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Enthesopathies (lesions of muscular insertions) as indicators of the activities of Neolithic Saharan populations.

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Enthesopathies (Lesions of Muscular Insertions) as Indicators of
the Activities of Neolithic Saharan Populations
Laboratoire de Gbologie du Quaternaire, C. N.R.S., Centre Uniuersitaire de
Luminy, 13288 Marseille, Cedex 9, France.
Paleopathology, Overuse syndromes, Sporting
Enthesopathies are bony lesions involving the sites of inserABSTRACT
tion of muscles or ligaments. Those caused by hyperactivity of the relevant
muscles may be distinguished clearly from those of metabolic or inflammatory
origin. Observations from sporting and occupational medicine indicate that
specific enthesopathies are correlated with different activities. Examination of
the enthesopathies present on two groups of well-preserved neolithic skeletons
from separate regions of the Sahara with different paleoenvironments show
that overall 20% of the skeletons presented lesions. Three different forms of
enthesopathy involved the arm, principally the elbow, and may be tentatively
correlated with javelin throwing, wood cutting, and archery. Two types of
lesion involving the foot were observed in skeletons from a hunter-gatherer
population and may be correlated with much walking or running over hard
ground. I suggest that the analysis of such lesions on ancient skeletons may,
in concert with other archaeological data, throw light on the activities of
ancient people.
Bony lesions a t the sites of muscles or tendon insertions on the skeleton, or enthesopathies, are well known in sporting and
occupational medicine to be associated with
prolonged hyperactivity of the relevant muscles. A notorious example is "tennis elbow,"
where lesions at the sites of insertion of specific muscles on the lateral epicondyle of the
humerus may result in a hyperostosis that is
sometimes visible on radiological examination. Other enthesopathies are quite specifically associated with over use of different
sets of muscles. Such lesions may be confidently detected on well-preserved skeletal remains, and they may provide indications
about the muscular activities of the individuals examined and, hence, about the habitual activities of the populations to which they
In this article some typical enthesopathies
found on skeletons from two different neolithic Saharan populations are described, and
the implications for the physical activities of
these groups will be discussed.
This study was performed on two different
neolithic Saharan populations that have been
0 1986 ALAN R. LISS, INC.
more fully described elsewhere (Dutour and
Petit-Maire, 1983; Dutour, 1984;Paris, 1984).
The study groups consist of 1) a collection
of 25 skeletons (eight male, five female, 12
unsexable) from the Saharan region of Mali
Hassi el Abiod (19"06'N, 3" 50'W). This population is being investigated as part of a
study of the Saharan paleoenvironment under the direction of Nicole Petit-Maire
(C.N.R.S. Luminy). Archeological data indicate that this population inhabited a lacustrine environment and that fish were a major
item of their diet. Radiocarbon dating places
the age of these skeletons at 7,000-6,000
years BP (Petit-Maire and Riser, 1983).
The second group was a collection of 16
skeletons (five male, two female, nine unsexable) from the Chin-Tafidet site (17" 30'N, 6"
20'E) in the Niger.
This population consisted of hunter-gatherers and dates from 4,000-3,000 years BP
(Paris, 1984).
Skeletons from the two sites are frequently
complete and in a good state of preservation;
the index of preservation does not differ sigReceived January 15,1986;revision accepted Apyil7,1986
flattened, slightly curved exostoses are present on the posterior superior faces of the right
and left olecranon processes (Fig. 2). The lesions are more pronounced on the right side.
