Entheseal Changes as Activity Markers? Current Knowledge, Limitations, and Future Directions

ABSTRACT Various skeletal markers have been used to reconstruct physical activity patterns in past populations, including cross‐sectional geometry, trabecular bone microarchitecture, osteoarthritis, and morphological changes at musculoskeletal attachment sites, known as entheseal changes (ECs). The aim of this paper is to systematize and critically discuss the current state of knowledge regarding the utility of ECs as physical activity markers and to suggest future research directions in this field. The study is based on a review of the articles published from 2011 to 2025 in the Web of Science database, and discusses the most commonly used EC recording systems. The review shows that, although clinical data and studies based on documented osteological collections suggest a relationship between EC and activity, the available evidence remains inconsistent and is highly dependent on the recording method, anatomical location, and study design among the reviewed papers. ECs are shaped by a complex, multifactorial etiology and reflect cumulative influences acting throughout the life course. Therefore, they should not be interpreted as direct markers of specific activities without controlling for age, sex, body size, pathology, enthesis type, method, and broader contextual factors. Current research highlights the need for more standardized, objective, and interdisciplinary approaches, including the development of quantitative methods for analyzing entheseal morphology in human skeletal remains.