2. The human lower limb is built for support and propulsion. The two hip bones
articulate with one another in front at the pubic symphysis, and each is firmly
fixed to the lateral part of the sacrum by the relatively immobile sacroiliac
joint.
While STANDING: The pelvis transmits the body weight through the
acetabulum of the hip bone to the lower limb and likewise transmits the
propulsive thrust of the lower limb to the hip bone
While SITTING: The body weight is transmitted to the ischial tuberosities and
the legs are free to rest.
3. The lower limbs (extremities) are extensions
from the trunk specialized to support body
weight, for locomotion (the ability to move from
one place to another), and to maintain balance.
The lower limbs has these major regions:
1. Gluteal region (buttocks) is the transitional
region between the trunk and free lower limbs. It is
posterolateral region between the iliac crest and
the gluteal fold, that defines the lower limit of
buttocks
4. 2. Femoral region (thigh) is the region of the free
lower limb that lies between the gluteal,
abdominal, and perineal regions proximally and
the knee region distally.
3. Leg region (L. regio cruris) is the part that lies
between the knee and the narrow, distal part of
the leg. It includes most of the tibia and fibula
4. Foot region (L. regio pedis) is the distal part of
the lower limb containing the tarsus, metatarsus,
and phalanges. The toes are the digits of the
foot
6. The gluteal region lies posterolateral to the bony pelvis and proximal end of
the femur.
It is bounded superiorly by the iliac crest and inferiorly by the fold of the
buttock.
The region is largely made up of the gluteal muscles and a thick layer of
superficial fascia.
7. SKIN:
The gluteal region is covered with hairy skin.
FASCIA:
The superficial fascia is thick, especially in women. It is impregnated
with large quantities of fat that contribute to the prominence of the
buttock.
The deep fascia is continuous below with the deep fascia, or fascia
latae, of the thigh. In the gluteal region, it splits to enclose the
gluteus maximus muscle
Above the gluteus maximus, it continues as a single layer that covers
the outer surface of the gluteus medius and attaches to the iliac crest.
8. CUTANEOUS INNERVATION OF GLUTEAL REGION:
Upper medial quadrant: supplied by the posterior
rami of the upper three lumbar nerves and the
upper three sacral nerves
Upper lateral quadrant: supplied by the lateral
branches of the anterior rami of the
iliohypogastric (L1) and 12th thoracic nerves
Lower lateral quadrant: supplied by branches
from the lateral cutaneous nerve of the thigh (L2
and L3, anterior rami)
Lower medial quadrant: supplied by branches
from the posterior cutaneous nerve of the thigh
(S1, S2, and S3, anterior rami)
9. BLOOD SUPPLY OF SKIN AND FAT:
Derived from branches of the superior and inferior
gluteal arteries
LYMPHATIC DRAINAGE:
Into the lateral group of the superficial inguinal lymph
nodes
10. LIGAMENTS AND FORAMINA:
The sacrotuberous and sacrospinous
ligaments are two prominent structures in the
gluteal region.
Sacrotuberous ligament connects the back of
the sacrum to the ischial tuberosity
Sacrospinous ligament connects the back of
the sacrum to the spine of the ischium.
The arrangement of these ligaments forms
the greater and lesser sciatic foramina
11. Greater Sciatic Foramen:
The greater sciatic foramen is formed by the greater
sciatic notch of the hip bone and the Sacro tuberous and
sacrospinous ligaments. It provides an exit from the pelvis
into the gluteal region.
Bound by:
1. Greater sciatic notch
2. Lateral margin of sacrum
3. Upper parts of Sacro tuberous and sacrospinous
ligaments
12. Contents:
1. Piriformis muscle; which divides the greater sciatic foramen into
two parts.
2. Superior gluteal nerves and vessels (above piriformis)
3. Sciatic nerve,
4. Inferior gluteal nerve and vessels,
5. Pudendal nerve and internal pudendal vessels,
6. Posterior cutaneous nerve of the thigh,
7. Nerve to the obturator internus and gemellus superior
8. Nerve to the quadratus femoris and gemellus inferior
All structures apart from the superior gluteal nerves and
vessels pass below the piriformis
4
1. piriformis
3.
