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The gluteal region forms the posterior part of the pelvis and upper thigh.
It lies between the iliac crest above and the gluteal fold below.
The region is divided into two symmetrical parts — buttocks — separated by the natal cleft.
Functionally, it relates to the hip joint, pelvic stability, and thigh movement during locomotion.
The main muscle bulk is gluteus maximus, covered by thick, fatty skin and fascia.
It provides a passage for major nerves and vessels between the pelvis and lower limb through the greater and lesser sciatic foramina
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.Rounded bulge in the lower part of the gluteal region.
Separated in the midline by the natal cleft (begins at the third sacral spine).
The gluteal fold marks the lower limit, but does not correspond to the lower border of gluteus maximus.
Large bony prominence deep to gluteus maximus, about 5 cm from the midline and 5 cm above the gluteal fold.
Palpated by pressing fingers upward in the medial part of the gluteal fold.
Large bony prominence on the lateral aspect of the hip, a hand’s breadth below the iliac crest.
Palpable landmark useful for intramuscular injection guidance.
Thick, curved ridge forming the upper boundary of the gluteal region.
Extends from ASIS to PSIS.
Highest point corresponds to the L3–L4 vertebral level, important for lumbar puncture.
The ASIS to greater trochanter line marks the junction between the gluteal region and the front of the thigh.
The PSIS lies 5 cm from the midline at the level of the second sacral spine, opposite the sacroiliac joint.
Sacral spines palpable in the midline; coccyx forms the floor of natal cleft and is slightly mobile under pressure
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.Lies deep to the lower border of gluteus maximus; felt by firm pressure between lower sacrum and ischial tuberosity
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.Heavily laden with fat, especially in females.
Tough and stringy over the ischial tuberosity, forming a cushion for sitting.
Contains cutaneous nerves, vessels, and lymphatics
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.The skin of the gluteal region receives innervation from nerves approaching from all directions:
Upper anterior part:
Lateral cutaneous branches of subcostal (T12) and iliohypogastric (L1) nerves.
Upper posterior part:
Posterior primary rami of L1–L3 and S1–S3 spinal nerves.
Lower anterior part:
Branches from the posterior division of the lateral cutaneous nerve of thigh (L2, L3).
Lower posterior part:
Branches from the posterior cutaneous nerve of thigh (S1–S3) and perforating cutaneous nerve (S2–S3)
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.Arterial supply: From superior and inferior gluteal arteries.
Venous drainage: Through veins accompanying the above arteries.
Lymphatic drainage: To the lateral group of superficial inguinal lymph nodes
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.Above and anterior to gluteus maximus (over gluteus medius) → thick, dense, and pearly white.
Over gluteus maximus → thin and transparent.
The fascia splits to enclose the gluteus maximus and continues inferiorly as the fascia lata of the thigh.
Laterally, it thickens to form the iliotibial tract (IT band), which stabilizes the knee joint during standing and walking
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.Incisions:
From the spine of the second sacral vertebra along the iliac crest to its tubercle.
Vertical incision from S2 spine down to the natal cleft.
Curve laterally and inferiorly to the middle of the back of the thigh.
Reflect the thick skin and fascia laterally.
Cutaneous nerves and vessels are difficult to find; best studied in the text.
After removing deep fascia, define the attachments of gluteus maximus
The gluteal region contains ten major muscles arranged in layers.
Origin: Outer slope of dorsal iliac crest, posterior gluteal line, dorsal sacrum and coccyx, sacrotuberous ligament, and fascia covering gluteus medius.
Insertion: Upper three-fourths into the iliotibial tract, lower one-fourth into the gluteal tuberosity of femur.
Nerve supply: Inferior gluteal nerve (L5, S1, S2).
Action: Chief extensor of the hip; assists in lateral rotation, abduction (upper fibers), and stabilization of knee via IT tract.
Origin: Gluteal surface of ilium between anterior and posterior gluteal lines.
Insertion: Lateral surface of greater trochanter.
Nerve: Superior gluteal nerve (L4, L5, S1).
