Advances in Anthropology
2012. Vol.2, No.1, 24-30
Published Online February 2012 in SciRes (
Copyright © 2012 SciRes.
Golfer and Tennis Elbow in Byzantine Turkey: Epicondylitis
a Neglected Occupation/Activity Marker in Antiquity
Mark Spigelman1,2*, Yilmaz S. Erdal3, Helen D. Donoghue1,4, Ron Pinhasi5
1Centre for Clinical Microbiology, University College London, London, UK
2Department of Anatomy and Anthropology, Sackler Medical School, Tel Aviv University, Tel Aviv, Israel
3Department of Anthropology, Hacettepe University, Ankara, Turkey
4The UCL Centre for the History of Medicine, University College London, London, UK
5Department of Archaeology, University College Cork, Cork, Ireland
Email: *
Received October 21st, 2011; revised November 24th, 2011; accepted December 15th, 2011
Both lateral and medial epicondylitis are well known in modern medicine as diseases of occupation, leav-
ing recognizable lesions on the epicondyles. We report on 36 individuals from the 8th-10th century AD
Byzantine period from Kovuklukaya, near Sinop, Middle Black Sea region, Northern Anatolia, Turkey.
The present study focuses on medial and lateral epicondylitis with lesions of enthesopathies and bony pits,
assessing the frequency of these lesions in the skeletal series and whether these characters provide new
and/or additional criteria for the diagnosis of activity patterns in archaeological specimens. We then dis-
cuss the significance of these lesions in interpreting the activities of past populations, possible reasons
why these lesions were not previously reported by paleopathologists and the application of our findings to
the assessment of activity patterns and occupational stress markers in past populations.
Keywords: Epicondylitis Lateral; Medial, Elbow; Occupational Markers; Entheses
Examination of archaeological human bones by trained ob-
servers allows one to assess, from the marking left on the bone,
the body frame of the individual and their activity during life
(Benjamin et al., 2002). This has proved useful for archaeo-
logical studies. It is known that the ridges, tubercles and tube-
rosities that decorate bones serve for the attachment of tendons
and ligaments, which are usually more conspicuous in males
than in females, reflecting the greater strength of men (Ban-
nister et al., 1995). The search for activity and occupational
markers on skeletons from the past can tell us about task alloca-
tion and division of labour in a society. To understand these
aspects in past populations it is important to understand the
activities of present-day people and the markers they leave on
bone, and then to apply this to the study of past populations—
see for example studies by Masmejean et al. (1997) and Crubézy
et al. (2002) on joint involvement that may be associated with
changes in activities.
Hawkey and Merbs (1995) developed the term ‘muscle stress
markers’ (MSM) to describe the markings on cortical bone at
muscle and ligament attachment sites. Chapman (1997) used
these markers to note changes in activity patterns in pre- and
post-Spanish contact at Pecos Peublo in America. Changes in
the shoulder, particularly in the acromio-clavicular joints, were
recognized in populations from 16th century Scotland and 19th
century London (Miles, 1996; 1999), suggesting that these were
associated with industrialization. Numerous other studies on a
variety of MSM markers have been reported (Stirland, 1991;
Larsen, 1995, Al-Oumaouı et al., 2004; Molnár, 2006; Cardoso
& Henderson 2010; Havelekova et al., 2011). In a study of
Neolithic (early farmers) in the Levant, changes in activity
patterns were identified and quantified by the analysis of MSM
in the upper limb (Eshed et al., 2004). The MSM pattern for
males and females indicates a gender-based division of labour
both in the Natufian and the Neolithic. In this study most of the
mean MSM scores of the upper limbs are higher in the Neo-
lithic population, suggesting that the manual workload was
greater in the Neolithic Levant than during the Natufian Period.
These finds are expected as activities related to a food produc-
ing, farming economy demand heavy manual work, much
greater than is necessary in hunting.
