International Journal of Osteoarchaeology

Int. J. Osteoarchaeol. 27: 409–417 (2017)

Published online 30 September 2016 in Wiley Online Library
(wileyonlinelibrary.com) DOI: 10.1002/oa.2564

A Test of the Effectiveness of the Coimbra

Method in Capturing Activity-induced
Entheseal Changes
E. MICHOPOULOU,a E. NIKITAb* AND C. Y. HENDERSONc
a
Department of Biology, Division of Animal and Human Physiology, National and Kapodistrian University of
Athens, Athens, Greece
b
Science and Technology in Archaeology Research Center, The Cyprus Institute, Nicosia, Cyprus
c
CIAS – Research Centre for Anthropology and Health, Department of Life Sciences, University of Coimbra,
Coimbra, Portugal

ABSTRACT The current paper tests the effectiveness of entheseal changes in expressing activity patterns when the
former have been recorded using the new Coimbra method. Changes on the subscapularis and biceps
brachii were recorded using the Coimbra method on 78 men from the documented Athens Collection.
Generalised linear models were adopted with entheseal changes as dependent variable and
cross-sectional geometric properties, age and body mass as predictors. The results suggest that age is
the factor most frequently affecting entheseal changes; however, its impact is not as systematic as found
in previous studies. Body mass is rarely statistically significant, again contradicting earlier studies. Finally,
activity proxied by cross-sectional geometric properties is occasionally significant, but no clear pattern
emerges that can associate specific entheseal morphological changes with specific directions of mechanical
loading. Copyright © 2016 John Wiley & Sons, Ltd.
Key words: activity patterns; Coimbra method; entheses; generalised linear models

Introduction Despite the impact of mechanical loading on the

Bioarchaeological research has systematically explored
evidence of past activity patterns as imprinted on skel-
etal remains (e.g. Kieser et al., 2001; Marchi, 2008;
Robson Brown et al., 2008; Üstündağ, 2009; Jiménez-
Brobeil et al., 2010; Ogilvie & Hilton, 2011). Among
the primary anatomical areas examined have been the
entheses, that is, the sites where muscles, tendons or
ligaments attach on the bones (e.g. Hawkey & Merbs,
1995; Nagy, 1999; Weiss, 2003, 2015; Eshed et al.,
2004; Molnar, 2008; Villotte et al., 2010, 2016;
Havelková et al., 2011; Yonemoto, 2016). The relation-
ship between activity patterns and entheseal changes
(ECs) relies on biomechanical and clinical information,
which supports that bone reacts to mechanical stress by
increasing blood flow in the area under loading, which
in turn results in elevated bone growth, hence visible
ECs (e.g. Parfitt, 2004).
* Correspondence to: Efthymia Nikita, Science and Technology in Archae-
ology Research Center, The Cyprus Institute, Nicosia, Cyprus.
e-mail: e.nikita@cyi.ac.cy
skeleton, several studies noted that activity patterns
are often difficult to discern using ECs (Alves Cardoso
& Henderson, 2010; Villotte et al., 2010; Niinimäki,
2011; Milella et al., 2012). This lack of direct associa-
tion between activity and ECs has been attributed to
the fact that a combination of factors, such as age,
body mass, sex, metabolism, genetic predisposition
and certain pathological conditions, also contribute to
EC development (e.g. Benjamin & McGonagle, 2001;
Henderson, 2008, 2013; Jurmain et al., 2011;
Niinimäki, 2011; Milella et al., 2012; Weiss et al.,
2012). Indeed, several studies have found that age is
the primary factor affecting ECs with older individuals
generally exhibiting more pronounced changes (e.g.
Weiss, 2003, 2004, 2007; Alves Cardoso & Henderson,
2010; Niinimäki, 2011; Milella et al., 2012). This phe-
nomenon may be due to the cumulative effect of activ-
ity patterns or be the outcome of tissue degeneration
occurring with increasing age. Moreover, ECs differ
between men and women. This differentiation may be
attributed to sexual division of labour, thus be indica-
tive of daily activity patterns, but it has also been

