International Journal of Osteoarchaeology, Vol.

6: 167--178 ( 1 9 9 6 )

Injuries to the Skeleton due to

Prolonged Activity in Hand-to-Hand
Combat
1. HERSHKOVITZ,'**L. BEDFORDI3 L. M. JELLEMA,2 AND B. LATIMER2v3
'Department of Anatomy and Anthropology, Sackler Faculty of Medicine, Tel Aviv
University, Tel Aviv, 69978, Israel; 2The Cleveland Museum of Natural History, 1 Wade
Oval Drive, University Circle, Cleveland, Ohio 44706-1767, USA; and 3Department of
Anatomy, Case Western Reserve University, Faculty of Medicine, Cleveland, Ohio
44106-1767, USA

ABSTRACT Two complete skeletons from the Hamman-Todd collection of the Cleveland Museum of Natural
History (CMNH) show a suite of pathological lesions that suggest the individuals had been involved
in boxing or other hand-to-hand combat.These lesions were studied and compared with medical and
autopsy records.The aims of the research were to estimate the accumulated damage to the bones
over time, to characterize the different types of the damage, and to establish criteria for hand-to-
hand combat or violence for archaeological material. Our inspections showed that besides the
muscle markings developed and the numerous healed fractures that are expected when someone
is involved in such activities, other types of lesion are present that are helpful for a proper differential
diagnosis.These are: degenerative changes at the lesser tuberosity of the humerus; focal necrotic
changeslbone growth on the trochlea of the humerus; necrotic changes on the distal head of the
ulna; bony patches on upper limb bones only; secondary centres of ossification failing to fuse
(mainly in vertebrae and acromion); a huge conoid tubercle on the clavicle; bony spurs on the distal
articular head of the metacarpals; necrotic changes on the femoral head next to the fovea and on the
roofoftheacetabulum; andadeveloped bonyridgefor theattachmentofthe iliotrochanteric ligament.
Finally, we propose a set of criteria that will help to identify people in archaeological material who
were involved in hand-to-hand combat.

Key words: Bone injury; sports; violence.

Introduction life history of individuals. As we become more

O n e of the major aims of physical
anthropologists is to reconstruct the life history
of an individual based on its skeleton. Usually,
the only source of information we have are
the skeletal remains, which are a record of the
major life events. The problem is that the
recording is carried out in different languages,
palaeodemographic, palaeopathological, morpho-
logical, biochemical, histological, metric, and so
on. These require us t o become more and more
specialized. Although our reading of the bones
has been greatly improved over the last decade,
we frequently forget t o put all the pieces of
information together, and therefore we do not
reach our original goal, which is t o delineate the
ccc 1047-482x/96/020 167-1 2
0 t 996 by John Wiley & Sons, Ltd
specialized we tend to focus on smaller parts of
the picture and on temporary events in the
individual's life history. However, the parts give
an incomplete and sometimes misleading
impression of the individual's life. Most of the
palaeopathological studies use a medical
approach, in which the phenomenon itself is
the object of interest and not the individual
person, that is, they report on frequencies of
pathology within a population. Using a
hypothetical example, a paper reports that 30
per cent of the individuals in a certain population
manifest fractured nasal bones. What does this
tell us about the life history of each of the 30 per
cent affected individuals? Almost nothing. What
does a comparison with another population tell
Received 6 May 1995
Accepted 7 June i 995
168 I. Hershkouitz et a/.

