Structural re-evaluation of the human gluteus maximus muscle

doi:10.21203/rs.3.rs-4773342/v1

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Structural re-evaluation of the human gluteus maximus muscle

https://doi.org/10.21203/rs.3.rs-4773342/v1

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The gluteus maximus (GM) is a powerful hip joint extensor acting strongly on the femur. However, most anatomical studies report that the larger superior portion of the GM inserts into the iliotibial tract rather than the femur, creating an apparent discrepancy between its structure and function. To address this, we re-evaluated the GM structure in 25 formalin-fixed Japanese cadavers. We found that the superior three-fourths of the GM formed a strong plate-like tendon inserted into the gluteal tuberosity of the femur, with partial adhesions to the iliotibial tract. The remaining inferior portion terminates at a complex involving the lateral femoral intermuscular septum, strong plate-like tendon of the superior portion, and proximal tendon of the vastus lateralis. These findings resolve the functional anatomy discrepancy of the GM: the larger superior portion primarily inserts into the femur, contributing hip joint movement, while the smaller inferior portion supports this function. Kinesiological data on the GM should be reinterpreted based on this precise anatomy. This will significantly improve our understanding of human GM function.

gluteus maximus

functional anatomy

macroscopic anatomy

kinesiology

hip joint

iliotibial tract

The gluteus maximus (GM) is the largest muscle in the superficial gluteal region in humans. Its major function is widely regarded as hip joint extension, with an additional function in stabilizing the knee joint during extension, as noted in anatomy^1–3 and kinesiology^4,5 textbooks. This strong hip extensor muscle has attracted substantial interest from researchers in kinesiology and comparative anatomy, particularly regarding human bipedalism. Kinesiological analyses using electromyography, 3D motion analysis systems, and biomechanical musculoskeletal models have established the GM as a major contributor to hip joint movement^6–8. Comparative anatomy studies, including anthropological and primate research, have demonstrated that a well-developed GM is crucial for upright posture and bipedalism, with hip joint extension, in humans^9–13.

Many anatomical descriptions, from classical to modern textbooks and studies, state that the major superior or superficial portion of the GM is inserted into the iliotibial tract, a thickened lateral part of the fascia lata stretched between the iliac crest and the lateral condyle of the tibia, stabilizing the knee joint, while the minor inferior or deep portion is inserted into the gluteal tuberosity, which transitioned into the lateral lip of the linea aspera of the femur, extending the hip joint^1–3. However, following these descriptions, the smaller volume portion of the GM serves its primary function (hip joint extension), whereas the larger portion serves an additional function (knee joint stabilization). The reasons for this apparent discrepancy are unclear.

Recently, a kinesiological study using electromyography and ultrasound imaging demonstrated that GM’s mechanical influence on the iliotibial tract is negligible in humans¹⁴, indicating its primary function is limited to hip joint movement. This new kinesiological knowledge suggests that a structural re-evaluation of the GM could clarify this discrepancy.

In our study, we re-evaluated the GM structure using the classical method of dissection in situ and isolated muscle specimens. Our recent studies using isolated muscle specimens on various skeletal muscles, including the hamstrings^15,16, vastus intermedius¹⁷, soleus¹⁸, facial muscles¹⁹, and upper-extremity muscles²⁰, have provided new insights. This approach allows for comprehensive observation of individual muscles from all aspects, overcoming the limitations of in situ dissection.

In our structural re-evaluation, we delineated two distinct portions of the human GM based on structural differences in the distal region:

1) The superior portion is inserted into the gluteal tuberosity of the femur via a strong tendon.

2) The inferior portion terminates at the complex formed by the lateral femoral intermuscular septum (LFIS), distal tendon of the superior portion, and proximal origin of the vastus lateralis.

No remarkable structural differences were observed in GM’s origin, insertion, muscle-tendon structure, and proximal and distal regions based on individual or sex. The following sections describe our findings in detail.

Observations of superficial and deep aspects of the GM

After removing the gluteal fascia, the muscle fascicles on the superficial surface of the GM ran inferolaterally and then appeared to be merged and inserted into the iliotibial tract (Fig. 1a). The iliotibial tract, located in the superficial lateral thigh region as a thickened part of the fascia lata, stretched between the iliac crest and the lateral condyle of the tibia. This was fixed to the lateral lip of the linea aspera, lateral supracondylar line, and lateral epicondyle of the femur by the LFIS. Upon detaching the GM origin from the bony pelvis and reflecting the proximal half of the GM to observe its deep surface, the muscle fascicles visible on the deep surface appeared to attach to the gluteal tuberosity via a distal (insertion) tendon (pink region in Fig. 1b) and directly to the LFIS (black arrowheads in Fig. 1b, 1b', and 1c).

