GLUTEAL REGION, BACK OF THE

THIGH AND POPLITEAL FOSSA

KIMAIGA H.O
1ST YEAR MBChB(UoN)
 Extents of gluteal region
• Superiorly: Iliac crest
• Medially: Natal cleft

• Inferiorly: Gluteal fold

• Laterally: Curved line joining

anterior superior iliac spine,
greater trochanter and lateral
end of gluteal fold.

• Anteriorly: A curved line

between anterior superior iliac
spine and greater trochanter.
 Palpable Landmarks
• Iliac crest
• Anterior superior iliac spine
• Greater trochanter
• Dorsal sacrum and coccyx
• Posterior superior iliac spine. This
is at the level of: 2nd sacral spine.
• The middle of sacroiliac joint
marked by a skin dimple.
ILIAC CREST
GLUTEAL FOLD
NATAL CLEFT
 Bones of the Gluteal region:

• The gluteal region comprises dorsal surfaces

of three bones
– Hip bone
– Sacrum
– Proximal femur
 Siding the Pelvicbone

1. •  Acetabulum faces antero-laterally

•  Obturator foramen is antero-inferior
•  Pubis faces Anteriorly
•  Ischial tuberosity is postero-inferior
•  Iliac crest faces supero-lateral

2. In the anatomical position, the anterior superior

iliac spine is in the same plane as the pubic
symphysis.
Anterior Superior Iliac Spine Lumbar vertebral bodies

Ilio Sacral Joint

Sacrum

Pubic tubercle

acetabulum

Coccyx
Ischial tuberosity Ischial tuberosity
 Siding the femur:

• The head of the femur faces supero-medial.

• The greater trochanter faces laterally.
• The anterior surface is convex while the posterior is
concave.
• Femoral condyles are inferior.
 tip of
Head of the Femur Pit of the head ofthe femur Greater
trochanter
tip of
Trochanteric Fossa
Greater
trochanter
Neck of femur
Trochanteric crest

Intertrochanteric line

Lesser trochanter

Lesser trochanter
Gluteal tuberosity

Spiral line

Shaft of the femur

Shaft of the femur
 Cutaneous Nerves
• Subcostal
• Iliohypogastric
• Branch of lateral cutaneous
nerve of the thigh.L2,L3
• Posterior cutaneous nerve
of the thigh. S1-S3
• Dorsal rami of L1-3; S1-3.
Cutaneous Nerves
 POSTERIOR FEMORAL CUTANEOUS NERVE
Arises from the sciatic nerve and passes with the sciatic nerve to emerge in the thigh.
It gives numerous cluneal branches at the inferior edge of the gluteus maximus muscle.
 Gluteal Fascia
• Encloses gluteus
maximus and tensor
fascia lata.
• Covers gluteus medius.
• Bound to skin below
gluteus maximus to
produce the gluteal fold.
• Continuous with fascia
lata.
 Gluteal muscles
THREE LARGE GLUTEUS MUSCLES SIX SHORT ROTATORS AND HIP
EXTENSORS
• Gluteus maximus inserted • Piriformis
onto the Iliotibial tract • superior gamellus
• Gluteus medius • Inferior gamellus
• Gluteus minimus • Obturator externus
• *Tensor fascia latae • Obturator internus
• Quadratus femoris
 Three large gluteal muscles:

Muscle ORIGIN INSERTION INNERVATION MAIN ACTION

Gluteus Ilium posterior ¾ fibers insert into Inferior gluteal nerve (L5, Extends thigh (especially
maximus to posterior Iliotibial tract that inserts S1, S2) from flexed position) and
gluteal line; into lateral condyle of assists in its lateral
Dorsal surface of tibia; rotation; steadies thigh
sacrum and ¼ fibers insert into gluteal and assists in rising from
coccyx; tuberosity sitting position
Sacrotuberous
ligament
Gluteus External surface Lateral surface of greater Superior gluteal nerve (L5, Abduct and medially
medius of ilium between trochanter of femur S1) rotate thigh; keep pelvis
anterior and level when ipsilateral limb
posterior gluteal is weight bearing and
lines advance opposite
Gluteus External surface Anterior surface of greater Superior gluteal nerve (L5, (unsupported) side during
minimus of ilium between trochanter of femur S1) its swing phase
anterior and Gluteus medius tilts pelvis
inferior gluteal when walking to enable
lines opposite leg to clear
ground
*Tensor of Anterior superior Iliotibial tract, which Superior gluteal nerve (L5,
fascia lata iliac spine; attaches to lateral condyle S1)
anterior part of of tibia
iliac crest
 SIX SMALL LATERAL ROTATORS:
PROXIMAL
MUSCLE ATTACHMENT DISTAL ATTACHMENT INNERVATIONA MAIN ACTION
Piriformis Anterior Superior border of Branches of anterior Laterally rotate
surface of greater trochanter of rami of S1, S2 extended thigh and
sacrum; femur abduct flexed thigh;
sacrotuberous steady femoral head in
ligament acetabulum
Obturator Pelvic surface Medial surface of Nerve to obturator
internus of obturator greater trochanter internus (L5, S1)
membrane (trochanteric fossa) of
and femurb
surrounding
bones
Superior and Superior: Medial surface of Superior gemellus:
inferior ischial spine greater trochanter same nerve supply as
gemelli Inferior: (trochanteric fossa) of obturator internus
ischial femurb Inferior gemellus: same
tuberosity nerve supply as
quadratus femoris
Quadratus Lateral border Quadrate tubercle on Nerve to quadratus Laterally rotates thigh;c
femoris of ischial intertrochanteric crest femoris (L5, S1) steadies femoral head
tuberosity of femur and area in acetabulum
inferior to it
 GLUTEUS MAXIMUS
MUSCLE

arises from the posterior iliac crest and from

the underlying sacrotuberous ligaments. It
extends downward and laterally to attach to
the iliotibial tract and the gluteal tuberosity of
the femur.
 GLUTEUS MEDIUS
MUSCLE
It arises from the iliac crest to
insert on the greater trochanter
of the femur.
 GLUTEUS MINIMUS
MUSCLE

It arises from the outer surface of the

ilium and inserts on the greater
trochanter of the femur.
Sacrotuberous ligaments
 HARMSTRING MUSCLES
• Composed of
– Semitendinosus
– Semimembranosus
– Long head of biceps femoris
• Functions
– Flexion of knee joint
– Extension of thigh at hip joint during walking
• Innervated by Tibia nerve
• Origin is from ischial tuberosity
 ISCHIAL TUBEROSITY
Origin of Biceps femoris, Semitendinosus and
Semimembranosus
SEMIMEMBRANOSUS
MUSCLE
SEMITENDINOSUS
MUSCLE
 LONG HEAD OF THE
BICEPS FEMORIS
MUSCLE

Arises from the ischial tuberosity from a

common tendon with the semitendinosus
muscle. It runs downward and laterally and its
joins with the SHORT HEAD OF THE BICEPS
FEMORIS MUSCLE.
 SHORT HEAD OF THE
BICEPS FEMORIS MUSCLE
Arises from the distal part of the lateral aspect
of the femur. It joins the LONG HEAD OF THE
BICEPS FEMORIS to insert on the lateral aspect
of the head of the fibula.
 Clinical notes on Harmstring muscles
HAMSTRING STRAIN / A PULLED HAMSTRING
• Tear in one of the hamstrings muscles (semitendinosus,
semimembranosus and biceps femoris) that run down the
back of the thigh.
• Occurs when too much stress has been applied to the
muscle(s) resulting in small tears or a rupture.
• A pulled hamstring feels like a sharp, sudden pain on the
back of the upper leg.
• A strain happens most often during running, sprinting or
jumping activities when the muscle is called upon to stretch
beyond its normal limit.
PIRIFORMIS MUSCLE
 OBTURATOR
INTERNUS MUSCLE

Arises in the interior of the pelvis from

the obturator memebrane.
Its fibers form a tendon which emerges
from the lesser sciatic notch to insert on
the greater trochanter of the femur
SUPERIOR AND INFERIOR
GEMELLI MUSCLES

Arise from the rim of the lesser sciatic notch

above and below the obturator internus to
insert in conjuction with the tendon of the
obturator internus muscle.
QUADRATUS FEMORIS
MUSCLE

Lies below the inferior gamellus.