us, barely nothing. Why? Because the history and of Natural History. Both skeletons were from
the cause of the disease or trauma in each black males, one aged 45 years (HTH 2372) and
individual will be different. the other 42 years (HTH 2961) at the time of
Unless we correlate the disease with other death.
parameters, such as sex, age, ethnic origin, Detailed morphological observations were
geographic location, socio-economic class, made on both skeletons. Because these
culture, and especially other diseases or changes observations largely duplicate one another, we
in the bones, the picture will remain incomplete, present data for skeleton HTH 2372 and refer
and in many cases be distorted. to the other skeleton only when presenting
Of all sports, the one most likely to cause additional information.
severe damage to the skeleton is boxing (the term
boxing is here used in its general sense, implying
all types of hand-to-hand combat). As Freidrich Results
Unterharnscheidt noted, 'Boxing is different from
all other athletic endeavors in that the nature of Tbe skull
the sport causes injury by intention rather than by
accident'. 1 Both the zygomatic arches show displaced healed
Most of the literature dealing with bodily fractures (Figures 1 and 2). They were
damage due to sports activity associated with compressed medially and as a consequence no
boxing focuses on craniocerebral trauma. Reports longer flare outward (Figure 3). The right
of bony damage are surprisingly few, and zygomatic arch was fractured in two places:
generally contain only findings (based mainly near the zygomaticotemporal suture, and close to
on X-rays) on specific parts of the body, e.g. the root of the zygomatic process, just before it
multiple fractures in the mandible,2 trauma to widens posteriorly as it approaches the squamous
nasal bones,3 a fracture of the hyoid bone,4 a part of the temporal bone (Figure 1). The arch on
fracture of the fifth metacarpal bone5 and fracture the left was also fractured in two places, close to
of the trapezium.6 The accumulated damage to the root (as on the right) and also at its most
the skeleton over time due to prolonged boxing outward protruding part (Figure 2). The anterior
activity has never been reported. O n the other half of the arch, from the zygomaticotemporal
hand, the medical literature on injuries, due to suture to mid-arch (where the more anterior
deliberate violence, is plentiful,7-"J Nevertheless, fracture is located) is displaced medially,
it suffers from the weakness that it tells us almost presenting an angular profile in superior view.
nothing about the individual. Medical statistics The nasal bones are fractured in several places,
based mainly on a non-random sample of specific and the entire nasal region is twisted to the right
injuries are of no help when analysing the life (Figure 2). O n e fracture runs horizontally,
history of an individual or measuring violent dividing each nasal bone into two segments.
activity in an historic population. The other runs vertically, just medial to the
T h e aim of the present study is to describe nasomaxillary suture (Figure 2). A third fracture is
what repetitive damage to the skeleton, due to seen on the maxilla, along the upper lateral
hand-to-hand combat, may look like, and to border of the nasal aperture.
establish reliable criteria for identifying boxing- The right zygomatic bone was fractured in two
like activities (versus injuries due to violence) in places: posteriorly, along the sphenozygomatic
archaeological material. suture, and anteriorly, running vertically between
orbitale and the zygomaticomaxillary tubercle.
The latter fracture cuts across the
Materials and methods zygomaticomaxillary suture. N o major damage
was observed on the calvaria, except for small
Two skeletons of individuals who had engaged bony patches inferior to the temporal line.
regularly in boxing are located in the Hamann- Inspection of the internal part of the skull
Todd collection, housed at the Cleveland Museum revealed no obvious damage.
Bone Injuv in Boxing 169

Figure 1. Anterolateral view of the left side of

skull HTH 2372. The zygornatic arch is
broken in two places and bent inwards.

Figure 2. Anterolateral view of the right side

of skull HTH 2372. The zygomatic arch is
broken in two places.

Figure 3. Basilar view of skull HTH 2372.