Action: Abduction and medial rotation of thigh; maintains pelvic stability during walking.
Origin: Gluteal surface of ilium between anterior and inferior gluteal lines.
Insertion: Anterior surface of greater trochanter.
Nerve: Superior gluteal nerve.
Action: Same as gluteus medius — abducts and medially rotates thigh.
Origin: Outer lip of iliac crest (anterior 5 cm).
Insertion: Iliotibial tract.
Nerve: Superior gluteal nerve.
Action: Abductor and medial rotator of thigh; helps extend the knee via IT tract.
Origin: Pelvic surface of sacrum (S2–S4), upper margin of greater sciatic notch.
Insertion: Apex of greater trochanter.
Nerve: Ventral rami of S1, S2.
Action: Lateral rotation and abduction of thigh; acts as the key muscle of gluteal region dividing structures above and below it.
Superior: From ischial spine. Nerve to obturator internus (L5–S2).
Inferior: From ischial tuberosity. Nerve to quadratus femoris (L4–S1).
Action: Lateral rotators of thigh; assist obturator internus.
Origin: Inner surface of obturator membrane.
Insertion: Medial surface of greater trochanter.
Nerve: Nerve to obturator internus (L5–S2).
Action: Lateral rotator of thigh.
Origin: Ischial tuberosity.
Insertion: Quadrate tubercle on intertrochanteric crest.
Nerve: Nerve to quadratus femoris (L4–S1).
Action: Lateral rotation and adduction of thigh.
Origin: Outer surface of obturator membrane.
Insertion: Trochanteric fossa of femur.
Nerve: Posterior division of obturator nerve (L2–L4).
Action: Lateral rotation of thigh.
Gluteus medius and minimus
Piriformis
Obturator internus with superior and inferior gemelli
Quadratus femoris
Upper hamstring origins from ischial tuberosity
Adductor magnus (upper fibers)
Superior and inferior gluteal vessels
Internal pudendal vessels
Ascending branch of medial circumflex femoral artery
First perforating branch of profunda femoris
Trochanteric and cruciate anastomoses
Superior and inferior gluteal nerves
Sciatic nerve (L4–S3)
Posterior cutaneous nerve of thigh
Pudendal nerve (S2–S4)
Nerve to obturator internus
Nerve to quadratus femoris
Perforating cutaneous nerves
Sacrotuberous and sacrospinous ligaments
Trochanteric bursa, ischial bursa, and bursa between gluteus maximus and vastus lateralis
Superior gluteal nerve
Deep branch of superior gluteal artery
Gluteus minimus muscle
Trochanteric bursa of gluteus medius
Reflected head of rectus femoris
Capsule of hip joint
Reflect gluteus maximus by cutting from origin to insertion along the posterior cutaneous nerve of thigh.
Identify piriformis — the key muscle.
Above piriformis: Superior gluteal nerve and vessels.
Below piriformis: Inferior gluteal nerve and vessels, sciatic nerve, posterior cutaneous nerve of thigh, and pudendal vessels.
Note the ischial tuberosity and hamstring origins beneath the lower gluteus maximus.
Trendelenburg Sign: Paralysis of gluteus medius and minimus (superior gluteal nerve injury) causes pelvis to drop on the opposite side when standing on one leg.
Sciatic Nerve Injury: Wrongly placed intramuscular injection in the lower medial quadrant may injure the sciatic nerve → paralysis of hamstrings and all muscles below the knee.
Piriformis Syndrome: Compression of sciatic nerve by tight piriformis → pain radiating down posterior thigh.
Trochanteric Bursitis: Inflammation due to friction between gluteus maximus and greater trochanter.
Ischial Bursitis: “Weaver’s bottom” — inflammation due to prolonged sitting.
Safe Injection Site: Upper lateral quadrant of gluteal region — gluteus medius area — avoids major vessels and nerves.
A strong, long ligament forming part of the boundary of the pelvic outlet.
Attachments:
Above: Posterior superior and inferior iliac spines, lower transverse tubercles of sacrum, lateral sacral margin, and upper coccyx.
