Class of 2009 Co-op Writer: Marisa Chapman

Clinical Human Anatomy

November 28, 2005 (112805)
Hour A/B; 1pm-2pm
Gluteal Region; Dr. Mark Niedfeldt

The Gluteal Region

Note: Dr. Niedfeldt’s lecture followed the outline in the class notes, as well as previous years’ co-op
notes nearly verbatim.

I. Bony Anatomy (N340-342); use as landmarks

A. Iliac Crest:
The iliac crest is at the level of L4-L5 vertebrae; used as a landmark during epidural
B. Anterior superior iliac spine: This is where your hands are when they are “on your
hips.”
C. Posterior superior iliac spine: These are the dimples on either side of the sacrum. A
clinical landmark for the sacroiliac joint.
D. Ischial tuberosity: You’re sitting on them; hamstrings attach here.
E. Greater trochanter (of the femur): The bony aspect on the side of either hip. Several
muscles attach here (listed below). The overlying bursa can be injured, resulting in
trochanteric bursitis. Refer to N469.
Note: The sciatic nerve is located between the ischial tuberosity and greater trochanter.

II. Muscles
Refer to body building magazines (or Netter)
A. Main Functions in the gluteal region:
• leg extension
• abduction
• lateral rotation (turning foot outwards)
B. Leg Extension (N477, 484)
1. Gluteus Maximus
a. Action: primary hip extensor, lateral rotation of the thigh, raising the trunk from a
seated or flexed position. The little old man with a flat butt has an atrophied
gluteus maximus due to decreased activity, and will have problems getting out of
his chair and walking up steps. Tell your elderly patients that if they want to
maintain their independence, they need to maintain their gluteus maximus.
b. Gluteus maximus is a fast twitch muscle = only flexed in movement. It does
not fire when standing; during normal walking you don’t use the gluteus maximus
very much.
c. One of the largest muscles in the body; forms a thick pad over ischial tuberosity
for sitting comfort
d. Origin: broadly from the iliac crest, sacrum, coccyx, and sacrotuberous ligament
e. Insertion: 2/3 of gluteus maximus inserts on the iliotibial tract (fascia) and the rest
on the gluteal tuberosity of the femur. For more intense activities such as
running, the iliotibial band will tighten up and recruit the gluteus maximus.
f. Innervation: inferior gluteal nerve (S1), below piriformis.
g. Test by having person lie prone (face down), bend the knee to relax the hamstring
and isolate the gluteus maximus, and raise the thigh off the table.
h. Arterial Blood Supply: Inferior Gluteal Artery
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 2. Hamstring muscles (3 of them coming down the posterior aspect of the thigh)
a. Biceps femoris laterally- most lateral muscle
1) two heads- long and short
2) Origin: long head- ischial tuberosity; short head- linea aspera and lateral
supracondylar line of femur (note: I took this from the textbook for the sake of
completeness, but he did not specifically state this in lecture)
3) Insertion: lateral side of head of fibula (again, from textbook)
4) Innervation: long head- tibial division of sciatic nerve (S1); short head- fibular
(peroneal) division of the sciatic nerve (S1)
b. Semitendinosis and semimembranosis medially
1) Common origin: ischial tuberosity
2) Insertion: semitendinosis- medial tibia; semimembranosis- medial tibial
condyle
3) Innervation: tibial division of the sciatic nerve (L5)
c. Action of hamstring muscles: extensors of thigh and flexors of the leg
d. Test hamstrings by having the patient lie supine (face up) and provide resistance
as they attempt to flex their leg

C. Abduction (N484)
1. Gluteus medius
a. Thick, triangular muscle
b. When looking at someone from behind, this is the hollow dimple of the butt, as
opposed to the round area
c. Action: primary abductor; also flexor, medial rotator (anterior portion) & lateral
rotator and extensor (posterior portion), also responsible for tilting of the hip/pelvis
d. Origin: ilium tuberosity
e. Insertion: lateral surface of greater trochanter
f. Innervation: superior gluteal nerve (L5)
g. Stabilizes hip when walking and standing
h. Weakness can result in Trendelenburg gait (aka “sexy walk”), in which the hip
drops and swings out when weight is transferred to the leg (individual cannot
stabilize hip and must move their center of gravity to keep from falling). Could
result from an injury to the superior gluteal nerve, but also seen in long-distance
runners (weakness in gluteus medius from continual forward motion can stretch
the IT band, causing the trochanter bursa to flare up, thus creating hip & knee
pain, and resulting in a subtle, shifting movement, i.e., a less obvious
Trendelenburg gait). In the case of runners, treatment involves sideways walking
with resistance to strengthen the hips. Why don’t basketball players get this?
Because of strong gluteus medius muscles from continual sideways motion.
i. Test by having patient lie on side and provide resistance as they try to abduct the
leg

