Pain Medicine, 22(5), 2021, 1072–1079

doi: 10.1093/pm/pnab057
Advance Access Publication Date: 10 February 2021
Original Research Article

NEUROMODULATION & MINIMALLY INVASIVE SURGERY SECTION

Innervation of the Posterior Hip Capsule: A Cadaveric Study

Ameet S. Nagpal , MD, MS, MEd,* Caroline Brennick, DO,* Annette P. Occhialini, MD,†
Jennifer Gabrielle Leet, MD,‡ Tyler Scott Clark, MD,‡ Omid B. Rahimi, PhD,†Kendall Hulk, DO,‡ Brittany

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Bickelhaupt, MD,§ and Maxim S. Eckmann , MD*

Departments of Anesthesiology, UT Health San Antonio Joe R. & Theresa Lozano Long School of Medicine, San Antonio, Texas; †Department of Cell
Systems & Anatomy, UT Health San Antonio Joe R. & Theresa Lozano Long School of Medicine, San Antonio, Texas; ‡Department of Rehabilitation
Medicine, UT Health San Antonio Joe R. & Theresa Lozano Long School of Medicine, San Antonio, Texas and §Bone & Joint, Wasau, Wisconsin, USA

Correspondence to: Ameet Nagpal, MD, MS, MEd, Department of Anesthesiology, UT Health San Antonio Joe R. & Theresa Lozano Long
School of Medicine, 5282 Medical Dr., Suite 180, San Antonio, TX 78229, USA. Tel: 210-450-9850; Fax: 210-450-6095; E-mail:
nagpala@uthscsa.edu.

Funding sources: None.

Conflicts of interest: Dr Eckmann reports conflicts of interest as an advisory board member for Avanos Medical and Abbott U.S.

Abstract
Objective. Recent studies of hip anatomy have turned to the posterior hip capsule to better understand the anatomic
location of the posterior capsular sensory branches and identify nerves with potential for neural blockade. Current
literature has shown the posterior hip capsule is primarily supplied by branches from the sciatic nerve, nerve to
quadratus femoris, and superior gluteal nerve (1, 2). This cadaveric study investigated the gross anatomy of the pos-
terior hip, while also identifying potential targets for hip analgesia, with emphasis on the superior gluteal nerve and
nerve to quadratus femoris. Design. Cadaveric study. Setting. UT Health San Antonio Anatomy Lab. Methods. In total,
10 total cadavers (18 hips total), were posteriorly dissected identifying nerve to quadratus femoris, superior gluteal
nerve, and sciatic nerve. Nerves were labeled with radio-opaque markers. Following the dissections, fluoroscopic
images were obtained at sequential angles to identify neural anatomy and help expand anatomic knowledge for in-
terventional pain procedures. Results. The posterior hip capsule was supplied by the sciatic nerve in 1/16 hips, the
nerve to quadratus femoris in 15/18 hips, and the superior gluteal nerve in 6/18 hips. Conclusions. The nerve to quad-
ratus femoris reliably innervates the posterior hip joint. Both the sciatic nerve and superior gluteal nerve have small
articular branches that may be involved in posterior hip innervation, but this is not seen commonly. The results of
this study may elucidate novel therapeutic targets for treatment of chronic refractory hip pain (i.e., the nerve to quad-
ratus femoris).

Key Words: Joint Innervation; Cadaver, Hip; Cadaveric Dissection; Radiofrequency; Peripheral Joint

Introduction of hip capsule innervation [1]. The posterior hip capsule

Currently, the anterior hip capsule has been an estab-
lished target of neural blockade due to dense anterior in-
nervation provided by the obturator and femoral nerves
(ON, FN) [1–4]. Therefore, interventional pain proce-
dures often target the ON and FN to relieve intracapsular
hip pain [1]. However, ON and FN blocks alone may
provide unsatisfactory analgesia for intracapsular hip
pain, which has led to the investigation of other sources
innervation has received comparatively less attention,
however literature supports innervation from branches of
the sciatic nerve (SN), superior gluteal nerve (SGN), infe-
rior gluteal nerve (IGN) and nerve to quadratus femoris
muscle (NQF) [1, 2, 4, 5]. The IGN’s contribution to the
posterior hip capsule is controversial [1, 5, 6].
The fibrous capsule of the femoroacetabular joint
attaches to the border of the acetabulum and the

