GLUTEAL REGION
BONES OF THE PELVIS
LIGAMENTS OF THE PELVIC GIRDLE AND HIP JOINT
A. Sacroiliac ligament
B. Iliolumbar ligament
C. Sacrospinous ligament and Sacrotuberous ligament
• Sacrospinous and sacrotuberous ligaments convert the greater and lesser sciatic
notch into foramens
• Prevents upward rotation of the sacrum at the sacroiliac joint
Structures passing through the Greater sciatic foramen
• Piriformis
• Sciatic nerve
• Posterior cutaneous nerve of the thigh
• Superior and inferior gluteal nerves
Structures passing through the Lesser sciatic foramen
• Tendon of Obturator internus muscle
• Nerve to Obturator internus
• Pudendal nerve
• Internal pudendal artery and vein
D. Iliofemoral ligament (Y ligament of Bigelow)
• Fan-shaped that resembles an inverted letter Y
• Apex is attached to the AIIS
• Two arms of the Y attach along the intertrochanteric line of the femur
• Thickest and strongest hip ligament
• Maintenance of erect posture without constant muscle contraction
• When LOG falls posterior to the hip joint, the iliofemoral ligament prevents the
pelvis from rolling backward on the femoral head and stabilizes the hip by pulling
the femoral head firmly into its socket
• With pubofemoral ligament, it limits external rotation
E. Ischiofemoral ligament
• Proximal attachment –ischium, below the acetabulum
• Distal attachment –joint capsule posteriorly
• Limits internal rotation and adduction in a flexed position
F. Pubofemoral ligament
• Proximal attachment –superior ramus of pubic bone and obturator membrane
• Distal attachment –lower, anterior part of joint capsule
• Prevents excessive abduction and helps iliofemoral ligament in checking
extension and external rotation
THE LUMBAR PLEXUS
1. Iliohypogastric nerve
• External oblique, Internal oblique, Transversus abdominis
• Skin over lower anterior abdominal wall and buttock
2. Ilioinguinal nerve
• External oblique, Internal oblique, Transversus abdominis
• Skin of upper medial aspect of thigh, root of penis and scrotum in males; mons
pubis and labia majora in females
3. Genitofemoral nerve
• Cremaster muscle in males
• Skin over anterior surface of thigh
• Nervous pathway for cremasteric reflex
4. Lateral femoral cutaneous nerve
• Skin of anterior and lateral surfaces of the thigh
5. Obturator nerve
• Gracilis, Adductor brevis, Adductor longus, Obturator externus, Pectineus,
Adductor magnus (adductor portion)
• Skin on medial surface of thigh
• Articular branches to hip and knee joints
6. Femoral nerve
• Iliacus, Pectineus, Sartorius, Quadriceps femoris
• Intermediate cutaneous branches to the skin of the anterior surface of the thigh
and by Saphenous branch to the skin of the medial side of the leg and foot
• Articular branches to hip and knee joints
THE LUMBOSACRAL PLEXUS
1. Superior gluteal nerve
• Gluteus medius, Gluteus minimus, Tensor fascia latae
2. Inferior gluteal nerve
• Gluteus maximus
3. Pudendal nerve
• Innervates the external genitalia of both sexes as well as sphincters for both
bladder and rectum
• Originates in Onuf’s nucleus in sacral region of spinal cord
4. Posterior femoral cutaneous nerve (a.k.a. Posterior cutaneous nerve of thigh)
• Innervation to the skin of the posterior surface of the thigh and leg, as well as to
the skin of the perineum
5. Sciatic nerve
• Largest nerve in the body
• Appears below the Piriformis muscle
• Gives no branches in the gluteal region
• Divides into Common peroneal nerve and Tibial nerve
A. Common peroneal nerve
• Smaller terminal branch of the Sciatic nerve
• Arises in the lower third of the thigh
• Winds laterally around the neck of the fibula
a. Superficial peroneal nerve – supplies the Peroneus longus and brevis
b. Deep peroneal nerve –supplies the EDL, PT, and EHL
B. Tibial nerve
• Larger terminal branch of the Sciatic nerve
• Arises in the lower third of the thigh
• Enters the posterior compartment of the leg by passing beneath the Soleus muscle
a. Sural nerve –supplies the skin on posterior leg
b. Muscular branches –supplies the Gastrocnemius, Soleus, Plantaris, and
Popliteus
c. Articular branches to the knee joint
ARTERIAL SUPPLY OF THE GLUTEAL REGION
1. Superior Gluteal Artery
• Enters the gluteal region through the upper part of the greater sciatic foramen
above the Piriformis
• The largest branch of the Internal iliac artery
2. Inferior Gluteal Artery
• Enters the gluteal region through the lower part of the greater sciatic foramen
below the Piriformis
3. Trochanteric Anastomosis
• Provides the main blood supply to the head of the femur
a. Superior Gluteal artery
b. Inferior Gluteal artery
c. Med. Fem. Circum. artery
d. Lat. Fem. Circum. artery
4. Cruciate Anastomosis
• Situated at the level of the lesser trochanter of the femur, together with the
trochanteric anastomosis, provides a connection between the internal iliac and
femoral arteries
a. Inferior Gluteal artery
b. Med. Fem. Circum. artery
c. Lat. Fem. Circum. artery
d. The first perforating artery, a branch of the Profunda femoris artery
VENOUS DRAINAGE OF THE GLUTEAL REGION
MUSCLES OF THE GLUTEAL REGION
Gluteus maximus
1. Origin
• Outer surface of ilium, sacrum, coccyx, and sacrotuberous ligament
2. Insertion
• Iliotibial tract and gluteal tuberosity of femur
3. Innervation
• Inferior gluteal nerve
4. Action