Epicondylitis may be observed on both the lateral and medial
epicondyle of the humerii, and the relationship between the
disease and activity can be noted on living people—especially
with sporting activity (Priest et al., 1977; Walker-Bone, et al.,
2004). However, there are few studies and little or no evidence
collected about the type and frequency of epicondylitis in past
populations (Miller, 1985; Crianni & Fornaciari, 2003). This
study focuses on epicondylitis with lesions of enthesopathies
and bony pits in an archaeological population from Northern
Anatolia, as occupational and/or activity markers. It first re-
views the anatomical and pathological aspects of the condition,
then proceeds to address the indication of this condition in the
Anatolian skeletal sample, and its implications to the study of
this condition in other skeletal populations.
Functions of Muscles Attaching to the
Muscles attached to the lateral epicondyle are responsible for
straightening the fingers, dorsiflexion of the wrist in and rotat-
ing the forearm with the palm uppermost (Figure 1). Muscles
attached to the medial epicondyle are responsible for flexing
*Corresponding Author.
Figure 1.
Anterior aspect of the distal end of the humerus indicating sites of
muscle attachment on the medial and lateral epicondyles.
the fingers, palmar flexion of the wrist, and the forearm with
the palm down.
Epicondylitis occurs in activities requiring repeated or for-
ceful movements of the fingers, wrist, and forearm. Lateral
epicondylitis (tennis elbow) can arise because of a single for-
ceful act or blow. Gripping or twisting activities done repeat-
edly and forcefully in awkward positions without proper rest
periods if done with extended arms well away from the body,
can contribute to lateral epicondylitis in a modern day popula-
tion. Such activities include bending of the wrist and rotating
the forearm at the same time, holding an object with force for
lengthy periods, and jerky throwing movements (the Canadian
Centre for Occupational Health and SafetyCCOHS
Medial epicondylitis (Golfer’s elbow) has similar causes but is
a far less frequent problem in today’s society (Barton et al.,
1990). Epicondylitis leaves two visible lesions on the bony
skeleton: entheses and bony pits.
The entheses are the sites of attachment of ligaments, ten-
dons, and joint capsules to bone. Claudepierre and Voisin (2005)
noted that early in the development of a fibro-cartilaginous en-
thesis, the tendon attaches directly to hyaline cartilage. The
hyaline cartilage undergoes endochondral ossification, where
the bone gradually erodes the undersurface of the hyaline carti-
lage, replacing it by bony trabeculae. The end tendon cells un-
dergo metaplasia into cartilage cells, which lay down a layer of
fibro-cartilage. When this is completed, the enthesis is com-
posed of tendon, then fibro-cartilage, and finally bone, with no
hyaline cartilage. Repeated strenuous physical activities, in-
cluding sporting activities, are the leading cause of sympto-
matic enthesopathy but age and some specific diseases may also
be responsible for their development. Niepel and Sit’aj (1979)
suggest that enthesopathies are the source of both symptoms and
disorders of function. Gore et al. (1980) noted the following
osseous manifestations of elbow stress associated with sports
activities: bony hypertrophy, loose bodies, traction spur forma-
tion, osteochondral and humeral shaft fractures. In the elbow
we use various terms for these changes: endostheses, endos-
teophytes, traction spurs, or osteophytes. As we believe these
names all refer to the same process, we shall call them ‘endos-
theses’ (Figure 2).
Bony Pits
Further signs of occupational stress are pits on the bone—
these are shallow “scooped out” areas which represent places
where the tendons are anchored to the bone and then pulled off
but will not show up on radiographs or magnetic resonance
imaging (MRI). One of the authors (MS) as a surgeon per-
formed numerous (100+) operations on people suffering from
both lateral and medial epicondylitis, noting where the tendon
had pulled away from the epicondyle there was a certain gritti-
ness of the ends of the tendon, which we believe must be due to
small calcified entheses pulling off the epicondyle. This minor
finding, of no clinical significance, is unreported and unpub-
lished. As the operation generally involves “shaving” the epi-
condyle, the “scooped out” shallow scars will not be available
to future paleopathologists on any patients who have had the
operation; a shaved epicondyle will be the proof of past epi-
condylitis. One or two such pits with rounded edges may rep-
resent nutrient canals for the passage of blood vessels; however,
in epicondylitis they become too numerous for us to accept this
Physiological changes form the background of pathological
changes, particularly those resulting from repeated stressing of
the entheses beyond the safe limits of their capacity. The tend-
inous fibres rupture, the coherence of bone and cartilage is
reduced, the continuity of the cartilage zone is impaired and
bone may be denuded so that small portions of cartilage and
Figure 2.