Copyright © 2016 John Wiley & Sons, Ltd. Received 5 July 2016
Revised 18 August 2016
Accepted 24 August 2016
410
linked to the different body size (Weiss, 2003, 2004,
2007), as well as hormonal differences between the
two sexes (Wilczak, 1998; Niinimäki, 2011). Finally,
body size affects ECs because bigger individuals
exhibit more pronounced changes (Weiss, 2003,
2004, 2007; Niinimäki, 2011). This may be explained
by the fact that individuals with greater body size
require more effort for movement.
Given the multifactorial aetiology of ECs, recent
studies exploring these markers to deduce past activity
patterns have adopted statistical models such as analy-
sis of covariance or generalised linear models (GLM),
which allow the study of the simultaneous impact of
multiple variables, namely, age, sex, body mass and
activity, on ECs (Villotte et al., 2010; Niinimäki,
2011, 2012; Nikita, 2014; Henderson & Nikita,
2015). Such methods allow the study of the impact of
activity patterns on ECs while controlling for the effect
of other contributing factors. The results have so far
supported the primary role of age in EC expression,
followed by body size, while activity patterns also
appear to exert a subtle impact on the observed
changes (for example, Henderson & Nikita, 2015;
Michopoulou et al., 2015, but see also Villotte et al.,
2010 for a more pronounced impact of activity).
Despite the availability of statistical tests that allow
the effective study of multifactorial phenomena, such
as ECs, the optimum way to record ECs in order to
capture activity-induced alterations remains unclear. A
recent study by Michopoulou et al. (2015) showed that
when ECs are scored using the most commonly
adopted recording protocols, that is, the Hawkey and
Merbs (1995), Mariotti et al. (2004) and Villotte et al.
(2010) methods, there does not appear to be a system-
atic significant contribution of activity [proxied by
archival profession data and cross-sectional geometric
(CSG) properties] on ECs. However, the same paper
noted a differential contribution of age, and secondar-
ily body mass, on EC expression on the right-sided
and left-sided upper limbs, which is potentially related
to the underlying impact of activity.
The current paper examines whether recording ECs
using the new Coimbra method (Henderson et al.,
2013, 2015) can reveal a more systematic significant
contribution of activity to EC expression. The new
Coimbra method for recording fibrocartilaginous
entheses was developed as a method to score different
features of the ECs and determine their aetiology
(Henderson et al., 2013, 2015). The method is only
defined for fibrocartilaginous entheses because, unlike
fibrous entheses, these have a ‘normal’ baseline appear-
ance devoid of any roughness, pores or other alter-
ations (Henderson et al., 2013). The features recorded
Copyright © 2016 John Wiley & Sons, Ltd.
E. Michopoulou et al.
by the method encompass the spectrum of changes
seen at fibrocartilaginous entheses from new bone
formation, erosions, textural change, porosity (both
fine porosity and macroporosity) and cavitations
(Henderson et al., 2013, 2015; Villotte et al., 2016).
Due to the higher fibrous content at the acute attach-
ment of the fibres to the bone, this zone (zone 1) is
recorded separately from the remaining bone surface.
To date, there are limited clinical data on the underly-
ing aetiology of the observed changes on entheseal
sites, and this is one of the reasons that the new
Coimbra method records and analyses each feature sep-
arately, to determine which feature or features are most
closely linked to biomechanics and thus are most appro-
priate for identifying activity patterns in the skeleton.
Therefore, it is interesting to see if this method has
the potential to capture activity-related markers more
effectively but also to examine which of the recorded
morphological changes appear to be more strongly
influenced by activity, rather than other factors.
Materials and methods
The sample under examination included 78 male skele-
tons, which form part of the Athens collection, housed
at the Department of Biology, Division of Animal and
Human Physiology, National and Kapodistrian Univer-
sity of Athens, and consists of individuals that lived and
died in Greece during the 20th century (Eliopoulos
et al., 2007). The documented age of these individuals
ranges from 24 to 96 years and has the following distri-
bution: 20–40 years: 7 individuals, 40–60 years: 29 indi-
viduals, 60–80 years: 31 individuals and over 80 years:
11 individuals. Individuals suffering from seronegative
spondyloarthropathy, Diffuse Idiopathic Skeletal
Hyperostosis (DISH) and/or acromegaly (conditions
identified following Ortner, 2003 and Waldron, 2008)
were excluded because these conditions demonstrably
influence entheseal morphology (e.g. Belanger & Rowe,
2001; Benjamin & McGonagle, 2001; Henderson,
2008). Note that the individuals included in the current
study are a subset of the 90 individuals used in the paper
of Michopoulou et al. (2015). Twelve individuals of the
original study had to be excluded from the current one
because of their unavailability at the time of data
collection.
Only fibrocartilaginous entheses of the upper limbs
were examined, namely, the subscapularis on the
humerus and biceps brachii on the radius. The reasons
underlying our decision to focus only on
fibrocartilaginous entheses were two: (i) it has been
suggested that fibrocartilaginous entheses exhibit a