2.
5.
6.
7.
13. Lesser Sciatic Foramen:
The lesser sciatic foramen is formed by the lesser sciatic notch
of the hip bone and the sacrotuberous and sacrospinous
ligaments.
It provides an entrance into the perineum from the gluteal
region. Its presence enables nerves and blood vessels that have
left the pelvis through the greater sciatic foramen above the
pelvic floor to enter the perineum below the pelvic floor.
Contents:
1. Tendon of obturator internus muscle
2. Nerve to obturator internus
3. Pudendal nerve
4. Internal pudendal artery and vein
1. Obturator
internus
2.
3.
4.
16. Organized into two layers:
The superficial layer of muscles of the gluteal region consists of the three
large overlapping glutei (maximus, medius, and minimus) and the tensor
fasciae latae. These muscles all have proximal attachments to the
posterolateral (external) surface and margins of the ala of the ilium, and are
mainly extensors, abductors, and medial rotators of the thigh.
The deep layer of muscles of the gluteal region consists of smaller muscles
(piriformis, obturator internus, superior and inferior gemelli, and quadratus
femoris) covered by the inferior half of the gluteus maximus
17. SUPERFICIAL LAYER:
1. GLUTEUS MAXIMUS:
It is the most superficial gluteal muscle. It is the
largest, heaviest, and most coarsely fibered muscle
of the body.
Origin: Ilium posterior to posterior gluteal line; dorsal
surface of sacrum and coccyx; sacrotuberous ligament
Insertion: Most fibers end in iliotibial tract, which
inserts into lateral condyle of tibia; some fibers insert
on gluteal tuberosity
The fibers of gluteus maximus slope inferolaterally
at a 45° angle from the pelvis to the buttocks
18. Action:
Extension and lateral rotation of the thigh
Although a strong extensor, it acts mostly when force is necessary (rapid
movement or movement against resistance)
It functions primarily between the flexed and standing (straight) positions of
the thigh, as when rising from the sitting position, straightening from the
bending position, walking uphill and up stairs, and running.
It is used only briefly during casual walking and usually not at all when
standing motionless
19. Because the iliotibial tract crosses the knee and attaches to the anterolateral
tubercle of the tibia, the gluteus maximus and tensor fasciae latae together
are also able to assist in making the extended knee stable.
It also assists the lateral rotators of thigh.
Nerve supply:
Inferior gluteal nerve.
20. Gluteal Bursae.
Gluteal bursae separate the gluteus maximus from adjacent
structures.
1. Trochanteric bursa separates superior fibers of the gluteus
maximus from the greater trochanter. It is the largest and is present
at birth.
2. Ischial bursa separates the inferior part of the gluteus maximus
from the ischial tuberosity; it is often absent.
3. Gluteofemoral bursa separates the iliotibial tract from the
superior part of the proximal attachment of the vastus lateralis.
21. 2. GLUTEUS MEDIUS:
Origin:
External surface of ilium between anterior and posterior gluteal
lines
Insertion:
Lateral surface of greater trochanter of femur
Action:
Abduct and medially rotate thigh;
keep pelvis level when ipsilateral limb is weight-bearing and advance
opposite (un supported) side during its swing phase
Nerve supply:
Superior gluteal nerve
22. 3. GLUTEUS MINIMUS:
Origin:
External surface of ilium between anterior and inferior gluteal
lines
Insertion:
Anterior surface of greater trochanter of femur
Action:
Abduct and medially rotate thigh;
keep pelvis level when ipsilateral limb is weight-bearing and
advance opposite (un supported) side during its swing phase
Nerve supply:
Superior gluteal nerve
23. The two muscles together are constantly called
into play as the foot on one side is raised during
walking and running, when the muscles on the
opposite (supporting) side contract to prevent
the pelvis from sagging on the unsupported side
If they are paralyzed the gait is markedly
affected, the trunk swaying from side to side
towards the weightbearing limb to prevent
downward tilting of the pelvis on the
unsupported side.
24.