The arrow points to entheses on KK’02 SK 7/2. This formation is
sometimes referred to as a traction osteophyte.
Copyright © 2012 SciRes. 25
bone are separated from one another by the pull of the tendi-
nous fibres. The damage induces repair, and reconstruction in
the bone and the cartilaginous zone. A typical feature of healing
zone is calcification by means of the deposition of calcium
apatite into collagen fibres, together with the formation of new
bone on the site of damaged cartilage and bone. This leads to
the formation of enthesopathies, analogous to osteophytes in
osteoarthritis (Niepel & St’aj 1979).
Kovuklukaya is located 300 m to the northeast of Çulhalı
village, in Sinop province, Northern Anatolia. A Byzantine
cemetery was at the top of the mound; measuring 70 m × 80 m.
Thirty-six human skeletons were unearthed in 25 rectangular
pits and cist graves (Erdal, 2008). The excavated skeletal series
includes 17 males, 15 females and four subadults. A radiocar-
bon determination of one of the skeletons a female aged 28
years has yielded a calibrated age range of 770 A.D. – 970 A.D.
± 2σ (95.4% probability). Sex of each individual was deter-
mined by cranial and post-cranial morphology based on Buik-
stra and Ubelaker (1994). The age at death was determined by
pubic symphysis, auricular surface of the os coxae, cranial su-
ture closure, and other metamorphic changes on the skeletons
(cf. Lovejoy et al., 1985; Brooks & Suchey, 1990; Meindle &
Lovejoy, 1985, 1989; Buikstra & Ubelaker, 1994). Age groups
were separated as young adults (15-30 years old), middle adults
(30 - 45 years old) and old adults (45+).
The epicondyles of 59 distal adult humerii were examined
macroscopically with a hand lens (10×). The statistical analy-
sis of the epicondylitis, in relation to age and sex, was tested
using the χ2 test in an SPSS 13.0 software package. Due to the
limited sample size, Yates’s correction was performed in the χ2
test; in cases when the samples were fewer than five, Fisher’s
exact χ2 test was used.
Medial epicondylitis, a condition that demonstrates itself as
pitting on the anterior surface of the medial epicondyle and as
small-calcified entheses around the epicondyle, was observed
on 25.5 % of the 55 humerii from the Kovuklukaya population
(Table 1). Figure 2 illustrates the condition in KK’02 SK 7/2, a
male aged about 37 - 38 years, whose skeletal remains showed
signs of heavy labour. The bony pits created by the pulling
away of the tendon of the left lateral epicondyle are visible, as
well as a small number of entheses. The close up view of the
left medial epicondyle is in Figure 3. The entheses appear as
raised bony points and the few pits have quite rounded edges,
suggesting some tendon tear (partial) in the past with healing.
Among the overall population, approximately one out of every
four humerii has medial epicondylitis. The frequency of medial
epicondylitis among males (26.7%) is slightly higher than
among the females (25%) (Table 1). Although the difference
between the frequency of medial epicondylitis in males and
females is not statistically significant, in general epicondylitis
on the right medial epicondyles were much more severe in both
sexes (Figure 4).
The surfaces of the attachment portion of medial epicondyles
on young adult individuals are smooth. A higher frequency of
epicondylitis was observed in middle-aged individuals, who
had more pronounced bony pitting and entheses than other age
Table 1.
Distribution of medial epicondylitis in relation to sex.