Divisions of the GM

The GM is divided into superior and inferior portions based on structural differences in the distal regions. The superior GM fascicles formed a plate-like distal tendon that runs deep and appears to partially unite with the deep aspect of the iliotibial tract (Figs. 1a and 1b). These structures can generally be separated without transversely cutting the tendinous fibers. The inferior fascicles, lacking a distal tendon, attached muscularly to the LFIS and a small superficial part of the iliotibial tract, not the femur (black arrowheads in Fig. 1b). In situ specimens, in which all muscles were removed from the gluteal, posterior, and medial thigh regions except for the GM, showed that the inferior fascicles had no attachment to the femur (black arrowheads in Figs. 1b' and 1c).

Anatomy of the superior portion

Approximately superior three-quarters of the GM fascicles originated from the posterior end of the iliac crest, thoracolumbar fascia, sacrum, posterior sacroiliac ligament, and upper part of the sacrotuberous ligament (areas indicated by black dotted lines in Figs. 1b and 1b'). The uppermost deep region fascicles originated via a proximal tendon (black asterisks in Figs. 1b', 2b, 2b', 2d, 3b, and 3b'), while the rest originated muscularly.

After removing the inferior fascicles attached to the LFIS and iliotibial tract, the distal tendon of the GM was inserted into the femur was clearly visible (Fig. 2). The superior portion of the GM fascicles transitioned into tendinous fibers forming a thick, plate-like distal tendon, which descended posterior to the greater trochanter with a mild curve, contacted the trochanteric bursa, twisted, and was inserted into the gluteal tuberosity (Fig. 2). The entire morphology of the distal tendon was confirmed on the deep surface of the isolated specimens without deformation (pink areas in Fig. 3, black dotted lines, and pink areas in Fig. 4). Additionally, the distal tendon united with the upper part of the LFIS and the proximal tendon of the vastus lateralis, forming a complex (Figs. 3b', 3b'', and 4) that served as the attachment site for inferior fascicles (described below).

At the superficial surface, each fascicle appeared to be attached to the iliotibial tract, as mentioned above. However, by carefully tracing the tendinous fibers of the individual fascicles, most of these fibers joined the thick plate-like tendon, which was approximately 95% of the superior portion (Supplementary Fig. S1). The remaining small tendinous fibers adhered to the iliotibial tract. A small number of tendinous fibers derived from the uppermost superficial region of the GM adhered to the iliotibial tract, forming a thin sheet-like tendon included in the LFIS (yellow asterisks in Fig. 2) and also joined the deep aspect of the iliotibial tract as a thick, long band-like tendon (light blue asterisks in Fig. 2). The band-like tendon, approximately 15 mm in width and 0.5 mm in thickness, extended to the lateral epicondyle of the femur and tibia.

Anatomy of the inferior portion

The remaining inferior one-fourth of the GM originated from the lower end of the sacrum, coccyx, and lower part of the sacrotuberous ligament (black dotted lines in Figs. 1b, 1b', 2a', 2c, 3b, and 3b'). These fascicles did not transition into tendinous fibers, and attached directly to the medial surface of the complex formed by the thick plate-like tendon, LFIS, proximal tendon of the vastus lateralis, and extremely small superficial part of the iliotibial tract (light-green dotted lines in Figs. 3a'' and 3b'' and light-green areas in Figs. 4b, 4b', 4c, and 4c'). Some small tendinous arches for blood vessels were observed at the distal attachment site.

Quantitative data of the superior and inferior portions

The physiological cross-sectional areas (PCSAs) and muscle fiber lengths of the superior and inferior portions of the GM were evaluated in nine isolated GM specimens. The mean PCSAs were calculated to be as follows: 191.96 ± 43.27 mm² in the superior portion, 56.54 ± 8.60 mm² in the inferior portion, and 248.50 ± 46.63 mm² in the whole. The relative mean PCSAs were 76.77 ± 4.27% in the superior portion and 23.23 ± 4.27% in the inferior portions. The mean muscle fiber lengths were 99.1 ± 7.79 mm in the superior portion and 142.08 ± 5.55 mm in the inferior portion. There was a statistically significant difference in the relative mean PCSA and mean muscle fiber length between the two groups (Fig. 5).