Notice how the two zygornatic arches were
pushed inward.
170
No fractures were observed on the mandible.
Most lower and upper teeth were lost pre-
mortem, except for the two premolars and first
molar on the right side in the mandible, and the
right first and second molars in the maxilla.
The skull of the second skeleton displayed
similar lesions. The right zygomatic arch was
fractured and compressed medially, as in the first
boxer. The nasal bones were also broken, as were
the upper lateral margins of the nasal aperture. In
the middle region of the frontal bone, a large
bony scar is present.
Most of the second boxer's teeth were retained,
except for two in the maxilla (the right central
incisor and left lateral incisor) and five in the
mandible (right first and second molars, and left
second premolar, and second and third molars).
Alveolar bone resorption is evident all along the
dental arch, accompanied by bony tubercles. No
clear damage or morphological changes in the
mandible were observed, except for a developed
torus mandibularis.
Postcrania: upper limb bones
Muscle markings on all upper limb bones are
prominent. T h e scapula is wide and low in
general shape. The inferior part is blunt, wide,
rugose, and the inferior angle is obtuse rather
than acute, indicating a strong teres major muscle.
Figure 4. Lesions on the lesser tuberosities of the right and left humeri.
I. Hershkouitz et a / .
The acromion (attachment for the deltoid
muscle) is not fused with the scapular spine.
The superior surface of the spine is extremely
rugged, with small bony ridges at the trapezius
attachment. O n the most medial part of the right
coracoid process there is a bony spine and a
prominent ridge, which may indicate a strong
conoid ligament. O n the subscapular fossa, on
both sides, there are prominent bony ridges for
the intramuscular tendons of the subscapularis
muscle. O n the left scapula, a bony lesion, just
inferior to the root of the spine, penetrates the
entire thickness of the bone. In lateral view, the
glenoid cavities on both sides have lipping around
their borders, and minor necrotic changes on
their surfaces. The infraglenoid tubercles are
massive, and the prominent crests running
inferiorly divide the lateral borders of the
scapulae into two equal halves, instead of a
small dorsal part and a much larger ventral part.
The former morphology implies a large teres
minor muscle.
The right clavicle shows arthritic changes at
both acromial and sternal ends. The articular
surface of the sternal end extends further than
usual on to the inferior aspect of the bone,
creating a larger range of movement at the joint.
Also of note is the rugged surface of the bone and
the enlarged conoid tubercle.
On both humeri, the lesser tuberosites exhibit
evidence of an inflammatory process (Figure 4).
The area for the attachment of the pectoralis
Bone Injury in Boxing
Figure 5. Osteological changes on the distal part of the left
humerus: (A) bone patches, (B) bony spur (medial
epicondyle), (C) extended articular surface of the capitulum
for the radial head.
major, latissimus dorsi and teres minor muscles is
very rugose, encroaching over the lower part of
the bicipital groove. O n the upper border of the
medial epicondyle of the left humerus, there is a
Figure 6. Lesion on the humeral trochlea
171
pronounced bony spur at the attachment site for
the humeral head of the pronator teres (Figure
5(B)). O n the right humerus, there is a small
groove at the site of this attachment site. O n the
right trochlea, a focal necrotic area (subchondral
lesion) is seen (Figure 6). O n the left trochlea,
there is an osteophytic ridge separating the
trochlea from the capitulum. Also on the left
humerus, on the lower third of the shaft, there is a
large bony patch on the medial side, probably
due to local inflammation (Figure 5(A) ). A similar
bone growth appears on the right humerus at
about the same level on the posterolateral aspect.
Expansion of the articular surface of the