Int. J. Osteoarchaeol. 27: 409–417 (2017)
Effectiveness of the Coimbra Method
higher correlation with activity than fibrous entheses
(Villotte et al., 2010), and (ii) the baseline normal
appearance of fibrocartilaginous entheses is recognised,
whereas the fibrous entheses have no identifiable base-
line normal appearance. The subscapularis and biceps
brachii were chosen because their zones are most
clearly described in the original publication of the
Coimbra method by Henderson et al. (2013); thus, they
can be easily identified and accurately recorded. Both
right and left elements were included in the sample.
The EC recording scheme used was developed
during a workshop organised in Coimbra, Portugal, in
2009, and its latest version is described in detail in
Henderson et al. (2015). In brief, the Coimbra method
divides each enthesis into two zones and subsequently
records a series of morphological alterations manifest-
ing as new bone formation or resorption using an ordi-
nal scale, as described in the Introduction section. A
single observer (E. M.) performed all EC data collection
in order to avoid biases because of interobserver error.
The possible impact of intraobserver error was tested
by repeating data collection on 10 individuals 3 weeks
after the original data collection was completed. The
results of the two rounds of data collection showed a
high and significant correlation (Spearman's ρ or ϕ
coefficient always >0.9 and p-value <0.05).
The age of each individual was obtained from docu-
mented records. Body mass was used as a proxy for
body size, and it had already been calculated in the
context of the paper of Michopoulou et al. (2015).
Activity was proxied by the CSG properties of the
humerus and radius. These properties had been calcu-
lated in the context of the study of Michopoulou et al.
(2015) and included TA, Ix/Iy and Imax/Imin, whereby
the total subperiosteal area of the diaphyseal cross
section (TA) expresses resistance to tension, compres-
sion or shear, whereas the second moments of area
(Ix, Iy, Imax and Imin) express resistance to bending forces
(Stock & Pfeiffer, 2001; Ruff, 2008). The CSG proper-
ties were calculated based on periosteal moulds, which
were obtained at the midshaft of the radius and at 35%
distance from the distal end of the humerus in order to
avoid the deltoid tuberosity (see Nikita et al., 2011 for
details).
It must be noted that in the paper by Michopoulou
et al. (2015), additionally to CSG properties, docu-
mented profession was also used as an activity proxy,
and the individuals under study were divided into a
‘manual’ and a ‘non-manual’ group. In the current paper,
it was decided to restrict our activity markers to CSG
because data on profession were available for less than
two-thirds of our sample and in order for complex sta-
tistical tests to provide accurate results, sample sizes
Copyright © 2016 John Wiley & Sons, Ltd.
411
should be as large as possible. Our decision was addi-
tionally based on a number of inherent limitations of
documented profession as an activity proxy that have
been identified by other scholars (see discussion in
Alves Cardoso and Henderson, 2013), and the fact that
in the paper of Michopoulou et al. (2015), the conclu-
sions drawn when using profession and CSG properties
were largely similar.
In order to examine the impact of activity, age and
body mass on ECs, as captured by the new Coimbra
method, GLM were used. In these models, ECs were
assigned as dependent variable and CSG, age and body
mass as independent variables. It must be noted that
whereas in the paper of Michopoulou et al. (2015),
the GLM models included all independent variables
simultaneously, in the current paper two approaches
were followed. First, the models were run including
the main effects of all variables, like in the paper of
Michopoulou et al. (2015). Second, the models were
run including the main effects and the two-way interac-
tions between TA-body mass, TA-age and body mass-
age. In the latter case, due to the large number of inde-
pendent variables, the optimum model was identified
based on the Akaike information criterion, which is a
measure of the relative quality of the GLM model,
and this is the one reported in the following sections.
To identify the optimum model, initially, all indepen-
dent variables (main effects and selected two-way inter-
actions) were included in the model; then, the
independent variable exhibiting the highest p-value
(thus the least significant contribution to the model)
was eliminated, and the test was repeated with the
remaining variables until the lowest Akaike value was
reached. All tests were run in R version 3.3.1 using
the clm() function of the ‘ordinal’ library, whereas for
the determination of the optimum model based on
the Akaike criterion, the stepAIC() function of the
‘MASS’ library was used.
Results
Table 1 presents the sample sizes for the material under
study per side and element, as well as descriptive statis-
tics. Tables 2–5 show the p-values for the model coef-
ficients, as well as the Akaike information criterion.
Note that Tables 2, 3 present the results obtained when
the main effect of all predictors is included in the
model, whereas Tables 4, 5 show the best models,
based on the smallest Akaike information criterion,
when all main effects as well as the interactions be-
tween TA-age, TA-body mass and body mass-age are
considered. The reason TA was preferred over the
Int. J. Osteoarchaeol. 27: 409–417 (2017)
412 E. Michopoulou et al.