It originates from the ischial tuberosity to
insert on the intertrochanteric ridge of
the femur.
Role of gluteus medius and minimus in bipedal
striding?

Lateral balance control

• Supportive mechanism in which the Gluteus medius and
minimus of supporting limb abduct the pelvis tilting and
holding it so that the pelvis on the swinging side is
prevented from sagging to the unsupported side.
• Its integrity depends on three main features:
– The two muscles must be functioning normally.
– Head of femur must be located normally in acetabulum.
– The length and neck shaft angle  of the femur must be normal
– Neck of femur must be intact.
Applied Anatomy of lateral balance control mechanism

TRENDELENBURG'S GAIT
• When any of the features of lateral balance control fails, the
supporting is upset.
• The pelvis falls on the unsupported side when the individual
stands on the affected limb. This is called Trendelenbug sign.
The person walks with a characteristic lurching or waddling gait.
• Causes of such a condition include:
– Paralysis of the gluteus minimus and medius
– Dislocation of the hip joint
– Fractures of the neck of the femur
– Collapse of the head of the femur e.g. from avascular necrosis, slipped
epiphysis, tuberculosis of head of femur
– Severe arthritis of the hip joint
A
Negative trendelenburg's test
Hip abductors are acting
normally tilting the pelvis
upwards when the opposite
leg is raised from the ground
B
Positive trendelenburg's test
Hip abductors are unable to
control the dropping of the
pelvis when the opposite leg
is raised
 SACROSPINOUS
LIGAMENT

Runs from the sacrum and coccyx to

attach to the ischial spine.
It separates the greater and lesser sciatic
notches forming the greater and lesser
sciatic foramen.
 GREATER SCIATIC
NOTCH
Superior communication between the
pelvic cavity and the gluteal region.
LESSER SCIATIC NOTCH
Inferior is the communication between
the pelvic cavity and the gluteal region.
It is separated from the greater sciatic
notch by the ischial spine and the
sacrospinous ligament
NERVE TO THE OBTURATOR
INTERNUS
Crosses the sacrospinous ligament most
laterally to innervate the obtruator internus
muscle.
 PUDENDAL NERVE
Most medial of the structures crossing into
the lesser sciatic foramen.
The INTERNAL PUDENDAL VESSELS lie
adjacent to the nerve and follows a similar
course.
After crossing into the lesser sciatic
foramen the pudendal neurovascular
bundle pass into the genital region.
 SUPERIOR GLUTEAL
NERVE AND ARTERY

Emerge from the greater sciatic foramen

to pass between the gluteus minimus and
medius muscles.
 INFERIOR
GLUTEAL NERVES
AND ARTERIES

They emerge from the greater sciatic

foramen
 Nerves Of The Gluteal Region
Inferior gluteal nerve:  
• Root Value L1 - L2
• Distribution:
• Gluteus Medius
• Gluteus Minimus
• Tensor fascia lata
• How would bipedal striding
be impaired in case of
injury to the superior
gluteal nerve?
Hint: Trendlenberg's gait
 Course and relations:
•  Identify the points labelled 1
to 6 which form relations to
the sciatic nerve (pointed )
• Deep anterior to gluteus
maximus
• Lies on (posterior to the
following from above
downwards):
– Ischium
– Obturator internus and gamelli
– Quardratus femoris
 SCIATIC NERVE
Emerges from the pelvis below the
piriformis muscle .
Travels downward in the posterior thigh on
the surface of the adductor magnus muscle
It is crossed posteriorly by the long head of
the biceps femoris muscle.
 TIBIAL NERVE
The more medial and larger terminal branch of
the sciatic nerve,
Descends to the posterior leg in the midline
 COMMON PERONEAL
NERVE