capitulum into radial fossa is also noted (Figure
5(C)).
O n both radii, two areas are exceptionally well
developed: the radial tuberosities, which exhibit
marked lipping; and the proximal part of the
interosseous crest. Also on the left radius, on its
mid-posterior aspect close to the interosseous
crest, a large bony patch is present.
The left ulna was broken in midshaft (Figure 7).
Although the fracture healed, the bone did not
return to its normal shape and is 1 O mm shorter
than the right. O n the distal articular surfaces of
both ulnae, there are advanced necrotic changes
(subchondral lesions) (Figure 8). O n the right
ulna, the distal articular surface for the radius
shows extreme lipping.
The bones of the hands show marked lesions.
In the right hand there are arthritic changes on
172
Figure 7. Fractured ulna at midshaft.
Figure 8. Lesions on the distal articular surface of the ulna.
the head of the first metacarpal and a bony
growth on the head of the second. In the left
hand, all the distal phalanges show arthritic
changes, and many phalangeal distal articular
surfaces as well as that of the third metacarpal
show small bony growths. The head of the first
1. Hershkouitz et 61.
metacarpal is flattened; the proximal end of the
fifth metacarpal has a healed fracture (Figure 9).
T h e second skeleton manifests a similar pattern
of bone damage to the upper limb bones. The
scapulae show two things worth mentioning: a
wide flat scapular angle and the failure of the
acromion to fuse with the spine (on the left side
only). The articular surface of the sternal end of
the right clavicle extends on to the inferior aspect
of the bone, as in the first individual. Muscle and
ligament markings overall are exceptionally well
developed. Destruction of the lesser tuberosity of
the humerus and overdeveloped muscle markings
for the pectoralis major, latissimus dorsi and teres
major are present in this boxer, as are bony bulges
on the mid-trochlear area. Large osteophytes
appear on the lateral epicondyle of the left
humerus. Both radii manifest extremely well-
developed radial tuberosities with associated
lipping. Major changes are found at the head of
the ulnae, including marked lipping and extension
and destruction of the articular surface, with clear
eburnation on the right side. T h e bones of the
hands show a fracture of the right first
metacarpal, and arthritic changes in many of the
carpal bones on both sides, sometimes to the
stage of eburnation, as on the right lunate (on the
articular surface for the radius) and left Iunate (on
the articulation surface for the triquetral).
Pelvis and lower limb bones
As expected for an athlete, the lower limb bones
show pronounced muscle markings. On the
innominates, the iliac crests, anterior and
posterior gluteal lines, posterior-superior iliac
spines and the attachment areas for the gluteus
maximus are especially well developed. Necrotic
changes appear on the upper part of the
acetabulum. Both femora are very robust with
pronounced muscle markings. On each side, next
to the fovea capitis, there is a large necrotic area
(Figure 10). Both patellae exhibit cystic lesions on
the articular surfaces, and lipping around their
circumferences (Figure 1 I ) . T h e tibiae are
massive, with soleal lines that are so extremely
rugose that they form large elevated bony crests.
The left fibula was fractured approximately
Bone Injury in Boxing
Figure 9. Healed fracture of the first metacarpal bone.
Figure 10. Necrotic area on the head of the femur adjacent to
the fovea capitis.
173
50mm below the proximal end. Despite a large
callus at the fracture site, the bone retained its
length and remained straight. However, arthritic
changes were observed on the proximal articular
surface of that bone. In the left foot, the tarsal
bones show no abnormalities. However, the
proximal ends of the second, third and fourth
metatarsals manifest pronounced topography on
their plantar aspect. The first proximal phalanx