Table 1. Sample sizes and descriptive statistics for entheseal changes

Zone Character N Min Max % Frequency

R L R L R L R L

0 1 2 0 1 2

M. sub-scapularis 1 BF 75 71 0 0 2 2 6.7 29.3 64.0 11.3 42.2 46.5

ER 75 71 0 0 2 2 65.3 29.3 5.4 71.8 25.4 2.8
2 TC 75 71 0 0 0 0 100 0 – 100 0 –
BF 75 71 0 0 2 2 46.7 41.3 12.0 57.7 35.3 7.0
ER 75 71 0 0 2 2 86.6 10.7 2.7 93.0 5.6 1.4
FPO 75 70 0 0 2 2 78.6 18.7 2.7 77.1 20.0 2.9
MPO 75 71 0 0 2 2 80.0 5.3 14.7 78.8 11.3 9.9
CA 75 71 0 0 2 2 90.7 5.3 4.0 93.0 2.8 4.2
M. biceps brachii 1 BF 78 72 0 0 2 2 14.1 29.5 56.4 5.6 30.6 63.8
ER 78 72 0 0 2 2 73.0 24.4 2.6 72.2 26.4 1.4
2 TC 78 72 0 0 1 1 88.5 11.5 – 81.9 18.1 –
BF 78 72 0 0 2 2 65.3 24.4 10.3 72.2 19.5 8.3
ER 78 72 0 0 2 2 71.8 17.9 10.3 80.5 18.1 1.4
FPO 78 72 0 0 2 2 67.9 29.5 2.6 72.2 22.2 5.6
MPO 78 72 0 0 2 2 83.3 10.3 6.4 84.7 8.4 6.9
CA 78 72 0 0 2 2 89.7 9.0 1.3 91.6 5.6 2.8

BF, bone formation; ER, erosion; TC, textural change; FPO, fine porosity; MPO, macro-porosity; CA, cavitation.

second moments of area in the examination of interac-
tions was because this is the only true CSG property
calculated from periosteal moulds.
Regarding age, it can be seen that this predictor only
has a systematically significant impact in the right
subscapularis (Table 2). However, in the left
subscapularis, as well as the right and left biceps
brachii, the impact of age is small and inconsistent
(Tables 2, 3). This observation applies to both when
uncorrected and Holm–Bonferroni corrected p-values
are inspected. When the best models, including inter-
actions, are examined (Tables 4, 5), it is seen that age
is the main factor exhibiting a significant association
with ECs, but again, this is mostly prevalent in the
right subscapularis. In contrast, age only affects signif-
icantly bone formation in zone 1 in the remaining
cases, as well as microporosity in the left biceps brachii,
and bone formation in zone 2 in the right biceps
brachii. In addition, the interaction of age with other
independent variables relating to activity and body
mass does not appear to have a significant impact on
any of the ECs.
Activity, expressed as CSG properties, rarely
appears to have a significant effect on ECs when
the main effect of all predictors is input in the model
(Tables 2, 3). It is striking that after Holm–
Bonferroni correction, the only significant relation-
ship is that between TA and bone erosion in zone