C The Author(s) 2021. Published by Oxford University Press on behalf of the American Academy of Pain Medicine.
V
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Innervation of Posterior Hip: Cadaver Study
Figure 1. Fibrous capsule of the femoroacetabular joint in anterior and posterior views.
acetabular labrum superiorly. It then attaches to the fe-
mur at the intertrochanteric line anteriorly and wraps
around the posterior neck of the femur, superomedial to
the intertrochanteric crest [7, 8]. This fibrous capsule is
then reinforced or strengthened by three ligaments: the
iliofemoral and pubofemoral ligaments anteriorly and
the ischiofemoral ligament posteriorly (Figure 1). The
ischiofemoral ligament wraps around the neck of the fe-
mur and attaches to the anterior and superior part of the
intertrochanteric line. Therefore, it is understood that the
extent of the joint capsule is less extensive posteriorly.
The SN is the largest nerve in the human body,
comprising both the anterior and posterior divisions of
the lumbosacral plexus (ventral rami of L4—S3). The
SN supplies motor innervation to a significant portion
of musculature in the posterior thigh, leg, foot, and cu-
taneous innervation to the lateral leg and entire foot
[9]. In the most common anatomic variant, the SN
exits the greater sciatic foramen as a single structure
below the piriformis muscle, but has been noted to de-
viate from this course in nearly 15% of cases
(Figure 2) [9]. Articular branches from the SN were
less commonly found in anatomic studies, but when
present, supplied the posteromedial or posterosuperior
hip capsule [1, 2].
The SGN arises from the posterior divisions of the
lumbosacral plexus (ventral rami of L4—S1) and pro-
vides motor innervation to the gluteus medius, gluteus
minimus, and tensor fasciae latae (TFL) muscles.
1073
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Articular branches have been observed to supply the pos-
terolateral hip capsule in cadaveric studies [1, 5].
Birnbaum et al. examined eleven hips and found 36% of
the hips were innervated by articular branches of the
SGN [1].
The NQF arises from the lumbosacral plexus (ventral
rami of L4—S1) and provides motor innervation to the
quadratus femoris muscle and inferior gemellus, muscles
that assist in lateral rotation of the thigh. The NQF
branches directly from the SN in up to 25% of cases [1, 2].
Articular branches from the NQF supply the posterior hip
capsule more consistently than the SN or SGN [1, 2, 5].
Birnbaum et al. examined 11 hips and Wertheimer et al.
examined 53 hips, and both found 100% were innervated
by the NQF [1, 2]. Anatomic studies report varying
numbers of short articular branches extending from the
main nerve trunk, proximal to its termination in the quad-
ratus femoris muscle, coursing laterally along the surface
of the ischium to the posteromedial or posteroinferior hip
capsule [1, 2, 5].
The IGN arises from the lumbosacral plexus (ventral
rami of L5—S2) and provides motor innervation to the
gluteus maximus. The IGN’s contribution to the poste-
rior hip capsule is contentious and probably infrequent.
An anatomical study from 1857 by Rudinger found that
an articular branch of the IGN contributed, but this was
contraindicated in 1933 by Sadovsky [10]. Additional re-
search in 1935 by Geselevich confirmed IGN contributed
in one specimen [10]. Dee et al. examined five human
1074
Figure 2. Sciatic nerve exiting the greater sciatic foramen inferior to the piriformis muscle.
specimens and found that IGN did not contribute to the
posterior hip capsule innervation [5].
Current literature supports the posterior hip is inner-
vated by branches of the sciatic nerve, superior gluteal
nerve, and nerve to quadratus femoris muscle [1, 2, 5, 8].
The contribution of the inferior gluteal nerve to the pos-
terior hip is disputed [1, 5, 6]. This cadaveric study inves-
tigated the gross anatomy of the posterior hip to identify
potential targets for hip analgesia from an interventional
pain perspective. Detailed understanding of innervation
to the posterior hip is critical when considering novel in-
terventional pain procedures to achieve analgesia.
Methods
Ten embalmed cadavers, including 18 hips total, were
posteriorly dissected identifying NQF, SGN, IGN, and
SN. Nerves leading to the joint capsule were labeled with
radio-opaque markers. Following the dissections, fluoro-
scopic images were obtained at sequential angles to iden-
tify neural anatomy and propose an approach to be
considered to access these structures safely with a needle
or cannula.
Embalmed body donors were made available by the
UT Health San Antonio Body Donation Program, a
Nagpal et al.
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member institution of the State Anatomical Board of
State of Texas (SAB). Protocols and procedures used in
this study were according to the guidelines set forth by
the SAB and approved by the Program. Two hips were
excluded due to histories of extensive orthopedic
interventions.
Each cadaver was placed in the prone position. First,
the gluteus maximus was dissected. An incision was
made midway through the muscle belly and retracted.
The gluteus medius, piriformis, and TFL were identified
after dissection of the fascial components deep to the glu-
teus maximus. The IGN was identified as it innervated
the gluteus maximus and then followed proximally as it
emerged between the piriformis and gluteus medius. The
IGN was examined for any small articular branches div-
ing to the posterior hip capsule.
The layer of the gluteus medius was then examined
for any nervous or vascular structures. If nerves were
identified, then they were isolated and preserved. An inci-
sion to the midway point of the gluteus medius was made
to reveal branches of the SGN in the plane between the
gluteus medius and minimus. Eventually, the gluteus
medius was retracted entirely revealing the SGN, supe-
rior gluteal vasculature, and fascia. Further dissection of
the fascial tissue was performed to identify the SGN as it
Innervation of Posterior Hip: Cadaver Study 1075