manifests a poorly healed compression fracture
associated with infection (Figure 12). All distal
phalanges show advanced arthritic changes. The
morphology of the right pedal bones is similar to
that of the left. Evidence for gout (Figure 13(A) )
(small pits on the lateral aspect) and
spondyloathropathy (Figure 13(B) ) is clearly
seen on the heads and/or bases of some
metatarsals and phalanges.
In the second boxer, muscle markings are also
exceptionally rugose on both innominate bones,
accompanied by osteophytic growths. Necrotic
changes appear on the most superior part of the
acetabulae, on the articular surfaces. The femora
show necrotic changes on the heads and large
bony growths are present at the attachments of
the lateral bands of the iliofemoral ligaments (i.e.
iliotrochanteric ligaments). This was also the case
in the first boxer. Both tibiae of the second boxer
display overdeveloped tuberosities and both
174
Figure 11. Lesions on the articular surface of the patella.
Figure 12. Compression fracture of the first proximal pedal
phalanx.
fibulae exhibit healed fractures close to the distal
end. All distal phalanges flaunt advanced arthritic
changes. The right first metatarsal bone manifests
a healed fracture.
I. Hershkovitz et al.
Thoracic cage
The most obvious changes in the thoracic cage
are the numerous fractures of the ribs. On the
right side four ribs were broken, mainly in the
upper part of the thoracic cage: the second and
fifth ribs were broken in the middle; the third rib
was broken 30 mm lateral to the anterior end, and
the fourth rib was broken close to the sternal
junction. The fifth rib also shows advanced
arthritic changes at the vertebral end. O n the
left side, the fifth rib was broken 50 mm lateral to
the head, the six rib was broken in the middle
(also showing arthritic changes at the head),
and the ninth rib was broken close to its sternal
end.
In addition to fractures of the ribs, evidence of
local inflammation along the costal grooves is
common. Muscle attachments on the superior
surfaces of the second ribs (for serratus anterior
and posterior scaleni muscles) are vely prominent.
The first costal cartilages are ossified.
In the sternum, arthritic changes are present at
the sternal angle and at the sternoclavicularjoint.
The thoracic cage of the second boxer also has
several fractured ribs. O n the left side, ribs seven
and eight show healed fractures in the anterior
third of their lengths. O n the right side, ribs four
to nine and twelve exhibit healed fractures in the
middle third (Figure 14).
Bone Injury in Boxing
Figure 13. Pits (arrows) in metatarsal bones caused by gout (A) and spondyloathropathy (5).
Figure 14. Fractures of the ribs in specimen HTH 2961.
Vertebrae
In general the vertebral column seems to be the
least affected part of the body, with a few
exceptions. T h e seventh cervical vertebra has a
broken anterior costal bar (which delimits the
anterior part of the foramen transversarium
(Figure 15). The third to sixth thoracic
vertebrae show beak-like extensions of the
spinous processes. In the distal six thoracic
vertebrae and all lumbar vertebrae the
secondary centre of ossification at the spinous
processes and transverse processes failed to fuse.
On L-4 and L-5 there are arthritic changes,
175
including eburnation on the left articular
processes. Bony changes are also present on the
tip of the spinous process of L- 1.
In the second boxer, the cervical vertebrae
from C-3 to C-7 show advanced arthritic changes
(osteophytes, lipping), including collapse of the
bodies of C-3 and C-4. Arthritic changes are less
pronounced in the thoracic region but some
spinous processes have a beak-like extended tip,
as in the first boxer. The lumbar vertebrae show
large osteophytes. There are large arthritic facets
on both superior and inferior aspects of the
spinous processes of the middle lumbar vertebrae
(Figure 16). These facets are probably due to a
176 I. Hershkouitz et a / .