Below: Medial margin of ischial tuberosity.
The part extending along the ramus of ischium is the falciform process.
Gives partial origin to gluteus maximus.
Pierced by perforating cutaneous nerve, S5 and coccygeal nerves, and branches of the coccygeal plexus.
Thin, triangular ligament lying deep to sacrotuberous ligament.
Attachments:
Base: Lateral margins of last piece of sacrum and coccyx.
Apex: Ischial spine.
Separates greater and lesser sciatic foramina.
Gives origin to the coccygeus muscle.
Morphologically, a degenerated part of the coccygeus.
Both ligaments bind the sacrum to the ischium and prevent upward tilting of the sacral lower end under body weight
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.Branch of lumbosacral plexus.
Enters the region via the greater sciatic foramen, above piriformis.
Runs between gluteus medius and minimus.
Supplies:
Gluteus medius
Gluteus minimus
Tensor fasciae latae
Action: Abduction and medial rotation of thigh; stabilizes pelvis during walking
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.Branch of sacral plexus.
Passes through greater sciatic foramen below piriformis.
Supplies: Only gluteus maximus, its sole motor target.
Functionally, it acts as the chief extensor nerve of the hip, vital in standing up, climbing stairs, and rising from a sitting position
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.Largest nerve in the body; main continuation of the sacral plexus.
Enters gluteal region through greater sciatic foramen below piriformis.
Runs downward between greater trochanter and ischial tuberosity, then under gluteus maximus to enter the posterior thigh.
No branches in gluteal region.
Later divides into tibial and common peroneal nerves.
Clinically important for nerve blocks and intramuscular injection safety
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.Trendelenburg Sign:
Paralysis of gluteus medius/minimus (superior gluteal nerve injury) causes pelvic drop on the opposite side during single-leg stance.
Sciatic Nerve Block:
Local anaesthetic injected 1.5 cm below midpoint of a line joining PSIS and upper border of greater trochanter to produce anesthesia of the posterior thigh and leg
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.Inferior Gluteal Nerve Lesion:
Leads to weakness of hip extension — difficulty rising from chair or climbing stairs.
Piriformis Syndrome:
Compression of sciatic nerve by piriformis → radiating pain down the posterior thigh (“sciatica”).
Safe Injection Zone:
Always in the upper lateral quadrant of gluteal region to avoid injury to sciatic and inferior gluteal nerves.
Root value: S1–S3.
Origin: From the sacral plexus.
Course:
Leaves the pelvis through the greater sciatic foramen below piriformis.
Lies deep to gluteus maximus and superficial to sciatic nerve.
Descends under the fascia lata in the posterior thigh up to the popliteal fossa.
Branches:
Inferior cluneal nerves — to lower part of buttock.
Perineal branches — to skin of perineum.
Cutaneous branches — to back of thigh and upper leg.
Function: Provides cutaneous sensation to posterior thigh and popliteal region.
Root value: L4, L5, S1.
Course:
Arises from anterior surface of sacral plexus.
Leaves pelvis through greater sciatic foramen below piriformis.
Lies anterior to sciatic nerve and obturator internus.
Branches:
To quadratus femoris and inferior gemellus.
Articular branch to hip joint
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.Root value: S2–S4.
Origin: From sacral plexus in pelvis.
Course:
Leaves pelvis via greater sciatic foramen below piriformis.
Crosses the sacrospinous ligament near the ischial spine.
Re-enters pelvis through lesser sciatic foramen to reach pudendal canal in the lateral wall of the ischioanal fossa.
Branches:
Inferior rectal nerve → to external anal sphincter and skin around anus.
Perineal nerve → to urogenital muscles and posterior scrotal/labial skin.
Dorsal nerve of penis/clitoris → terminal sensory branch.
Function: Chief motor and sensory nerve of the perineum and external genitalia
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.Clinical importance: Used for pudendal nerve block near ischial spine during obstetric procedures to anesthetize perineum
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.Root value: L5, S1, S2.