innervated the gluteus medius and minimus. After the Table 1. Table demonstrates the presence or absence, indi-
identity of the SGN was verified by proximal to distal cated by yes (Y) or no (N) respectively, of innervation to the
posterior hip capsule by the nerve to quadratus femoris (NQF)
tracing and identification of its motor branches to the and superior gluteal nerve (SGN)
gluteus minimus, gluteus medius and TFL, the SGN was
further examined distally for branches that may contrib- Specimen NQF to hip (Y/N) SGN to hip (Y/N)
ute to the posterior hip innervation. 1 Y N
Attention was then directed to the SN as it exited the 2 Y Y
greater sciatic foramen. The SN was dissected distally 3 Y Y
4 Y N
past the ischial tuberosity. As the SN may emerge above,
5 Y Y
below, or around the piriformis, a transverse incision 6 Y Y
was made to the piriformis to improve visualization of 7 Y Y
the SN and eventually the NQF. As the piriformis was 8 N Y

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dissected, the area was inspected for the nerve to pirifor-
mis and any contribution to the posterior hip innerva-
tion. With the piriformis retracted, the SN was examined
distally for small branches that may contribute to the
posterior hip innervation.
Moving medially, the pudendal nerves were identified
exiting the greater sciatic foramen. The pudendal nerves
in this location were used as a landmark to help locate
the NQF. Lateral to the pudendal nerves at this location,
the SN was slowly retracted laterally to identify the
NQF. The NQF was followed proximal to distal, identi-
fying the superior gemellus, obturator internus, inferior
gemellus, and quadratus femoris muscles and their re-
spective motor branches. The NQF traveled deep and in-
ferior to the superior gemellus, obturator internus, and
inferior gemellus, therefore these muscles were carefully
retracted to preserve the NQF. The NQF was examined
distally for small branches that may contribute to poste-
rior hip capsular innervation.
After dissection and identification of the aforemen-
tioned nerves, the suspected branches to the capsule were
marked with radio-opaque makers and then imaged by
fluoroscopy. Fluoroscopy served two purposes: to con-
firm that the final destination was the posterior hip cap-
sule and to look for potential bony landmarks for
intervention. Each cadaver was imaged with progressive
degrees of laterality in anticipation of planning interven-
tional approaches.
Results
Of the 18 hips dissected, the SGN was found to innervate
6 hips (33%, 95% CI 0.1334–0.5901) (Table 1, Table
demonstrates the presence or absence, indicated by yes
(Y) or no (N) respectively, of innervation to the posterior
hip capsule by the NQF and SGN Figure 4). The SGN
branched between the plane of the gluteus minimus and
medius in two patterns: inferolaterally extending towards
the greater trochanter of the femur or extending towards
the lateral aspect of the gluteus minimus and then cours-
ing caudally. In one hip, the SGN traveled caudally from
the gluteus medius and minimus to the superior gemellus
and then dove between the superior gemellus and obtura-
tor internus to reach the posterior hip capsule.
9 Y N
10 Y N
11 N N
12 N N
13 Y N
14 Y N
15 Y N
16 Y N
17 Y N
18 Y N
The NQF was found to innervate 15 hips (83%, 95%
CI .5858–.9642, Table 1). The NQF branched off the
lumbosacral plexus rostral to the superior gemellus, then
coursed deep to the superior gemellus, obturator internus
and inferior gemellus, where it reached the quadratus fe-
