The gluteus maximus has a bipartite distal insertion: the upper and superficial fibres insert into the iliotibial band via the lateral intermuscular septum (approximately 75% of the muscle), while the lower and deep fibres insert into the gluteal tuberosity of the femur (approximately 25%). The IT band insertion provides a lever arm for hip extension and aids knee stability through the IT band-TFL system, while the femoral insertion acts more directly on the hip.
The bipartite gluteus maximus insertion is relevant in high-energy pelvic trauma where the gluteal tuberosity may avulse with direct hip extension force. In hip arthroplasty via the posterior approach, the short external rotator tendons (piriformis, conjoint tendon of obturator internus and gemelli) are detached from the greater trochanter — the gluteus maximus insertion is preserved. The gluteal tuberosity insertion contributes to the femoral attachment relevant in lateral thigh flap planning. Fatty atrophy and tear of the gluteus maximus at its trochanteric insertion is seen on MRI in patients with chronic hip pain and posterior impingement.
Forced hip hyperflexion with hip extension load — such as in a stumbling fall forward — can avulse the deep gluteus maximus fibres from the gluteal tuberosity, producing posterior hip pain and ecchymosis; MRI confirms the partial or complete avulsion and large displaced fragments may benefit from surgical reattachment.
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