Right Left Total
* % n % n %
χ2 P
Male 4/1426.84/1625.0 8/30 26.7 0.0491.000
Female3/1323.13/1127.3 6/24 25.0 0.0561.000
Total 7/2825.07/2725.9 14/55 25.5 0.0061.000
χ2; df:10.048 0.018 0.005
P 1.000 1.000 1.000
*n: number of cases with epicondylitis /number of analyzed individuals.
Figure 3.
Close-up view of the bony pits—The rounded edges show evidence of
the healing process. The pits without rounded edges suggest more re-
cent trauma.
Figure 4.
Right and left lateral epicondyles of KK’02 SK 7/2. The arrow points to
pits on right—The left shows fewer pits and a small endosthese.
Copyright © 2012 SciRes.
groups (Table 2). Half of the individuals in this group have
medial epicondylitis. The distribution of epicondylitis in rela-
tion to age groups follows a similar path for the left and right
humerii and does not demonstrate a statistically significant
difference. There were no significant differences in distribution
of epicondylitis between the left and right humerii.
Lateral epicondylitis (Figure 5) was identified by noted
bumps, irregular grooves, and lateral cicatrical dimples on the
lateral epicondyles, but few pits were observed, suggesting
there was no tearing of the tendon. Figure 6 shows the bony
pits created by the pulling away of the tendon from the left
lateral epicondyle, also a small enthesis. A close-up view of the
left lateral epicondyle (Figure 7) shows few pits but some en-
dostheses. Some pits have rounded edges suggestive of healing,
but others have no rounding, indicating a more recent tear with
no remodelling.
The frequency of lateral epicondylitis among the Kovuklu-
kaya population (69.4%) was higher and greater among females
(73.9%) than males (64.4%) but did not reach statistical sig-
nificance. The frequency of lateral epicondylitis on the right
side was the same for males and females, but on the left hume-
rus it was higher in females (see Table 3).
Table 2.
Distribution of medial epicondylitis in relation to age.
Right Left Total
* % n % n %
χ2 P
Adult 0/3 0.0 0/2 0.0 0/5 0.0 - -
Adult 4/8 50,0 4/8 50.08/16 50.0 0.0001.000
Adult 3/17 17.6 3/17 17.6 6/34 17.6 0.0001.000
Total 7/28 25.0 7/27 25.914/55 25.5 0.0061.000
χ2 (df:2) 4.157 3.721 7.880
P 0.125 0.156 0.019
*n: number of cases with epicondylitis /number of analyzed individuals.
Table 3.
Distribution of lateral epicondylitis according to sex.
Right Left Total
* % n % n %
χ2 P
Male 9/13 69.2 8/13 61.517/26 64.4 0.1701.000
Female 9/13 69.2 8/10 80.017/23 73.9 0,3400.660
Total 18/26 69.2 16/23 69.6 34/49 69.4 0.001 1.000
χ2 0.000 0.910 0.418
P: 1.000 0.405 0.552
*n: number of cases with epicondylitis/ number of analyzed individuals.
Figure 5.
Left medial epicondyle with endostheses but few pits—
suggesting epicondylitis although tendon was not avulsed.
Figure 6.
Close up view of right medial epicondyle of KK’02 SK 7/2.
The raised entheses are visible, as is the pitting where bony
attachments avulsed when the tendon tore.
Figure 7.
Left lateral epicondyle showing the bony pits created by the
pulling away of the tendon and the endostheses.
Copyright © 2012 SciRes. 27
As observed on medial epicondylitis, no young adults were
diagnosed with lateral epicondylitis, but more than half of the
middle-aged and almost all older individuals (approximately
90%) had this lesion (Table 4). The collected data show lateral
epicondylitis is a lesion advancing with age (Table 4). The
frequency of this condition across different age groups is statis-
tically significant.