Figure 15. Healed fracture of the anterior

costal bar of the seventh cervical vertebra.

Figure 16. Presence of an articular surface

on the inferior aspect of a lumbar vertebral
spinous process.

Figure 17. Fracture of the hyoid bone.

Bone Injury in Boxing
deep lumbar lordosis, which caused the spinous
processes to press against each other. Similar
facets are present in the first boxer too, but to a
lesser extent. The fifth lumbar vertebra was fused
with the sacrum.
Hyoid bone
The second boxer had a healed fracture of the
hyoid bone on the left side (Figure 17).
Discussion and conclusions
Th e question of how far we can go in our
interpretation of osteological changes observed in
ancient skeletons is a crucial issue in
anthropology." It is well known that different
occupations may produce similar bony changes.
However, as demonstrated here, when we look at
the whole skeleton, rather than at selected parts,
it may be possible t o make a differential diagnosis
and to tell something significant about the
individuals' life. Isolated criteria, for both disease
or occupation, are misleading. Instead, a whole
set of criteria should be used t o reach a
comprehensive conclusion.
Below is a list of bony lesions that, in tandem,
may indicate regular involvement in boxing or
hand-to-hand combat:
degenerative changes on the lesser
tuberosity of the humerus;
(ii) focal necrotic changeshone growth on the
trochlea of the humerus;
(iii) necrotic changes on the distal head of the
ulna;
a large number of broken ribs, both sides,
usually in different places.
multiple fractures of fingers and toes;
fractures of the zygomatic arch and nasal
bones;
(vii) bony patches on upper limb bones;
(viii) failure of secondary centres of ossification
t o fuse (mainly in vertebrae and acromion);
a huge conoid tubercle on the clavicle;
bony spurs on the distal articular head of
the metacarpals;
necrotic changes on the femoral head, next
177
to the fovea, and on the roof of the
acetabulum;
(xii) a strong attachment of the iliotrochanteric
ligament to the femur.
Many of these criteria, such as fractured digits,
ribs, and facial bones, would obviously be
expected in the skeletons of people who had
engaged in hand-to-hand combat or were prone
to some violent activity. Strong muscle markings
were intentionally not included in the list of
criteria because they can be produced by many
types of strenuous work. However, ligament
attachment areas can be helpful in a differential
diagnosis. These are influenced directly by the
forces applied to the joints. In the case of the
boxers, we noticed two areas of ligament
attachment that are unusually well developed:
the conoid tubercle on the clavicle and the
iliotrochanteric crest on the femur. The conoid
and the iliotrochanteric ligaments help ensure
stability of shoulder girdle and hip, respectively.
Other criteria listed above may need further
explanation. The damage to the lesser tuberosity
of the humerus (in contrast to the greater
tuberosity) probably resulted from repeated,
forceful medial rotation of the humerus during
punching while training and boxing. The focal
necrotic area on the humeral trochlea and the
bony spurs on the metacarpal heads probably
developed from repetitive strike impact. The
bony patches on the upper limb bones are
probably due to their defensive role while
boxing, i.e. blocking the opponents' blows.
Necrotic changes on the femoral head could
result from the boxers' tendency to 'dance' or
bounce in one place on both feet while boxing
and training. In those whose training began
before adulthood, extreme tension in muscles
and ligaments may prevent fusion between
secondary and primary centres of ossification by
pulling the secondary centre away from the
primary, as in the case of the deltoid muscle on
the acromion. Evidence of gout was clearly noted
in one of the boxers studied. Although it is
certainly not conclusively related to boxing
activity, the disease may be correlated indirectly
with body-building sports like boxing. This is
because many body-builders consume large
quantities of red meat in order to develop their
178
muscles, and such consumption is a possible cause
for gout.I2
T h e question we should ask ourself now is:
why not violence? Indeed, some of the criteria
described by us, if described by themselves, e.g.
nasal fracture, would be a good indication for
accidental, temporary, interpersonal violence.
However, when we apply other information,
e.g. lesions of the humeral lesser tuberosity, it
becomes clear that we are not dealing with
deliberate accidental isolated case of violence but
rather with an individual who was engaged in
frequent hand-to-hand combat.
In summary, several types of lesion were
observed in the skeletons of two men known to
have been regularly engaged in hand-to-hand
combat. These included many healed fractures,
necrotic changes in some muscle attachments and
joints of the upper and lower limb, failure of
fusion of secondary ossification centres of the
vertebrae and acromion, and evidence of gout.
None of the lesions alone would suggest that
these men were engaged in such activity.
However, in combination, they indicate a
history of repeated skeletal trauma suggestive of
prolonged activity in boxing and other forms of
hand-to-hand combat. Combinations of similar
lesions in other skeletons may thus suggest a
similar long-term activity.
Acknowledgements
The excellent pictures were taken by D. Flocke, the
photographer of the Cleveland Museum of Natural
History. We are most gratehl to Ms Michelle
Scheuffler, Director of the Health Information
Service, University Hospitals, Cleveland, Ohio, who
provided us with the autopsy records, and to Mr M.
Kassuf, of the Division of Vital Statistics, Cleveland,
Ohio, for the death certificates.
The research was carried out during the sabbatical
of one of us (1.H.) at the Cleveland Museum of
Natural History.
I. Hershkouitz et al.
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