• Extends and laterally rotates the hip joint
Gluteus medius
1. Origin
• Outer surface of ilium
2. Insertion
• Lateral surface of greater trochanter of femur
3. Innervation
• Superior gluteal nerve
4. Action
• Abducts thigh at hip joint
• Tilts pelvis when walking to permit opposite leg to clear the ground
Gluteus minimus
1. Origin
• Outer surface of ilium
2. Insertion
• Anterior surface of greater trochanter of femur
3. Innervation
• Superior gluteal nerve
4. Action
• Abducts thigh at hip joint
• Tilts pelvis when walking to permit opposite leg to clear the ground
Tensor fascia latae
1. Origin
• Iliac crest and ASIS
2. Insertion
• Iliotibial tract
3. Innervation
• Superior gluteal nerve
4. Action
• It will flex, abduct, and internally rotate the femur at the hip joint
Piriformis
1. Origin
• Anterior surface of sacrum
2. Insertion
• Upper border of greater trochanter of femur
3. Innervation
• Nerve to Piriformis (S1-S2)
4. Action
• Laterally rotates the femur at the hip joint
Obturator internus
1. Origin
• Inner surface of obturator membrane
2. Insertion
• Upper border of greater trochanter of femur
3. Innervation
• Nerve to Obturator internus (L5-S2)
4. Action
• Laterally rotates the femur at the hip joint
Obturator externus
1. Origin
• Ischium and pubis (medial side of obturator foramen)
2. Insertion
• Trochanteric fossa of femur
3. Innervation
• Nerve to Obturator externus (L3-L4)
4. Action
• Laterally rotates the femur at the hip joint
Gemellus superior
1. Origin
• Ischial spine
2. Insertion
• Upper border of greater trochanter of femur
3. Innervation
• Nerve to Gemellus superior (L5-S2)
4. Action
• Laterally rotates the femur at the hip joint
Gemellus inferior
1. Origin
• Ischial tuberosity
2. Insertion
• Upper border of greater trochanter of femur
3. Innervation
• Nerve to Gemellus inferior (L5-S1)
4. Action
• Laterally rotates the femur at the hip joint
Quadratus femoris
1. Origin
• Lateral border of ischial tuberosity
2. Insertion
• Quadrate tubercle of femur
3. Innervation
• Nerve to Quadratus femoris (L5-S1)
4. Action
• Laterally rotates the femur at the hip joint
MUSCLES OF THE POSTERIOR ABDOMINAL WALL
Psoas major
1. Origin
• Transverse process of L1-L5 vertebrae
• Vertebral bodies of T12-L5
2. Insertion
• With Iliacus at the lesser trochanter of femur
3. Innervation
• L2-L4 nerves
4. Action
• Flexes the hip joint
Iliacus
1. Origin
• Anterior 2/3 of iliac fossa
2. Insertion
• With Psoas major at the lesser trochanter of femur
3. Innervation
• L2-L3 nerves
4. Action
• Flexes the hip joint
Quadratus lumborum
1. Origin
• Iliac crest
• Iliolumbar ligament
2. Insertion
• Rib #12
• L1-L4 vertebrae
3. Innervation
• T12-L3 nerves
4. Action
• Elevation of the pelvis as in hip hiking
SENSORY INNERVATIONS
THE SKIN OF THE BUTTOCK
1. Upper medial quadrant
• Posterior rami of the L1-L3 and S1-S3 nerves
2. Upper lateral quadrant
• Lateral branches of the iliohypogastric and the 12th thoracic nerves
3. Lower lateral quadrant
• Lateral cutaneous nerve of thigh (a.k.a. Lateral femoral cutaneous nerve)
4. Lower medial quadrant
• Posterior cutaneous nerve of thigh (a.k.a. Posterior femoral cutaneous nerve)
CLINICAL CORRELATIONS
Lateral femoral cutaneous nerve injury
• “Meralgia paresthetica”
• Occurs when the nerve is compressed as it passes under the inguinal ligament
• Caused by increased intra-abdominal pressure as in pregnancy, wearing of very
tight pants or very tight belts
• Sensory deficits???
• Motor deficits???
Sciatic nerve injury
• Sustained Piriformis muscle contraction impinges the Sciatic nerve as it passes
out of the greater sciatic foramen (Piriformis syndrome)
• Injection palsy, Fat wallet syndrome
• Sensory deficits???
• Motor deficits???
Intragluteal injections
• The gluteal region is a common site for injection of drugs
• These injections penetrate the skin, fascia, and muscles
• The muscles here are favored because they are thick and large and provide a large
surface area for the injection of drugs
Superior gluteal nerve injury
• May be injured during total hip arthroplasty
• Paralysis of the Gluteus medius and Gluteus minimus
• Gluteus medius gait and a positive Trendelenburg test
Inferior gluteal nerve injury
• May be injured during total hip arthroplasty, compression, and ischemia in
sedentary individuals
• Paralysis of the Gluteus maximus
• Gluteus maximus gait exhibiting posterior lurch
Ischial bursitis
• Repeated stress on the ischial bursa can result in inflammation of the bursa
• Ischial bursitis is friction bursitis caused by excessive friction between the ischial
bursae and ischial tuberosities
• It is often seen in weavers (“weaver’s bottom”) and in cyclists (“paddle soreness”)
due to their repetitive limb movements
Trochanteric bursitis
• An inflammation of the trochanteric bursa often results from repetitive actions
such as climbing stairs while carrying heavy objects or running on a steeply
elevated treadmill due to friction between the ITB and the greater trochanter
• This is a type of friction bursitis characterized by point tenderness over the greater
trochanter or lateral thigh region
Psoas bursitis
• Pain is experienced in the groin or anterior thigh and possibly into the patellar
area
• It is aggravated during activities requiring excessive hip flexion
