International Journal of Osteoarchaeology Int. J. Osteoarchaeol. 20: 280–290 (2010) Published online 10 February 2009 in Wiley InterScience (www.interscience.wiley.com) DOI: 10.1002/oa.1029 Pubic Symphyseal Face Eburnation: An Egyptian Sport Story? M. A. JUDD* Department of Anthropology, University of Pittsburgh, Pittsburgh, PA 15260, USA ABSTRACT Strenuous physical activity leaves scars on bone that attest to the demands of occupation, sport, aggression and recreation. During the assessment of 74 C-Group Nubians from Hierakonpolis (Egypt) dated to the Egyptian Middle Kingdom–Second Intermediate Period (2080–1700 BC), robust muscle insertions along the ilia and ischia were observed among some adults. In addition, a disproportionate degeneration of the pubic symphyseal faces when compared to other age-related features was also noted. In the case of one male (Burial 32), the pubic symphyseal faces were completely flattened and polished so that they resembled the eburnation that is pathognomic of osteoarthritis. Differential diagnoses are discussed and osteitis pubis, an increasingly diagnosed injury among modern athletes who participate in intense activity that involves running, kicking, twisting or leaping, is proposed as the most likely etiology. The exaggerated muscle insertions and pubic symphyseal wear, epitomised by the individual interred in Burial 32, are unique features that may be linked to the unexplained presence of this Nubian group deep in Egyptian territory during a period of political instability. Artefactual, artistic and documentary evidence records how the Egyptian pharaohs and elites conscripted Nubian athletes to the royal courts for staged contests and entertainment, part of a propaganda program engineered to reinforce among the general populace the dogma of Egyptian supremacy over the enemy. This Nubian community, serviced by Cemetery HK27C, may have functioned as a source for individuals skilled in athletics or other activities that required exceptional physical dexterity. The extraordinary modification of these pubic symphyseal faces underscores the importance of recognising paleopathological conditions that may further confound current macroscopic methods used to ascertain the chronological age of an individual. Copyright ß 2009 John Wiley & Sons, Ltd. Key words: osteitis pubis; activity; pubic symphysis; bioarchaeology; aging; Nubia Introduction The physiological and psychological benefits of physical activity are widely acknowledged. However, during the pursuit of physical wellbeing or competition the individual is exposed to injury risk, whether micro- or macro-trauma, and this is most paramount in sports (Burt & Overpeck, 2001; Jones, 2006; Bentley et al., 2007). * Correspondence to: Department of Anthropology, University of Pittsburgh, 3302 Posvar Hall, 230 S Bouquet St, Pittsburgh, Pennsylvania, USA, 15260. e-mail: mjudd@pitt.edu Copyright # 2009 John Wiley & Sons, Ltd. Injuries obtained in collision sports, such as football, hockey and soccer are known hazards of the game (Herbenick et al., 2008), but other insidious injuries are more subtle and go undetected for a period of time. Sports medicine reports a variety of these injuries that, once diagnosed, are resolved quickly through surgical intervention and physiotherapy to ensure the athlete’s prompt return to sport. Athletes faced similar injury risks in antiquity, but received limited treatment particularly if the injury was internal. An increasingly diagnosed and studied sports injury is osteitis pubis that, if left unattended, severely impairs the individual’s ability to walk Received 5 May 2008 Revised 20 September 2008 Accepted 22 September 2008 Pubic Symphyseal Face Eburnation and perform daily bodily functions. The manifestation of this injury does not figure prominently in the paleopathological literature, which may be attributed to three factors: (1) the pubic bone is exceptionally delicate and its survival and/ or condition after thousands of years is highly variable; (2) the earlier osseous changes of osteitis pubis may be confused with the degenerative changes of aging and, as a result, the condition has gone unnoticed; and (3) the etiology of this injury was unclear among clinicians until recently. A systematic search for ‘osteitis pubis’ in International Journal of Osteoarchaeology and American Journal of Physical Anthropology produced three articles: Ashworth et al. (1976), Kelley (1979) and Tague (1988). In each publication the researchers referred to dorsal pubis scarring believed to be associated with parturition as osteitis pubis. The etiology of the condition