Course:
Arises from sacral plexus.
Passes through greater sciatic foramen below piriformis, lateral to pudendal nerve.
Crosses ischial spine and re-enters through lesser sciatic foramen.
Branches:
To obturator internus.
To superior gemellus
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.Root value: S2–S3.
Origin: From the posterior surface of the sacral plexus.
Course:
Pierces the sacrotuberous ligament near its medial margin.
Passes below gluteus maximus to reach the skin over the lower medial part of the buttock.
Function: Supplies skin over inferomedial buttock; small, purely sensory branch.
The gluteal region is mainly supplied by three arteries — superior gluteal, inferior gluteal, and internal pudendal arteries, all branches of the internal iliac artery.
These vessels pass from the pelvis to the gluteal region through the greater sciatic foramen, accompanied by corresponding nerves.
Origin: Largest branch of the posterior division of the internal iliac artery.
Course:
Passes out of the pelvis through the greater sciatic foramen above the piriformis.
Divides into superficial and deep branches.
Branches and Distribution:
Superficial branch — supplies gluteus maximus and overlying skin.
Deep branch — divides into superior and inferior divisions between gluteus medius and minimus.
Superior division: To gluteus medius and minimus.
Inferior division: To tensor fasciae latae and contributes to trochanteric anastomosis.
Anastomoses: Joins inferior gluteal, lateral circumflex femoral, and first perforating arteries around hip joint.
Origin: Terminal branch of anterior division of internal iliac artery.
Course:
Leaves pelvis through greater sciatic foramen below piriformis.
Lies between piriformis and superior gemellus, emerging with inferior gluteal nerve.
Descends on posterior surface of sciatic nerve.
Distribution:
Supplies gluteus maximus, quadratus femoris, hamstring muscles, and sciatic nerve.
Anastomoses:
Contributes to cruciate anastomosis and trochanteric anastomosis.
Joins branches of internal pudendal, superior gluteal, and first perforating artery.
Origin: Smaller terminal branch of anterior division of internal iliac artery.
Course:
Leaves pelvis through greater sciatic foramen below piriformis with pudendal nerve.
Curves around ischial spine under gluteus maximus, then enters lesser sciatic foramen to reach the pudendal canal.
Distribution:
Supplies perineum, external genital organs, and anal region.
Gives inferior rectal, perineal, and artery of penis/clitoris branches.
Provides main arterial supply to head and neck of femur.
Formed by:
Descending branch of superior gluteal artery.
Ascending branch of medial circumflex femoral artery.
Ascending branch of lateral circumflex femoral artery.
Inferior gluteal artery (sometimes).
Clinical Note: Retinacular arteries from this anastomosis pierce capsule → supply femoral head; damaged in neck-of-femur fractures → avascular necrosis.
Lies at the level of the lesser trochanter, in the posterior upper thigh.
Provides collateral circulation between internal and external iliac systems.
Formed by:
Inferior gluteal artery (from internal iliac).
Transverse branch of medial circumflex femoral artery.
Transverse branch of lateral circumflex femoral artery.
First perforating artery of profunda femoris.
Function: Permits blood flow to the lower limb even if the femoral artery is occluded proximal to profunda femoris.
Superior gluteal nerve and vessels.
Inferior gluteal nerve and vessels.
Sciatic nerve.
Posterior cutaneous nerve of thigh.
Nerve to quadratus femoris.
Pudendal nerve.
Internal pudendal vessels.
Nerve to obturator internus.
“SISPPIN” →
Superior gluteal (above piriformis), then below piriformis: Inferior gluteal, Sciatic, Posterior cutaneous, Pudendal, Internal pudendal vessels, Nerves to obturator internus & quadratus femoris.
Tendon of obturator internus.
Nerve to obturator internus.
Internal pudendal vessels.
Pudendal nerve.
Functional Note:
The lesser sciatic foramen acts as the gateway to the perineum.
The pudendal nerve and internal pudendal vessels leave the gluteal region through this opening to enter the pudendal canal.
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