2. Gluteus minimus
a. Triangular muscle, deep to the gluteus medius
b. Action: secondary abductor & medial rotator of the thigh (more of a rotator than the
gluteus medius)
c. Origin: ilium
d. Insertion: anterior surface of greater trochanter
e. Innervation: superior gluteal nerve (L5)
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D. Lateral rotation
1. Piriformis
a. Action: lateral rotator; also abducts a flexed thigh (turning leg out while sitting)
b. Important landmark: In 85-86% of population, the sciatic nerve passes between
the piriformis and superior gemellus. In 10-12 % of people, the tibial part of the
sciatic nerve pierces the piriformis. In 0.5 % of people, the tibial part can actually
pass over the piriformis, in which case the sciatic splits the piriformis.
Note: A tight piriformis can put pressure on the sciatic nerve causing sciatica;
patients with the alternate sciatic nerve pathways are more prone to sciatica.
c. More landmarking: Nerves and vessels named according to relationship to
piriformis; those superior to (above) the piriformis are “superior” (e.g., superior
gluteal artery and nerve). Those below are “inferior” (e.g. inferior gluteal artery
and nerve).
d. Even more landmarking: Superior to the piriformis (estimated by tracing a line
between sacrum and the greater trochanter) is considered a “safe” area to give a
gluteal injection (you won’t hit the sciatic nerve)
e. Origin: anterior surface of sacrum & sacrotuberous ligament, through the greater
sciatic foramen
f. Insertion: superior border of greater trochanter
g. Innervation: ventral rami of S1, S2, (and S3)

2. Obturator internus
a. Action: laterally rotates an extended thigh; abducts a flexed thigh
b. Origin: pelvic surface of obturator membrane and surrounding bones
c. Exits pelvis via lesser sciatic foramen
d. Insertion: medial surface of greater trochanter
e. Innervation: nerve to obturator (L5, S1-S2)

3. Superior and inferior gemelli

a. Action: laterally rotates extended thigh and abducts a flexed thigh
b. Origin (superior): ischial spine
c. Origin (inferior): ischial tuberosity
d. Insertion (both): obturator internus tendon
e. Innervation (superior): nerve to obturator internus
f. Innervation (inferior): nerve to quadratus femoris
g. They surround and reinforce the obturator internus

4. Quadratus Femoris
a. Rectangular muscle
b. Action: Lateral rotation
c. Origin: lateral border of ischial tuberosity
d. Insertion: intertrochanteric crest of femur
e. Innervation: nerve to quadratus femoris

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 5. Big picture
From superior to inferior, the lateral rotators run in this order (w/ respective
innervation):
Piriformis- superior rami of S1, S2 (and S3)
Superior gemellus- nerve to obturator internus
Obturator internus- nerve to obturator internus
Inferior gemellus- nerve to quadratus femoris
Quadratus femoris- nerve to quadratus femoris

III. Nerves (N484)

A. Superficial gluteal nerves
1. Provides cutaneous innervation from several lumbral & sacral segments
2. Cluneal nerves (N468 & 509) – cutaneous to gluteal region
a. Superior cluneal nerves
1) Lateral branches from dorsal rami of 1st three lumbar nerves (i.e., L1-L3)
2) Supply upper 2/3 of buttocks
b. Middle cluneal nerves
1) Lateral branches from dorsal rami of 1st three sacral nerves (i.e., S1-S3)
2) Supply area over sacrum & surrounding buttock
c. Inferior cluneal nerves
1) Gluteal branches of posterior femoral cutaneous nerves
2) Pierces sacrotuberous ligament
3) Innervate lower 1/3 of buttocks