Studies of present day individuals shows that repetitive or
forceful tasks create a risk of epicondylitis (Marklin & Monroe,
1998; Pascarelli & Hsu, 2001). There is an association between
epicondylitis and sport activities (e.g. tennis, golf, and baseball,
cf. Priest et al., 1977) and daily activities such as meat process-
ing, woodcutting, shoemaking, and glassblowing (Vukovic et al.,
2004; Werner et al. 2005), where workers are required to un-
dertake repetitive or forceful tasks. Kurppa et al. (1991) found
the incidence of epicondylitis in a meat-processing factory was
up to 11 times greater than the normal population. O’Dwyer
and Howie (1995) studied 95 cases of medial epicondylitis and
noted that 90% were related to work and only 10% to sport or
leisure activities.
Epicondylitis has been used in a very limited way in studies
aimed at the identification of life style in the ancient human
populations (Peterson 1997). Miller (1985) conducted an early
study on lateral epicondylitis, but its prevalence was not given.
Crianni and Fornaciari (2003) studied the skeleton of the 18th
century cellist Boccherini and their combined macroscopic and
radiographic assessment showed that acquired muscle-skeletal
lesions related to activity. The joint of the left elbow revealed
bumps, irregular grooves and lateral cicatrical dimples sug-
gesting chronic epicondylitis.
Medial epicondylitis is less common and is caused by sports
needing strong flexion of the hand and fingers e.g. baseball,
javelin throwing, weight lifting, volleyball, climbing, tennis, or
golf (Priest et al., 1977; Walker-Bone et al., 2004). Priest et al.
(1977) examined 84 prominent and skilled tennis players, 54
men and 30 women. Elbow symptoms were experienced by
45% at some time during their playing careers, and 37% had
symptoms that were major, lasting weeks to 15 years. Eleven of
the players experienced lateral epicondylitis and twelve had
medial epicondylitis.
In the Kovuklukaya population medial epicondylitis was di-
agnosed in 25.5% and lateral epicondylitis in 69.3% of the
studied humerii, demonstrating that the forearms of the indi-
viduals were subjected to either major repetitive or severe phy-
sical stress. We found no significant difference between the
sexes in the frequency of epicondylitis, suggesting that both
sexes in this population were subjected to similar stress levels.
Medial epicondylitis was commoner in males whereas lateral
epicondylitis was commoner in females.
There is no archaeological evidence to explain these changes,
however, the ecological characteristics of the present day Boy-
abat district and the traditional life styles of the inhabitants
enable us to draw some conclusions (Erdal, 2004). Arable land
is scarce, grains raised in villages barely satisfies the needs of
the people (Başoglu, 1972). Mountainous regions, forests and
shrubs account for 62% of the land. The mountains surrounding
Boyabat are covered with pines and oaks, and they provide the
best lumber in Anatolia, hence, lumber production constitutes
the major source of subsistence in the region.
Table 4.
Distribution of lateral epicondylitis in relation to age groups.
Right Left Total
* % n % n % χ2 P
Adult 0/3 0,0 0/2 0,0 0/5 0.0 - -
Adult 5/8 62.5 4/8 50.0 9/16 56.3 0.2561.000
Adult 13/1586.7 12/13 92.3 25/28 89.3 0.2321.000
Total18/26 69.2 16/23 69.6 34/49 69.4 0.0011.000
χ2 (df:2)9.061 9.194 17.853
P 0.011 0.010 0.000
*n: number of cases with epicondylitis /number of analyzed individuals.
Seventy one percent of the male individuals in the sample
had some rib, coxae, Colles’, finger, femur, tibia and patella
fractures—all related to tree felling (Erdal, 2004). Vukovic et al.
(2004) point to the existence of a relationship between epi-
condylitis and woodcutting, with the use of axe and saw putting
stress on elbows and fingers. The gripping of an axe requires
finger flexion, identical to tennis players gripping a racket.
Flexion and extension are also relevant when using a saw.
Epicondylitis on males may have been caused by activities
such as tree felling, lumber production, and carrying timber.