moris (Figure 5). The branches providing innervation to
the hip, when present, originated distal to the inferior
gemellus muscle but proximal to the quadratus femoris
muscle (Figure 6).
The SN was found to innervate 1 hip (5.5%, 95% CI
.0014–.2729). An articular branch of the SN dove di-
rectly between the superior gemellus and obturator inter-
nus towards the posterior hip on gross examination.
Only one cadaver demonstrated the nerve to pirifor-
mis providing innervation to the posterior hip capsule
(5.5%, 95% CI .0014–.2729). IGN was not found to
provide innervation to the posterior hip capsule in any of
the cadavers, therefore it was excluded from Table 1.
To consider various interventional approaches, 8/18
dissected hip joints were placed prone under a fluoro-
scopic C-arm. The NQF and SGN were labeled with
radio-opaque markers (Figures 7 and 8]. The markers
were cut to a similar size and placed on top of the respec-
tive nerves to outline their course. Then, fluoroscopic
images were taken at sequential 10-degrees increments of
ipsilateral obliquity, ranging from 0 to 80, to explore an-
atomic landmarks for safe approaches to block the NQF.
The location of the SN superficial to the NQF posed a
barrier with less than 20 degrees of obliquity. At 20
degrees of ipsilateral obliquity or more (up to 80
degrees), the NQF is accessible without encountering the
SN (Figure 8). Other obstructions included the superior
and inferior gluteal arteries which considerably varied in
location. Considering the proximal branch of the SGN
1076
Figure 3. Nerve to quadratus femoris (NQF) provides contribution to the posterior hip capsule with small articular branches, note
the minimal distance between the articular branches traveling to the hip capsule and the branches supplying the muscle belly of
the quadratus femoris.
Figure 4. aSGN is an articular branch of SGN. SGN is seen
deep to the gluteus medius (reflected) and in relation to SN be-
low. GT is greater trochanter of the femur. The forceps are
retracting a bisected piriformis (PIRI). NVB is a single neurovas-
cular bundle of the SGN, but does not represent the entirety of
the SGN and related vascular structures.
lies between the gluteus medius and minimus, no consis-
tent bony landmarks were identified to consider a fluoro-
scopic approach.
Discussion
This cadaveric study surveyed the posterior hip anatomy
for innervation to the posterior hip capsule. The second-
ary goal of this study was to identify a potential denerva-
tion approach to be considered in an interventional pain
setting. Literature suggests the posterior hip is innervated
Nagpal et al.
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Figure 5. NQF coursing deep to the SN (reflected laterally by
forceps) and deep to the superior gemellus, obturator internus
and inferior gemellus muscles (each reflected), terminating in
the quadratus femoris muscle. QF is the quadratus femoris
muscle.
by branches of the sciatic nerve, superior gluteal nerve,
and nerve to quadratus femoris [3, 4, 6, 7].
In accordance with previous studies, this study found
the NQF supplied the posterior hip more consistently
than the SN or SGN, specifically innervating the poste-
rior hip 83% of the time [1–3]. A block of the articular
fibers of the NQF has not been studied as of the time of
this manuscript. Gardner et al. examined seven adult
humans and four fetus hips and illustrated multiple circu-
itous paths of the articular branches of the NQF [10].
Innervation of Posterior Hip: Cadaver Study 1077