Table 2. p-values for the model coefficients when only main effects are included in the model – data for the right and left humerus (M.
subscapularis)

L humerus R humerus

Character AIC Age Body mass TA Ix/Iy Imax/Imin AIC Age Body mass TA Ix/Iy Imax/Imin

BF (Z1) 134.8 0.001* 0.703 0.949 0.292 0.069 120.0 0.001* 0.645 0.043 0.520 0.902
ER (Z1) 105.8 0.161 0.371 0.354 0.275 0.248 119.1 0.012 0.483 0.584 0.481 0.291
TC – – – – – – – – – – – –
BF (Z2) 132.7 0.067 0.814 0.612 0.955 0.878 145.4 0.002* 0.670 0.428 0.535 0.843
ER (Z2) 40.8 0.465 0.004* 0.000* 0.142 0.152 60.1 0.000* 0.097 0.246 0.620 0.062
FPO 94.6 0.109 0.213 0.718 0.681 0.760 87.9 0.018 0.962 0.742 0.021 0.145
MPO 102.1 0.074 0.947 0.961 0.514 0.821 101.6 0.292 0.093 0.523 0.617 0.766
CA 36.2 0.371 0.459 0.020 0.025 0.138 48.3 0.005* 0.115 0.110 0.356 0.789

Bold values are statistically significant at α = 0.05, whereas the asterisks denote values that remain statistically significant after the
Holm–Bonferroni correction.
BF, bone formation; ER, erosion; TC, textural change; FPO, fine porosity; MPO, macro-porosity; CA, cavitation; AIC, Akaike information
criterion.

Copyright © 2016 John Wiley & Sons, Ltd. Int. J. Osteoarchaeol. 27: 409–417 (2017)
Effectiveness of the Coimbra Method 413

Table 3. p-values for the model coefficients when only main effects are included in the model – data for the right and left radius (M.
biceps brachii)

L radius R radius

Character AIC Age Body mass TA Ix/Iy Imax/Imin AIC Age Body mass TA Ix/Iy Imax/Imin

BF (Z1) 115.4 0.009* 0.538 0.441 0.124 0.460 151.9 0.001* 0.593 0.533 0.940 0.268
ER (Z1) 99.8 0.178 0.431 0.209 0.399 0.698 114.9 0.403 0.220 0.586 0.467 0.298
TC 75.2 0.394 0.245 0.830 0.668 0.369 66.8 0.823 0.723 0.551 0.556 0.627
BF (Z2) 117.0 0.115 0.949 0.369 0.131 0.100 138.8 0.022 0.814 0.990 0.395 0.641
ER (Z2) 88.3 0.110 0.361 0.773 0.354 0.294 130.2 0.092 0.519 0.431 0.601 0.505
FPO 112.2 0.254 0.845 0.324 0.046 0.272 113.7 0.005* 0.225 0.687 0.858 0.145
MPO 85.5 0.051 0.826 0.842 0.493 0.524 98.1 0.267 0.159 0.201 0.567 0.997
CA 51.8 0.427 0.577 0.423 0.538 0.090 65.4 0.079 0.480 0.130 0.093 0.037

BF, bone formation; ER, erosion; TC, textural change; FPO, fine porosity; MPO, macro-porosity; CA, cavitation; AIC, Akaike information
criterion.