In this study, we re-evaluated the anatomical structure of the human GM, updating information on its insertion. The large superior portion of the GM was mostly inserted into the gluteal tuberosity via the thick plate-like tendon, and the small inferior portion was inserted into the complex including the thick plate-like tendon, LFIS, and proximal tendon of the vastus lateralis. The GM superior portion can generate a large muscle force because of its significantly larger PCSA. Conversely, the inferior portion has a significantly smaller PCSA, although it had good muscle contractility, as evidenced by its significantly longer muscle fiber length, implying that more sarcomeres are arranged per muscle fiber.

Historically, American, British, and German literature have distinguished the GM into superior (large) and inferior portions based on structural differences in the distal region, whether the fascicles were inserted into the iliotibial tract (or the fascia lata) or the femur, since the 19th century^{1–3,21−39} (Table 1). From around 1900, there was a tendency to distinguish GM compartments as superficial (inserting into the iliotibial tract) and deep (inserting into the femur). Current anatomical descriptions incorporate these criteria for distinguishing GM portions. However, inconsistency exists: the deep fibers of the inferior portion are typically described as attaching to the femur, this contrasts with both some existing descriptions and our findings. In French literature, Testut (1896) described the GM insertion similarly to our findings, noting the inferior fascicles attach mostly to the fascia lata, with the remaining fascicles terminating on the gluteal tuberosity of the femur whereas it was not shown in any Fig. 4⁰. Poirier and Charpy (1901) illustrated the actual structure of the distal GM tendon with accurate drawings unique to previous reports, although this tendon was recognized as terminating at the fascia lata⁴¹. In recent French anatomy texts, such as Rouvière and Delmas (2002), descriptions not found in anatomy texts in English- or German-speaking countries have been eliminated⁴². The reason for this misunderstanding regarding the insertion of the human GM is unclear, although partial adherence of the superior portion to the iliotibial tract is a major contributing factor. Additionally, from all the descriptions and figures in each previous report, it is understandable that GM distal end is not pursued adequately in in situ observation, which may create long-standing misconceptions regarding GM insertion and division. The present structural re-evaluation based on in situ and isolated muscle specimen analyses enabled us to structurally characterize the distal region of the human GM and to establish the division of the GM into large superior and small inferior portions.

From a developmental anatomy perspective, Tický and Grim (1985) reported that the human GM comprised two fused fetal muscles: the fetal GM proper (superior) and the fetal coccygeofemoralis (inferior), which are constantly observed in human embryos and fetuses⁴³. Shiraishi et al. (2018) also found that the GM divides into superior and inferior portions in the early fetal period, with the inferior portion developing approximately 1 week later than the superior portion, and the two portions unite to form an adult form⁴⁴. If the superior and inferior portions of the fetal GM correspond to those of the adult GM, the division of the adult GM (and its structural differences) is presumably attributable to the developmental pattern in which the GM arises from two different muscle primordia.

Regarding functional anatomy, the GM is known for extending the hip joint and contributing to other hip joint motions, such as hip abduction and external rotation^6–8. Previous anatomical and kinesiological literature have described that the GM contributes to the movement and stabilization of the knee joint via the iliotibial tract^1–3,5,45. However, our findings suggest that any GM contribution to knee joint movement is minimal. A recent kinesiological study using electromyography and ultrasound tomography also showed that GM contraction does not contribute to the movement/deviation of the iliotibial tract¹⁴, supporting our present findings.

We found that the superior portion, with a large PCSA, was inserted into the femur with a strong tendon. The inferior portion was speculated to indirectly assist the superior portion by tensing the distal tendon of the superior portion. Additionally, the small accessory fibers of the superior portion that united the iliotibial tract are presumably unworkable for tibial movement because the iliotibial tract is fixed to the shaft of the femur by the LFIS, as previously described by several authors^38,46,47. Our findings indicate that GM contributes to hip joint movement. This aligns with kinetic studies by Preece et al. (2008) who found an unclear link between GM activity and tibial rotation during gait⁴⁸, and Besomi et al. (2022) who reported no correlation between GM activity and iliotibial tract displacement¹⁴. These findings support anatomical observations and functional suggestions in terms of kinesiology. Conversely, biomechanical studies of lower limb movement using muscle modeling, which are presented based on previous GM descriptions, reported that GM greatly contributes to the movements of both the hip and knee joints as a powerful extensor^49,50. Based on our precise anatomical data, kinesiological data on the GM should be re-interpreted. This will significantly improve our understanding of human GM function.