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Figure 6. NQF with a small articular branch, labeled aNQF. The
aNQF branches posterolaterally to provide innervation to the
posterior hip.
Figure 7. PA fluoroscopic image at zero degrees of ipsilateral
obliquity of a right hip in the prone position. The cephalad ra-
Our study examined eighteen adult human hips and dio-opaque marker is overlying the articular branches of the
found the NQF gave small, short articular branches to SGN. The caudal radio-opaque marker is overlying the NQF.
the posterior hip innervation as seen in Figures 3 and 6. The location of the sciatic nerve is demonstrated by the trans-
lucent yellow structure.
In our study, the superior gemellus, obturator internus,
and inferior gemellus muscles were retracted to better vi-
sualize the NQF path. There were no branches found
from NQF until just proximal to its termination at the
muscle belly of the quadratus femoris.
It may be reasonable to approach the articular branch
of the NQF with 20 degrees of ipsilateral obliquity and
avoid the SN (Figure 8). Because this was true in all 8 hip
joints studied and because the innervation of the poste-
rior hip joint from the NQF was stereotypical in all 18
hip joints dissected, we believe that it is reasonable to
state that this would be true in all cases. This approach
should be considered with its limitations. The approach
lacked anatomic landmarks that would guide the practi-
tioner to the target nerve without reaching the intra-
articular space, such as a bony prominence. The location
of the SN may vary based on the individual, therefore the
SN may still be pierced in an attempt to reach the articu-
lar branch of the NQF. Perhaps most importantly, these
experiments were performed on desiccated cadaver tis-
Figure 8. PA fluoroscopic image of the right hip in the prone
sue, and it is certainly possible that the angles may differ position with twenty degrees of ipsilateral obliquity. The nee-
in live humans. dle which is held in place by forceps over the superomedial
This study found that the SGN provided innervation portion of the acetabulum is approaching the NQF’s terminal
to the posterior hip 33% of the time, which is similar to innervation zone of the quadratus femoris muscle. The dissec-
tion pin which is overlying the cephalad portion of the femoral
Birnbaum et al., who found 36% of examined hips had head is used to identify the articular branches of the SGN,
SGN innervation. Of note, Dee et al. did not find any which are potential locations where a block can be performed.
branches of the SGN supplying the posterior hip in a The cephalad radio-opaque marker is overlying the articular
study of animal and human models [3]. branches of the SGN. The caudal radio-opaque marker is over-
lying the NQF. The location of the sciatic nerve is demonstrated
A process of blocking the articular branch of the SGN
by the translucent yellow structure.
was considered but found to be difficult to approach via
fluoroscopy due its course. It is located deep to the glu- Direct branches off the sciatic nerve cannot be confi-
teus medius and superficial to the gluteus minimus. dently included or excluded based on our dissection.
Therefore, the path of the SGN between two muscle Only one of the 18 hips clearly exhibited direct branches
planes is problematic to identify with fluoroscopy and from the SN supplying the posterior hip capsule on gross
may be better suited for exploration with ultrasound. examination. We cannot confidently exclude smaller
1078
articular branches from the SN in the remaining 17 hips
as these may have been inadvertently destroyed due to
the nature of the dissection and fragility of these small,
friable branches. However, our findings align with
Birnbaum et al. who used an operating microscope and
found that an articular branch of the sciatic nerve pro-
vided posterior hip innervation in one of the eleven hips
studied [1].
Nerve to piriformis was seen to innervate one of the
18 hips. Similar to the articular branches coming off the
SGN, this articular branch was very fine. Future research
may consider examining this nerve further.
Similar to studies by Dee et al. and Sadovsky et al., the
IGN was not found to contribute to the posterior hip
capsule innervation. Previous research has debated the
IGN’s contribution [1, 5, 6].
From an interventional pain management perspective,
the NQF might be considered a priority target as it most
consistently provided posterior hip innervation. From
our dissections and fluoroscopic images, it would be dif-
ficult to safely target the articular branch of the NQF
considering the structures obstructing the path of the nee-