2 for the left subscapularis. When the optimum Discussion

models are examined, no CSG property appears to
have a significant effect on the ECs recorded on
the biceps brachii, whereas TA, Ix/Iy and Imax/Imin have
a significant effect on the right and left subscapularis
but only in rare occasions and without any clear pat-
tern. In addition, none of the interactions between
TA and the other predictors appears significant after
the Holm–Bonferroni correction.
Body mass only has a significant impact on ECs
as an individual predictor in the case of bone
erosion in zone 2 of the left subscapularis
(Table 2), as well as in textural changes in the right
biceps brachii, and fine porosity in the right
subscapularis when the optimum models are
inspected (Tables 4, 5).
This study aims at complementing the results of an
earlier paper by Michopoulou et al. (2015) in investigat-
ing the effect that activity has on EC expression. The
main purpose of the current paper is to explore whether
activity markers show a strong correlation with ECs
when the latter are recorded using the new Coimbra
method in the Athens collection. It must be noted that
the earlier study using the Hawkey and Merbs (1995),
Mariotti et al. (2004) and Villotte et al. (2010) methods
found age to be the predominant factor affecting EC
expression, with body mass having the second most
significant effect, whereas activity was rarely signifi-
cant. Nevertheless, the same study identified a different
effect of age and body mass on the entheses of the left

Table 4. p-values for the optimum model coefficients – data for the right and left humerus (M. subscapularis)

Character AIC Age Body mass TA Ix/Iy Imax/Imin TA * body mass TA * age Body mass * age

L humerus
BF (Z1) 128.50 0.001*
ER (Z1) 98.97 0.216
TC – – – – – – – – –
BF (Z2) 120.42 0.058
ER (Z2) 38.34 0.062 0.006*
FPO 88.94 0.082 0.137
MPO 95.28 0.095 0.128
CA 30.32 0.057 0.071 0.113 0.037 0.058
R humerus
* *
BF (Z1) 114.38 0.001 0.043
ER (Z1) 114.82 0.012* 0.017*
TC – – – – – – – – –
BF (Z2) 138.86 0.001*
ER (Z2) 58.52 0.002* 0.028 0.063
FPO 83.53 0.015* 0.028
MPO 96.35 0.193
CA 44.27 0.006* 0.041 0.030 0.095 0.046

BF, bone formation; ER, erosion; TC, textural change; FPO, fine porosity; MPO, macro-porosity; CA, cavitation; AIC, Akaike information
criterion.

Copyright © 2016 John Wiley & Sons, Ltd. Int. J. Osteoarchaeol. 27: 409–417 (2017)
414 E. Michopoulou et al.

Table 5. p-values for the optimum model coefficients – data for the right and left radius (M. biceps brachii)

Character AIC Age Body mass TA Ix/Iy Imax/Imin TA * body mass TA * age Body mass * age

L radius
BF (Z1) 110.89 0.006* 0.058
ER (Z1) 94.40 0.132 0.037 0.067 0.092 0.051
TC 70.40 0.168 0.126
BF (Z2) 112.49 0.093
ER (Z2) 82.81 0.259
FPO 107.69 0.061
MPO 79.70 0.010*
CA 39.87 0.300 0.128 0.120 0.225 0.256 0.117 0.117
R radius
*
BF (Z1) 146.05 0.003
ER (Z1) 109.24 0.048 0.223 0.025 0.022 0.053
TC 59.26 0.127 0.008* 0.065 0.065 0.157
BF (Z2) 131.79 0.009*
ER ( 123.94 0.064
Z2)
FPO 108.60 0.013 0.054 0.698 0.146 0.068 0.023
MPO 92.87 0.435
CA 62.47 0.138 0.079

BF, bone formation; ER, erosion; TC, textural change; FPO, fine porosity; MPO, macro-porosity; CA, cavitation; AIC, Akaike information
criterion.