Ethnographic and archaeological data suggest different reasons
for epicondylitis in females. Miller (1985) noted that combina-
tion of flexion and extension, partial pronation, and prolonged
tension of the forearm musculature is needed to produce a
prominent lateral epicondylar enthesis. These pathological
changes were seen in the Nuvakwewtaga people in the South-
east United States and attributed to grinding maize. This se-
quence of movements shows similarity to the movement system
of the arms, during textile production on ground-looms. Mesio-
distally directed grooves on the anterior dentition of females
from Kovuklukaya were observed (Erdal, 2008). According to
the unusual abrasion on anterior dentition and the ethnographic
data, it is concluded that Kovuklukaya females used their ante-
rior dentition during yarn production. Weaving on a horizontal
ground-loom is a typical activity of women in this region from
early times to the present. The horizontal ground-loom has its
warp stretched between two beams fastened to two or four pegs
driven into the ground. Warp is put directly on the warp beams
and transferred to the loom later. The warp threads are divided
into two layers, half of which (the odd threads) are lashed to a
stick tied above the warp (the rod-heddle). When this rod-hed-
dle is raised a space, the shed, is formed through which the weft
can be passed. To obtain the “counter-shed” for the next pas-
sage of the weft, the even threads must be raised by means of
shed-rod, a piece of wood turned on edge. For this action to be
performed, the wooden instrument used for beating the weft is
forcefully pushed forward and pulled back with both arms.
Therefore, in textile production, a combination of flexion and
extension, partial pronation, and prolonged tension of the fore-
arm musculature occurs as fingers and thumbs tightly hold the
beating instrument. For a diagram and details of textile produc-
tion on horizontal ground-loom, see Barber (1991: 79-91) and
Forbes (1956: 192-195).
The above, taken together with finding of high prevalence
Copyright © 2012 SciRes.
rates of both lateral and medial epicondylitis in the Kovukkaya
sample, imply that these pathological changes were caused in
males by the use of an axe, and in females by yarn and textile
production on ground-looms as well as grinding of cereals—
activities that require the continuous use of both hands. There-
fore, the lack of statistically significant differences between the
right and left epicondylitis in the Kovuklukaya population can
be explained. However the pitting and enthesopathies on the
right side were more severe indicating more stress on the do-
minant right arm.
The risk of developing medial epicondylitis is much higher
in the presence of lateral epicondylitis (Walker-Bone et al.,
2004), which may contribute to the high incidence of medial
epicondylitis among the Kovuklukaya population. Lateral epi-
condylitis is most frequently observed among individuals ap-
proximately aged 45 - 54 years (Walker-Bone et al., 2004). The
increasing prevalence of lateral epicondylitis in Kovuklukaya
with age resembles this modern pattern. The greater proportion
of older females in Kovuklukaya (females lived on average 6
years more than males and demonstrated an average of 49.5
years of age at death) may explain the higher frequency of lat-
eral epicondylitis among females.
The frequency of medial and lateral epicondylitis was high in
the 8th-10th century Byzantine Kovuklukaya population and
indicates a similarity of the movements of the forearm and fin-
gers of these individuals to modern-day golf and tennis players.
Repetitive activities such as using an axe, producing yarn, and
weaving textile on a ground-loom are consistent with the flex-
ion, extension and pronation of the arms, which today are char-
acteristic injuries of golf and tennis, amongst a range of other
In studies oriented towards identifying the life style in an-
cient human societies, the presence of epicondylitis is a useful
indication of activity patterns in archaeological populations.
Analyzing these occupational markers on a population-based
level may in certain instances help us understand division of
labour in relation to (1) sex, (2) social complexity and (3) age.
This study therefore highlights the potential of accurate patho-
logical diagnosis of these conditions in skeletal series in con-
junction with available archaeological and osteological data
regarding sex, age, status, other pathologies and various addi-
tional indicators of the activities of past populations.
We acknowledge the help of Professor Israel Hershkovitz of
Tel Aviv University and for the C14 dating, Dr. Elisabetta Boa-
retto, Radiocarbon Dating Laboratory, Weizmann Institute of
Science, Rehovot, Israel. We thank the Director of Sinop Mu-
seum, Musa Ozcan, and the Museum assistant Fuat Dereli for
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