dle. Depending on the approach, the needle will have to
travel through the muscular layers of the gluteus maxi-
mus, while avoiding the inferior and superior gluteal vas-
culature and the large SN. The NQF lies directly deep
and slightly medial to the SN making injury to the SN
difficult to avoid. Risk of denervating the quadratus fe-
moris muscle would be high given that the contribution
of the NQF to the posterior hip is proximal to its inner-
vation of the quadratus femoris muscle, and there is mini-
mal distance between the articular branches and the
motor branches supplying the quadratus femoris.
Therefore it would be nearly impossible to localize the
articular branch without blocking the motor branch
(Figure 3). The quadratus femoris muscle functions as an
external rotator of the hip, recruited in hip extension
from a flexed hip position [4]. If it were to be denervated,
the functional impact on the stability of the femoroace-
tabular joint would have to be considered, specifically as
patients perform sit-to-stand transfers. This may be con-
cerning as most patients seeking relief of their hip pain
are elderly [1]. However, it is possible that the other ex-
ternal rotators of the hip might compensate for the dener-
vated quadratus femoris muscle.
In the future, it may be reasonable to target the NQF
in nonambulatory patients with refractory hip pain.
Theoretically, one may consider the use of ultrasound to
avoid important obstructing structures, such as the SN
and gluteal vasculature. Of note, the NQF is deep to the
SN, and the SN is deep to the gluteus maximus. As the
tissue depth increases, visualization of the target struc-
ture becomes increasingly difficult with ultrasound.
Therefore, if considering ultrasound for NQF interven-
tion, it may be best utilized in patients with normal to
low body mass index. Even if NQF can be targeted pre-
cisely, local anesthetic spread can potentially track to the
Nagpal et al.
sacral plexus and cause inadvertent SN block; this phe-
nomenon should be considered in the use of NQF periph-
eral nerve block for hip analgesia/anesthesia.
Our dissection protocol did not use surgical loupes
nor operating microscopes on all specimens. This may
have particularly impacted our results regarding the
branches of SN. In order to visualize the NQF during dis-
sections, the SN had to be manipulated and reflected in a
way that may have compromised any small articular
branches coming directly off of SN, especially those
branches embedded in fascia. Therefore, this research is
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specifically limited in the ability to remark on the pres-
ence or absence of small articular branches that would
have required surgical loupes for visualization and may
have been compromised during gross dissection of ca-
daver tissue. In support of our findings, Birnbaum et al.
mitigated this inherent pitfall by using an operating mi-
croscope during dissections but found similar results de-
spite magnification [1]. Additionally, our results could
have been impacted by the friability of preserved cadaver
tissue in specimens of advanced age (average 81 years)
who exhibited muscular hypotrophy and extensive
fascia.
Direct branches from the SN and nerve to piriformis
may be areas for further research for anatomical study.
Further research is needed to explore the NQF and its ar-
ticular branches as a possible target for posterior hip cap-
sule analgesia with other imaging modalities like
ultrasound or computerized tomography. Further re-
search is warranted to explore the option of nerve stimu-
lation as a means to mitigate risk of injury to the sciatic
nerve.
Conclusion
The NQF most consistently supplied the posterior hip
capsule; therefore, the results of this study elucidate the
NQF as a therapeutic target for treatment of chronic re-
fractory hip pain. The articular branch of NQF may be
approached with twenty degrees of ipsilateral obliquity
as described above, but not without potential blockade
of the SN and/or denervation of the quadratus femoris
muscle. Both the SN and SGN have small articular
branches that may be involved in posterior hip innerva-
tion, but not reliably so.
Acknowledgments
The authors wish to thank the individuals who gener-
ously donate their bodies and tissue for advancement of
education and research. Without their gift, this research
and countless hours of education would be impossible.
Special thanks to Denise Castillo, Laura Solis, and Eric
Ramos of the anatomy lab for their organization and
coordination.
Innervation of Posterior Hip: Cadaver Study
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