A. Deep gluteal nerves

Note: Dr. Niedfeldt said we should know these for both the lab and written exam.
1. Branches of the sacral plexus
2. Exit pelvis through greater sciatic foramen
3. All inferior to piriformis except superior gluteal nerve

4. Superior gluteal nerve

a. From posterior division of ventral rami of L4, L5, & S1
b. Superior to piriformis
c. Travels with superior gluteal artery
d. Supplies gluteus medius, gluteus minimus, and tensor fascia lata

5. Inferior gluteal nerve

a. From posterior division of ventral rami of L5, S1, & S2
b. Inferior to piriformis, superficial to sciatic nerve
c. Travels with inferior gluteal artery
d. Supplies gluteus maximus

6. Sciatic nerve
a. Main branch of sacral plexus; largest nerve in body
b. Ventral rami of L4, L5, S1-S3 converge at inferior border of piriformis
c. Most lateral structure entering gluteal region
d. Descends between the ischial tuberosity and greater trochanter
e. Does not actually supply anything in the gluteal region

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 f. Two portions make up the sciatic in a common sheath: the tibial (L4, L5, S1-S3)
and peroneal (common fibular) nerve (L4, L5, S1-S2).

7. Posterior (femoral) cutaneous nerve

a. Supplies more skin than any other cutaneous nerve, covering from the perineum
to the proximal leg
b. From ventral rami of S1 & S2 (posterior divisions) and anterior of S2 & S3
c. Exits pelvis with inferior gluteal nerve and sciatic nerve at the lower border of the
piriformis.
d. Descends between the gluteus maximus and posterior surface of the sciatic
nerve.

8. Nerve to quadratus femoris

a. From ventral rami (anterior divisions) of L4, L5, & S1
b. Exits pelvis deep to sciatic nerve & obturator internus
c. Innervates quadratus femoris and inferior gemellus
d. Articular branch to hip joint

9. Nerve to obturator internus

a. From ventral rami (anterior divisions) of L5, S1, & S2
b. Medial to sciatic nerve
c. Innervates superior gemellus, passes posterior to ischial spine, reenters through
lesser sciatic foramen to supply obturator internus

10. Pudendal nerve

a. From ventral rami (anterior divisions) of S2- S4
b. Most medial
c. Passes lateral to sacrospinous ligament, reenters pelvis through lesser sciatic
foramen to supply structures in the perineum.
d. Mainly a sensory nerve to perineal area; “pudendal block” often used in
association with childbirth
e. New bike seats have been developed (grooved and padded) to decrease
numbness and related impotency cases by transferring the pressure of sitting to
the ischial tuberosity instead of the pudendal nerve.

11. Sacral plexus – Dr. Niedfeldt didn’t mention this (as noted in previous co-op)
a. Tibial nerve and common fibular (peroneal) nerve combine to form sciatic nerve

IV. Arteries (N383)

A. All branches off the internal iliac artery

B. Superior gluteal artery

1. Largest branch of the iliac artery
2. Superior to piriformis; runs with superior gluteal nerve
3. Superficial branch to gluteus maximus and skin
4. Deep branches to gluteus medius, minimus, and tensor fascia lata – the main supply
5. Anastomosis with inferior gluteal artery and medial circumflex femoral artery

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 C. Inferior gluteal artery
1. Main branch is inferior to piriformis
2. Supplies gluteus maximus, obturator internus, quadratus femoris, and superior
hamstrings.
3. Anastomosis with superior gluteal artery, medial and lateral femoral circumflex
arteries and perforating arteries of profunda femoris

D. Internal pudendal artery

1. Lies anterior to inferior gluteal artery
2. Passes lateral to pudendal nerve and reenters pelvis with it through lesser sciatic
foramen
3. Supplies external genitalia and muscle in the pelvic region

V. Veins
A. Gluteal veins
1. Tributaries of internal iliac veins
2. Superior and inferior gluteal veins accompany the arteries
3. Communicate with tributaries of femoral vein

B. Internal pudendal veins

1. Accompany arteries
2. Form single vein which drains blood from the external genitalia and perineum

Dr. Niedfeldt concluded the lecture by reiterating the importance of the gluteal region for
functioning in everyday life, and advised that we memorize the muscles (along with the associated
nerves and vessels) as groups.