To clarify the GM structure in cadaveric dissections, we examined 25 sides (five right sides and 20 left sides) of 25 formalin-fixed adult Japanese cadavers (14 males and 11 females). We excluded cadavers with significant pathological alterations in muscle fibers (such as fatty degeneration, intramuscular hematoma, and severe muscle atrophy), traumatic lesions, or operative incisions. All examined cadavers were donated to the Juntendo University School of Medicine for medical education and research, and written informed consent was obtained from the individuals and their families. The study protocol was approved by the Ethics Committee of Juntendo University School of Medicine (Approval No. 2014138).

Dissection procedures

The structural re-evaluation of the GM was performed using macroscopic dissection and analysis of in situ specimens. The gluteal fascia was completely removed to observe muscle fascicles on the superficial surface of the GM. To observe the muscle fascicles on the deep surface, the proximal part of the GM was detached from the bony pelvis and reflected in its proximal half. In the in situ specimens, all muscles in the gluteal, posterior, and medial thigh regions, except the GM, were removed to confirm where the muscle fascicles and tendinous fibers of the GM were attached.

Additionally, the structures of the proximal and distal ends were re-evaluated by analyzing isolated GM specimens. The GM was completely isolated from half of the pelvis and thigh as follows: First, the proximal origin of GM was detached from the bony pelvis. The distal end of the GM was then detached from the femur and completely isolated from the thigh, along with surrounding structures such as parts of the iliotibial tract and LFIS, which are associated with the GM distal end (see the Results section). The nerves and blood vessels of the GM were severed to isolate the GM completely. All findings were recorded using photographs.

To estimate the contribution ratio of the portions of the GM to the total strength of the GM, we calculated the physiological cross-sectional area (PCSA) using the muscle fiber length, muscle weight, and angle of muscle fiber pennation (cos θ) in the muscle compartments of the nine isolated GM specimens following kinesiology texts^51,52. All muscular fibers of the GM were arranged in a straight line to the tendon and had no muscle fiber pennation angle (cos θ = 1). The length of the muscle fibers was measured using a tape measure between the most proximal and distal muscle fiber ends at ten locations (in the superior portion) or five locations (in the inferior portion) on each superficial and deep aspect of the isolated GM specimens, and the average was calculated. Furthermore, the relative PCSA of each GM portion was calculated by considering the total PCSA as 100%. All values are presented as mean ± standard deviation (SD). Differences were tested using Student’s t-tests. Statistical significance was set at P < 0.05.

Acknowledgments

The authors thank Mr. Naoaki Kimura, Mr. Hironori Matsuda, Ms. Makoto Sugiura, and Mr. Takafumi Ono for technical support. The authors also greatly appreciate the individuals who donated their bodies for medical education and research at the Juntendo University School of Medicine.

Author contributions

HA: concept/design, data acquisition, data analysis/interpretation, manuscript drafting, critical manuscript revision, and article approval KK and HK: concept/design, data acquisition, data analysis/interpretation, and article approval. TS and KI: concept/design, data analysis/interpretation, critical revision of the manuscript, and supervision and article approval.

Competing interest

The authors declare no potential conflict of interest.

ORCID

Hidaka Anetai: https://orcid.org/0000-0003-4170-5595

Koichiro Ichimura: https://orcid.org/0000-0001-6590-7912

Data availability

Upon reasonable request, data supporting the findings of the present study are available from the corresponding authors.

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Table 1 is available in the Supplementary Files section.

The authors declare no competing interests.

FigureS.tif
Supplementary information Figure S1. Muscle fascicles of the superior and inferior portions The numerous thick muscle fascicles of the GM are shown by removing the fascia and isolating the fascicles individually. (a) and (b) show the superior and inferior portions from their deep aspects, respectively. Light magenta area indicate the plate-like tendon of the GM, which reaches the attachment site to the gluteal tuberosity of the femur shown by the slightly darker magenta area. GA, gluteal aponeurosis; GM, gluteus maximus; ITT, iliotibial tract; LFIS, lateral femoral intermuscular septum; STL, sacrotuberous ligament.
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Structural re-evaluation of the human gluteus maximus muscle

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Abstract

Figures

Introduction

Results

Observations of superficial and deep aspects of the GM

Divisions of the GM

Anatomy of the superior portion

Anatomy of the inferior portion

Quantitative data of the superior and inferior portions

Discussion

Methods

Dissection procedures

Declarations

References

Tables

Additional Declarations

Supplementary Files

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