-iliac joint pain; FABER, Flexion, Abduction, External rotation.