In both cases the articular surfaces appear
normal. The lesions reflect stress on the lower
insertion of the triceps brachii tendon. The
triceps is a powerful muscle and is composed
of three separate elements with individual
upper insertions but a single common insertion on the olecranon. It is uniquely responsible for extension movement of the elbow,
and the common insertion site is subject to
microtrauma during complete elbow extension, particularly when the triceps brachialis
muscle is fully extended and working at full
power. These conditions are ideally met when
Nine of the skeletons examined (22%) the arm is horizontal and the elbow flexed
showed the presence of one o r more enthesop- (Kapandji, 1983). Under modern conditions,
athies. These were more frequent in the pop- the lesion is observed in wood cutters, blackulation from the Niger (7/16) than in that smiths, and some baseball players. The pafrom Mali (2/25). In eight cases the subject thology may be unilateral or bilateral,
was male: The ninth skeleton could not be depending on the type of activity involved.
sexed with certainty. The ratio of sexed skelBiceps brachii enthesopathies
etons to total skeletons was significantly
more important for those presenting lesions
In three cases, two mature adult males
(8/9) than in the whole population observed from the Niger and one mature adult of un(20/41). This discrepancy is probably due to determined sex from Mali, unilateral right
the fact that the enthesopathies could be ob- side lesions consisting of roughness, spicules,
served on the best preserved skeletons, which and osteophytes are present on the radial
could also be sexed. Three different lesions tuberosity. This is the site of insertion of the
(six cases) involved the arm, particularly the biceps brachii muscle, which is the principal
elbow. The remaining four cases showed two agent responsible for flexion of the elbow.
different lesions of the bones of the foot.
This type of enthesopathy is rather rare today (Genety, 1972) and is associated with
Enthesopathy of the medial epicondyle of the carrying heavy loads with the elbows bent
(masons, bakers). It is seldom unilateral.
One of the skeletons from the Niger with
In one case, a mature adult male from the
Niger, a small bony pad is present on the this lesion was particularly well preserved,
lower edge of the right medial epicondyle of and examination of other lesions was possithe humerus and extends into a vertically ble, leading to a new hypothesis. An osteodescending osteophyte near the epicondyle phytic band bordering a n imprint is visible
(Fig. I). The rest of the distal epiphysis is on the coronoid process of the right ulna.
normal as are the right radius and ulna. No Assembly of the joint demonstrated that this
lesions were found on the corresponding left corresponded to the location of the trochlea
of the humerus a t submaximal (120") elbow
elbow region.
This lesion reflects a n insertion pathology flexion. Further, the left humerus shows a
corresponding to hyperactivity of the mus- distinct modification consisting of a small
cles pronator teres, flexor carpi radialis, pal- bony patch on the distal face of the olecranon
maris longus, flexor digitorum superfkialis, fossa a t the contact with the olecranon proand flexor carpi ulnaris or of the ligament. It cess at full elbow extension. In addition, comis observed today in sporting medicine and parison of the paired humeri shows a
generally affects javelin throwers or golf profound asymmetry: The insertions of the
triceps brachii muscle are far more developed
on the left side, but the teres minor is much
Triceps brachii enthesopathies
more prominent on the right side. These obIn two cases a juvenile adult male from the servations indicate that the right arm was
Niger and a n aged male from Mali, large, submaximally flexed at the elbow against a
nificantly between the two sites. Only skeletons of adults with preserved long bones were
considered in this study, since significant enthesopathies are chiefly observed on the limb
bones, and immature individuals would not
be expected to have experienced a sufficiently long overuse of specific muscles for
bony lesions to have formed.
Enthesopathies were evaluated by nakedeye examination of the bones for rough
patches, irregularities, or osteophytes. They
were classified by comparison with radiological data from modern subjects suffering from
enthesopathies of known aetiology (La Cava,
Fig. 1. Enthesopathy of the medial epicondyle of the
humerus. Exostosis at the distal edge of the medial epicondyle of the humerus.
Fig. 2. Triceps brachii enthesopathy. Exostosis in the
form of a spur at the top of the olecranon (insertion of m.
triceps brachialis).
biceps brachialis b);and exostosis a t the insertion of m.
biceps brachialis (c).
