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Typical Joint
Code TH H3.
Anatomical terminology

The enthesis (plural: entheses) is the connective tissue between tendon or ligament and bone.[1]

There are two types of entheses: Fibrous entheses and fibrocartilaginous entheses.

In a fibrous enthesis, the collagenous tendon or ligament directly attaches to the bone, whereas the fibrocartilaginous interface encompasses four transition zones:

  1. Tendinous area displaying longitudinally oriented fibroblasts and a parallel arrangement of collagen fibres
  2. Fibrocartilaginous region of variable thickness where the structure of the cells changes to chondrocytes
  3. Abrupt transition from cartilaginous to calcified fibrocartilage—often called 'tidemark' or 'blue line'
  4. Bone


"Enthesis" is rooted in the Ancient Greek word, "ἔνθεσις" or "énthesis," meaning “putting in," or "insertion." This refers to the role of the enthesis as the site of attachment of bones with tendons or ligaments. Relatedly, in muscle terminology, the insertion is the site of attachment at the end with predominant movement or action (opposite of the origin). Thus the words (enthesis and insertion [of muscle]) are proximal in the semantic field, but insertion in reference to muscle can refer to any relevant aspect of the site (i.e., the attachment per se, the bone, the tendon, or the entire area), whereas enthesis refers to the attachment per se and to ligamentous attachments as well as tendinous ones.


A disease of the entheses is known as an enthesopathy or enthesitis.[2] Enthetic degeneration is characteristic of spondyloarthropathy and other pathologies.

The enthesis is the primary site of disease in ankylosing spondylitis.


Entheses are widely recorded in the field of bioarchaeology where the presence of anomalies at these sites, called entheseal changes, has been used to infer repetitive loading to study the division of labour in past populations.[3] Several different recording methods have been proposed to record the variety of changes seen at these sites.[4][5][6][7][8][9][10][11] However, research has shown that, whichever recording method is used, entheseal changes occur more frequently in older individuals.[12][5][13][14] Clinical research demonstrates that diseases, such as ankylosing spondylitis, have to be taken into consideration.

See also[edit]


  1. ^ "enthesis". Medcyclopaedia. GE. [dead link]
  2. ^ Benjamin, M.; Toumi, H.; Ralphs, J. R.; Bydder, G.; Best, T. M.; Milz, S. (April 2006). "Where tendons and ligaments meet bone: Attachment sites (‘entheses’) in relation to exercise and/or mechanical load". Journal of Anatomy. 208 (4): 471–90. PMC 2100202Freely accessible. PMID 16637873. doi:10.1111/j.1469-7580.2006.00540.x. 
  3. ^ Jurmain, Robert; Cardoso, Francisca Alves; Henderson, Charlotte; Villotte, Sébastien (2011-01-01). Grauer, Anne L., ed. A Companion to Paleopathology. Wiley-Blackwell. pp. 531–552. ISBN 9781444345940. doi:10.1002/9781444345940.ch29/summary. 
  4. ^ Hawkey, Diane E.; Merbs, Charles F. (1995-12-01). "Activity-induced musculoskeletal stress markers (MSM) and subsistence strategy changes among ancient Hudson Bay Eskimos". International Journal of Osteoarchaeology. 5 (4): 324–338. ISSN 1099-1212. doi:10.1002/oa.1390050403. 
  5. ^ a b Henderson, C. Y.; Mariotti, V.; Pany-Kucera, D.; Villotte, S.; Wilczak, C. (2013-03-01). "Recording Specific Entheseal Changes of Fibrocartilaginous Entheses: Initial Tests Using the Coimbra Method". International Journal of Osteoarchaeology. 23 (2): 152–162. ISSN 1099-1212. doi:10.1002/oa.2287. 
  6. ^ Henderson, C. Y.; Mariotti, V.; Pany-Kucera, D.; Villotte, S.; Wilczak, C. (2016-09-01). "The New ‘Coimbra Method’: A Biologically Appropriate Method for Recording Specific Features of Fibrocartilaginous Entheseal Changes". International Journal of Osteoarchaeology. 26 (5): 925–932. ISSN 1099-1212. doi:10.1002/oa.2477. 
  7. ^ Valentina, Mariotti,; Fiorenzo, Facchini,; Maria, Giovanna Belcastro, (2004-06-15). "Enthesopathies – Proposal of a Standardized Scoring Method and Applications". Collegium antropologicum. 28 (1). ISSN 0350-6134. 
  8. ^ Valentina, Mariotti,; Fiorenzo, Facchini,; Giovanna, Belcastro, Maria (2007-01-04). "The Study of Entheses: Proposal of a Standardised Scoring Method for Twenty-Three Entheses of the Postcranial Skeleton". Collegium antropologicum. 31 (1). ISSN 0350-6134. 
  9. ^ Villotte, Séb. "Practical protocol for scoring the appearance of some fibrocartilaginous entheses on the human skeleton". 
  10. ^ Villotte, Sébastien; Castex, Dominique; Couallier, Vincent; Dutour, Olivier; Knüsel, Christopher J.; Henry-Gambier, Dominique (2010-06-01). "Enthesopathies as occupational stress markers: Evidence from the upper limb". American Journal of Physical Anthropology. 142 (2): 224–234. ISSN 1096-8644. doi:10.1002/ajpa.21217. 
  11. ^ Villotte, Sébastien; Assis, Sandra; Cardoso, Francisca Alves; Henderson, Charlotte Yvette; Mariotti, Valentina; Milella, Marco; Pany-Kucera, Doris; Speith, Nivien; Wilczak, Cynthia A. (2016-06-01). "In search of consensus: Terminology for entheseal changes (EC)". International Journal of Paleopathology. 13: 49–55. doi:10.1016/j.ijpp.2016.01.003. 
  12. ^ Cardoso, F. Alves; Henderson, C. (2013-03-01). "The Categorisation of Occupation in Identified Skeletal Collections: A Source of Bias?". International Journal of Osteoarchaeology. 23 (2): 186–196. ISSN 1099-1212. doi:10.1002/oa.2285. 
  13. ^ Michopoulou, Efrossyni; Nikita, Efthymia; Valakos, Efstratios D. (2015-12-01). "Evaluating the efficiency of different recording protocols for entheseal changes in regards to expressing activity patterns using archival data and cross-sectional geometric properties". American Journal of Physical Anthropology. 158 (4): 557–568. ISSN 1096-8644. doi:10.1002/ajpa.22822. 
  14. ^ Milella, Marco; Giovanna Belcastro, Maria; Zollikofer, Christoph P.E.; Mariotti, Valentina (2012-07-01). "The effect of age, sex, and physical activity on entheseal morphology in a contemporary Italian skeletal collection". American Journal of Physical Anthropology. 148 (3): 379–388. ISSN 1096-8644. doi:10.1002/ajpa.22060. 

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