25. 4. TENSOR FASCIAE LATAE:
Origin:
Anterior superior iliac spine; anterior part of iliac crest
Insertion:
Iliotibial tract, which attaches to lateral condyle of tibia
Action:
Assits gluteus maximus
Nerve supply:
Superior gluteal nerve
26. DEEP LAYER
1. PIRIFORMIS: muscle of pelvic wall and gluteal region
Origin:
Anterior surface of sacrum; sacrotuberous ligament
Insertion:
Superior border of greater trochanter of femur
The piriformis leaves the pelvis through the greater sciatic
foramen, almost filling it, to reach its attachment to the
superior border of the greater trochanter
Action:
Laterally rotate extended thigh and abduct flexed thigh
Nerve supply:
Branches of anterior rami of S1, S2
27. Muscle Origin Insertion Nerve
supply
Action
2. Obturator internus Pelvic surface
of obturator
membrane and
surrounding
bones
Medial surface
of greater
trochanter
(trochanteric
fossa)
of femur
Nerve to
obturator
internus (L5,
S1)
Laterally rotate
extended thigh
and abduct
flexed thigh;
steady femoral
head in
acetabulum
3. Superior and
inferior gemelli
Superior: ischial
spine
Inferior: ischial
tuberosity
Medial surface
of greater
trochanter
(trochanteric
fossa)
of femur
Superior
gemellus:
same nerve
supply
as obturator
internus
Inferior
gemellus:
same nerve
supply
as quadratus
femoris
28. These muscles form a triciptal muscle which
occupies the gap between the piriformis and the
quadratus femoris. The common tendon of these
muscles lies horizontally in the buttocks as it
passes to the greater trochanter of the femur.
The obturator internus is located partly in the
pelvis, where it covers most of the lateral wall of
the lesser pelvis. It leaves the pelvis through the
lesser sciatic foramen, makes a right-angle turn
becomes tendinous, and receives the distal
attachments of the gemelli before attaching to the
trochanteric fossa of the femur.
29.
30. 4. QUADRATUS FEMORIS:
Origin:
Lateral border of ischial tuberosity
Insertion:
Quadrate tubercle on intertrochanteric crest of
femur and area inferior to it
Action:
Laterally rotates thigh; steadies femoral head in
acetabulum
Nerve supply:
Nerve to quadratus femoris (L5, S1)
32. Gluteus Maximus and Intramuscular
Injections
The gluteus maximus is a large, thick muscle
with coarse fasciculi that can be easily separated
without damage. The great thickness of this muscle
makes it ideal for intramuscular injections. The
injection should be given well forward on the upper
outer quadrant of the buttock to avoid injury to the
underlying sciatic nerve.
IM injections can also be given safely into the
anterolateral part of the thigh, where the needle
enters the tensor fasciae latae as it extends
distally from the iliac crest and ASIS.
33. Gluteus Maximus and Bursitis
Bursitis, or inflammation of a bursa, can be caused by acute or chronic
trauma. An inflamed bursa becomes distended with excessive amounts of fluid
and can be extremely painful. The bursae associated with the gluteus
maximus are prone to inflammation.
Ischial bursitis is a friction bursitis resulting from excessive friction between
the ischial bursae and the ischial tuberosities. Localized pain occurs over the
bursa, and the pain increases with movement of the gluteus maximus.
Calcification may occur in the bursa with chronic bursitis.
34. Injury to Superior Gluteal Nerve
Injury to this nerve results in a characteristic motor loss,
resulting in a disabling gluteus medius limp, to compensate
for weakened abduction of the thigh by the gluteus medius
and minimus, and/or a gluteal gait, a compensatory list of
the body to the weakened gluteal side.
Abduction and Medial rotation of thigh are also impaired
35. Normally: When a standing person is asked to lift
one foot off the ground and stand on one foot, the
gluteus medius and minimus normally contract as
soon as the contralateral foot leaves the floor,
preventing tipping of the pelvis to the unsupported
side
When a person who has suffered a lesion of the
superior gluteal nerve is asked to stand on one leg,
the pelvis on the unsupported side descends,
indicating that the gluteus medius and minimus on
the supported side are weak or non-functional.