Fig. 4. Adductor hallucis enthesopathy. Calcaneum:
Exostosis at the insertion of Achilles tendon (white arrow) and at the insertion of m. adductor hallucis (black
Fig. 3. Biceps brachii enthesopathy. Tuberosites radii
Normal bone (a); irregularities a t the insertion of m.
strong force with a n external rotation of the in modern marathon and long-distance runshoulder, while the left arm was extended ners (Clement et al., 1984).This skeleton also
and submitted to compressive force. This cor- shows a plantar enthesopathy (see below).
responds perfectly to the movement of a n
Adductor hallucis enthesopathies
I n three cases, two mature adult males and
Achilles tendon enthesopathy
one juvenile adult male all from the Niger, a
In one case, a mature adult male from the fine, pointed bony spur extends to the posteNiger, the posterior portion of the only cal- rioinferior tuberosity of the calcaneum. For
caneum found bears a vertically orientated two of the skeletons only one calcaneum was
exostosis. This enthosopathy, which involves present. In the third case the lesion was bithe insertion of the Achilles tendon, is seen lateral. This type of lesion indicates a plan-
tar enthesopathy involving the adductor
hallucis muscle. It is observed mainly among
people who do much walking or running on
hard sufaces (joggers) (Lehman, 1984).
Activity-induced pathology could be a good
tool with which to approach activities of ancient populations (Merbs, 1983). This study
describes the bony lesions involving the insertions of muscles or ligaments in ancient
skeletons and attempts to relate them to
causative muscular activities using knowledge derived from sports and occupational
medicine. The mechanism of formation of the
lesions, bony spurs, rough patches, and irregularities involves active bone formation and
thus cannot reflect postmortem changes.
Furthermore, enthesopathies caused by muscular hyperactivity are generally isolated lesions and may be readily distinguished from
those caused by metabolic or inflammatory
causes, e.g., rheumatoid arthritis, ankylosing spondylitis, or psoriasic arthritis, where
the joint surfaces are involved. Similarly, the
calcifications associated with Forestier disease (or DISH) are widespread and involve
the vertebrae. I am thus confident that the
enthesopathies described here may be related to prolonged and extensive use of the
correpsonding muscles. At the present time
only the bony spur on the calcaneum occurs
as a spontaneous lesion, and that particularly in old, overweight women. All three
skeletons with this lesion in the present
study belonged to quite young males, in
whom spontaneous occurrence is rare.
While the observed lesions may confidently
be described to the extensive use of certain
specific groups of muscles, the identification
of the precise activity involved remains more
speculative. The lesions of the elbow observed are related in modern conditions to
javelin throwing, wood cutting, and archery,
which are all quite possible activities within
the archeological context of these people. Differences in the incidence of lesions between
the two populations may reflect differences
in their life-styles. The Mali group lived in a
lacustrine environment, and the abundance
of large fish bones and the presence of harpoon heads indicates that fishing was a major activity for them. They provide only two
cases, one possible archer and a possible wood
cutter. The bow is used for fishing in certain
primitive populations, and certain of the harpoon heads found at this site are compatible
with mounting as arrowheads. Remains of
antelopes and other animals are also found
at this site, as are a few classical flint arrowheads. The “wood cutter” lesion should be
compatible with the action of casting a
weighted net. No lesions of the foot were
observed. The population from the Niger, by
contrast, had a high incidence of lesions,
which may be related to their activities as
hunter-gatherers. In particular, the incidence of foot lesions may reflect long and
strenuous exertion on hard and stony ground.
It may also be noteworthy that no lesions
were found on unequivocally female skeletons from either site.
In conclusion, the study of enthesopathies
present on ancient skeletons may provide additional data that, taken with other archaeological findings, can help in interpreting the
activities of ancient man.
I thank S. and E. Bernus (Orstom Paris) for
support and T. Greenland (C.N.R.S. Lyon) for
his assistance in preparing the manuscript. I
a m indebted to G. Meyer for helpful discussion. The skeletons from the Chin-Tafidet site
were studied with the kind permission of
Franqois Paris (Orstom Niamey), director of
a program of prehistorical and anthropological research in the southern Sahara. Figures
1-4 were generously provided by Franqois
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Kapandji, IA (1983) Physiologie articulaire. Schemas
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LaCava, G (1959)L’enthesite ou maladies des insertions.
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Am. Family Phys. 29t157-161.
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population, lesions, insertion, enthesopathies, saharan, indicators, muscular, activities, neolithic
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