lateral and smaller terminal branch of the

sciatic nerve,
Follows the medial border of the biceps
femoris muscle.
 Sciatic Nerve In The Gluteal Region:
Origin:
• •  Root value L4,5, S1,2,3
• •  Two nerves: Tibial and Common
peroneal.
• The sciatic nerve normally comes out
infrapiriformic with the tibial and
common peroneal components together.
• It separates in the popliteal region or
may divide high up the common
peroneal component passing through
the piriformis or over the piriformis.
• What is the root value of the tibial
component of the sciatic nerve?
• Look up piriformis syndrome and state its
manifestation.
Distribution:
Supplies NO muscles in the gluteal region.
Supplies hip joint through articular branches.
 

Landmarks:
Midway between ischial tuberosity and greater trochanter
 

Blood supply:
The sciatic nerve derives its blood supply from:
Inferior gluteal artery via the companion artery of sciatic nerve
Longitudinal anastomosis at the back of the thigh
 Posterior Cutaneous Nerve Of the thigh:
Origin: S 1-3
• Infrapiriformic under cover of
gluteus maximus.
• Runs with inferior gluteal
artery posterior or medial to
sciatic nerve.
Distribution:
• All cutaneous to:
• Gluteal region
• Perineum including scrotum or
labia majora
• Back of the thigh
 Arteries Of Gluteal Region
• Origin:
• The gluteal arteries
arise from the internal
iliac artery. They are the
superior and the
inferior gluteal arteries.
• Name the other
branches of the internal
iliac artery (6 Mks)
• Course:
• The superior and
inferior gluteal arteries
exit through the
suprapiriformic and
infrapiriformic
compartments of
greater sciatic foramina
respectively.
 Superior Gluteal:
Distribution:
• The superior Gluteal artery gives branches to
all the three large Gluteal muscles.
Anastomosis of Superior Gluteal artery:
• At the anterior superior iliac spine, it
anastomoses with:
• Deep circumflex iliac artery
• Ascending branch of lateral circumflex artery
• Both of these arise from the femoral artery
(from ext. iliac artery)
Trochanteric anastomosis:
• In the trochanteric fossa, the supeior gluteal
artery anastomoses with branches of:
• Inferior gluteal artery
• Ascending branches of the medial and lateral
circumflex femoral arteries
 Inferior Gluteal:
• It supplies the following structures:
• Gluteus maximus
• Hip joint
• Soft tissues behind the coccyx
• Sciatic nerve
Cruciate Anastomosis at lesser trochanter:

1. Inferior gluteal artery

2. Transverse branch of lateral circumflex femoral artery
3. Transverse branch of medial circumflex artery
4. Ascending branch of 1st perforating artery from
profunda femoris
• Note that through these three anastomoses, the
internal iliac and external iliac arteries communicate.
• In this way, there is provision for collateral circulation
should any of the arteries be occluded or ligated.
 Sciatic Foramina
• Greater and lesser sciatic
notches are converted
into foramina by
sacrotuberous and
sacrospinous ligaments.
• Identify the greater and
lesser sciatic foramina and
ischial spine on the pelvis
shown. Name two
muscles that attach onto
the ischial spine.
• The greater sciatic
foramen is divided into
two compartments by
the Piriformis muscle
namely the
Infrapiriformic and
Suprapiriformic
compartments below
and above the muscle
respectivel
• Note that the pudendal nerve and internal
pudendal vessels exit the pelvis through greater
sciatic foramen and enter the perineum through the
lesser sciatic foramen.
Infrapiriformic Suprapiriformic
4 nerves, 2 vessels: • 1 nerve, 1 vessel:
• Superior gluteal nerve
• Sciatic nerve
• Superior gluteal vessels
• Post. Cutaneous nerve
Lesser sciatic foramen
of the thigh • Pudendal nerve (*)
• Inferior gluteal nerve • Internal pudendal vessels (*)
• Pudendal nerve • Nerve to obturator internus
• Internal pudendal • Tendon of obturator
vessels internus
 Applied anatomy of sciatic nerve
• Can be compressed at lower border
of gluteus maximus by sitting on a
bench with a sharp edge.
• May be injured in posterior
dislocation of the hip joint.
• May be injured by misplaced deep
intravascular injections. To prevent
this, the injection is usually given in
the superolateral quadrant.
– The index finger is placed on the ASIS,
and the fingers are spread posteriorly
along the iliac crest until the tubercle of
the crest is felt by the middle finger An
intragluteal injection can be made safely
in the triangular area between the
fingers (just anterior to the proximal
joint of the middle finger)
 GLUTEAL REGION IS COMPLICATIONS OF
FAVOURED INJECTION IMPROPER INJECTION
SITE BECAUSE TECHNIQUE
1. Muscles thick and 1. Nerve injury
large 2. Hematoma
2. Substancial volume 3. Abscess
provided for fat
absorption of injected
substances
SCIATIC HERNIA
Pelvic structures may protrude through the greater sciatic foramen. This is called sciatic hernia.
It compresses thecontents of the foramina and may present with pain, numbness and weakness
in the lower limb if sciatic nerve is compressed.  
TROCHANTERIC BURSITIS
The extensive bursa between the great trochanter and the gluteal aponeurosis may be a site of
infection. Patient complains of pain and swelling in the trachanteric region. Sometimes there
may be a pus discharge.
SNAPPING HIP
In this condition, a snap is heard and felt on certain hip movements. The snap is attributed to
slipping of a tendinous aponeurosis- probably that of the gluteus maximus – over the greater
trochanter. It is harmless and treatment is not required.
SLIPPED DISC  
Pain of a prolapsed or strained lumbar intervertebral disc if often referred to the gluteal region
or lateral aspect of the thigh.
WEAVER'S BOTTOM
Inflammation of the bursa over the ischial tuberosity
 Piriformis syndrome
• When the sciatic nerve
divides in the pelvis, the
common peroneal nerve
may exit either:
– below Piriformis
– pierce piriformis
– pass above piriformis
• When it pierces piriformis, it
may be compressed by
contractions of this muscle.
This causes piriformis
syndrome
 Angle of inclination:

• The neck is about 5cm

long and makes an
angle of 125 ° with the
shaft in males and in
females (about 110° ).
• This is called the angle
of inclination. It is
widest at birth 135°and
diminishes with age till
adolescence.
Clinical anatomy of angle of inclination
COXA VARA COXA VALGA
• When angle of • When angle of
inclination is decreased inclination is increased
 Angle of anteversion

• The neck is also tilted

slightly forward at an
angle of 10-15° . This is
the angle of
anteversion.
• The proximal border of
the greater trochanter
is level with the centre
of the femoral head.
 Bryant's triangle:

• With the patient lying supine:

• Drop a perpendicular from
the anterior superior iliac
spine to the horizontal
• Project a second line upwards
from the tip of the greater
trochanter to meet the first
line at 90°
• Join the anterior superior iliac
spine to the tip of the greater
trochanter.
 Nelaton's line:

• This is a line between the

anterior superior iliac
spine and the ischial
tuberosity, with the
patient in the supine
position. The tip of the
greater trochanter lies on
or below this line. If it lies
above the line, the femur
has been displaced
upwards.
 Shoemaker's line:

• A line projected on each side

of the body from the greater
trochanter beyond the
anterior superior iliac spine.
The two lines normally meet
in the midline at or above
the umbilicus. If one femur is
displaced upwards, the lines
meet away from the midline.
If both are displaced
upwards the lines meet
below the umbilicus.
 Review Questions
1. Describe the attachments,innervation and functions of gluteus
medius and minimus, indicating their role in bipedal striding
and disorders thereof

2. State the root value, course and distribution of the main nerves
in the gluteal region. Add brief notes on possible sites and
effects of their injuries

3. Briefly describe the anastomoses in the gluteal region

indicating their significance