and right upper limbs, suggesting that activity must
play a subtle role in the bilateral expression of ECs.
Based on the results of the current study, ECs
recorded using the new Coimbra method rarely exhibit
a significant correlation with CSG properties, used as
activity markers. This lack of correlation applies both
when examining the main effects of all predictors as
well as when using optimum models with selected
interactions. In addition, no systematic association is
traced between a specific aspect of the ECs (e.g.
porosity, bone formation etc.) and CSG; therefore,
there do not appear to be any specific osseous
responses to mechanical loading that are more informa-
tive regarding past activity patterns than others.
At this point, it must be stressed that using CSG
properties as a proxy for activity has certain limitations,
which may underline the observed lack of association
between CSG and ECs. In specific, by means of
CSG, in the current study, we have captured the
rigidity of skeletal elements against bending and
compressive forces. However, we cannot exclude the
possibility that different types of mechanical stress,
such as high peak strain or shear strain, were more
important in producing ECs. In addition, the ontogeny
of CSG and EC responses may be different, and this is
potentially an important issue, especially given the
likelihood that profession/activity would change over
the life cycle of an individual/population.
What is striking in our current findings is the much
less pronounced overall impact of age, which contra-
dicts both our earlier findings (Michopoulou et al.,
2015) and studies by other authors, who have used
Copyright © 2016 John Wiley & Sons, Ltd.
different recording protocols (e.g. Wilczak, 1998;
Weiss, 2003, 2004, 2007; Benjamin et al., 2009;
Niinimäki, 2011; Milella et al., 2012). Note that in the
original publication of the Coimbra method, the
authors had tested the effect of age using ordinal
regression and found that bone formation in either
zone was most commonly associated with age;
however, this was not uniform across all entheses,
while even when there was a statistically significant
association, the effect of age was at most approximately
40% (Henderson et al., 2013).
Our statistical analysis shows that age is the primary
factor affecting EC expression using the new Coimbra
method, but the number of statistically significant
associations between age and EC is overall rather small.
Specifically, with the exception of the right
subscapularis, age rarely had a significant impact on
ECs in our sample, both as an individual factor and in
interaction with other predictors. This lack of a strong
association between age and ECs is striking considering
the age distribution of the sample under study, which
largely consisted of individuals aged between 40 and
80 years. Our findings may be explained by the
‘levelling off’ process. In specific, even though muscle
strength increases during growth, it plateaus between
25–30 years of age and starts declining after that time
(Henderson et al., 1995). Similarly, entheses, and
subsequently ECs, increase with age until approxi-
mately the age of 40–50 years, but after that age, the
process levels off (Klein et al. 2002; Milella et al.,
2012; Niinimäki, 2011; Robb, 1998). This phenome-
non has been attributed to physical activity decreasing
Int. J. Osteoarchaeol. 27: 409–417 (2017)
Effectiveness of the Coimbra Method
along with age (Milella et al., 2012), changing activity
patterns, or the fact that in old age, bones may have
reached their limits to react to biomechanical stress
(Robb, 1998; Niinimäki, 2011).
It is worth noting that the different impact that age
appears to have on the right and left sided elements is
in agreement with the findings of Michopoulou et al.
(2015) and may be interpreted as an indication of an
underlying impact of activity, which has not been
captured by CSG properties. However, it must be
stressed that this only applies to the subscapularis and
not the biceps brachii in the current study.
Finally, the impact of body size, proxied by body
mass in this study, appears to be minimal. This finding
contradicts earlier studies that identified body size as
one of the primary predictors of ECs (e.g. Weiss,
2003, 2004, 2007; Niinimäki, 2011; Weiss et al.,
2012). However, it must be stressed that earlier studies
had used specific bone dimensions as a proxy for body
size, rather than body mass. It is possible that although
body mass is a better overall measure of body size, the
dimensions of the bone elements on which the ECs
have been recorded approximate body size more di-
rectly with regard to the ECs under study. In any case,
the issue of the potential impact of body size on EC ex-
pression requires further consideration.
In conclusion, our results suggest that recording ECs
using the revised Coimbra method does not reflect ac-
tivity more effectively than earlier methods. However,
the apparent smaller impact of age and body size
(proxied by body mass) support that the Coimbra
method may be less affected by parameters that have
traditionally confounded the study of activity by means
of ECs. Finally, the differential impact of age on the
right and left subscapularis is notable and may reflect
an underlying effect of activity that has not been
captured by means of the CSG properties.
Acknowledgements
The authors wish to thank Professors Efstratios
Valakos and Sotiris Manolis for permission to study
the material used in the current study, as well as
two anonymous reviewers for their valuable
comments on the manuscript. This work was
supported by a Marie Skłodowska-Curie Individual
Fellowship granted to Efthymia Nikita [Programme/
Call: H2020 – H2020-MSCA-IF-2015, Proposal:
702991 – HumAn]. In addition, Charlotte Henderson
is funded by Fundação para a Ciência e a Tecnologia
[grant number SFRH/BPD/82559/2011].
Copyright © 2016 John Wiley & Sons, Ltd.
415
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