was also poorly understood by clinicians at this time, but the increasingly reported frequency of the symptoms and diagnosis of osteitis pubis has rectified this oversight. This case report expands upon previous work (Judd, 2007, 2008) to illustrate the long-term effect of an untreated pubic injury resulting from overexertion, rather than prostate surgery or childbirth. The pubic anatomy is reviewed, differential diagnoses are considered and osteitis pubis is explained. The significance of this skeletal anomaly within the Middle Kingdom Egyptian context in which it was found and the possible social role of the individual are discussed. The lesion also illustrates the vulnerability of the pubic symphyseal face to factors that are unrelated to the chronological aging of an individual. 281 period for Nubian/Egyptian relations and therefore the presence of Nubian C-Group people in Egypt is perplexing. The individuals interred at HK27C were believed to have been wealthy or ‘special’ due to the advanced age of some adults, general good health, heterogeneous demographic profile, intricate leatherwork and distinctive artefacts (Friedman, 2001, 2004, 2007). The ongoing excavation and skeletal analysis test the hypothesis that this particular group was permitted to reside at Hierakonpolis without fear of Egyptian reprisal because of some ascribed identity that has yet to be detected from the artefactual or biological remains. Any interpretation involving human (or animal) skeletal remains is contingent upon an assessment of biological sex and age of the sample. Numerous methods are available, but we applied the standards summarised by Buikstra & Ubelaker (1994) that assess the dimorphism of the skull (nuchal crest, mastoid process, supraorbital margin and ridge, mental eminence), innominate (sciatic notch, preauricular sulcus) and the pubic symphysis morphology (Phenice, 1969). Sternal rib aging using any of ribs 3–5 (Loth et al., 1994) was integrated into our analysis as multiple methods of aging are preferable and the innominate was not always recovered due to the fragmentary nature of many of the skeletons. The skeleton was systematically examined for pathological lesions (osteoarthritis, dental disease, cribra orbitalia and osteoperiostitis) and scored following the protocol of Steckel et al. (2006); other anomalies, such as trauma and infectious disease were recorded as presented. Results Materials and methods Skeletal remains from Burial 32 were excavated and analysed on site during the 2007 excavation at Hierakonpolis, which is located 113 km north of Aswan in Egypt (Figure 1). The burials at this cemetery, HK27C, were ethnically Nubian rather than Egyptian and were dated to the late Middle Kingdom and early Second Intermediate period (2080–1700 BC) (Friedman, 2001, 2004, 2007; Irish, 2007). This was an exceptionally troubled Copyright # 2009 John Wiley & Sons, Ltd. During this examination it became apparent that the youthful smooth or scalloped rims, incipient pit or V-shaped articular surface and smooth walls of an individual’s isolated sternal rib ends did not correspond with the more advanced age phases assigned to the corresponding pubic symphyses and auricular surfaces for several individuals (Judd, 2007). The pubic symphyses of the individual recovered from Burial 32 were most severely affected and are discussed here. Int. J. Osteoarchaeol. 20: 280–290 (2010) 282 M. A. Judd Figure 1. Map showing location of Hierakonpolis. The skeletal remains from Burial 32 were very fragmentary with only the left clavicle, right humerus and left innominate nearly complete (Figure 2). Smaller intact bones included four carpals, two metacarpals, four hand phalanges, eight tarsals, three metatarsals, thirteen foot phalanges, eight vertebrae and two tooth roots. The right and left pubis, sacrum and ribs were incomplete. The individual was an adult based on Copyright # 2009 John Wiley & Sons, Ltd. epiphyseal fusion and heavy dental wear of the permanent roots past the cemento-enamel junction (CEJ). The presence of tarsal and vertebral osteophytes also suggested an older adult, most probably middle-aged (35–50 years) at least. The subpubic concavity was narrow and characteristically male. The medial position of the ventral arc was visible on the right pubic body; the low plateau of the auricular surface was also a male Int. J. Osteoarchaeol. 20: 280–290 (2010) Pubic Symphyseal Face Eburnation 283 feature. A thick proliferation of osteophytes occurred on the inferior margin of the humeral head (Score ¼ 3) and enthesophytes projected from the subscapularis insertion and shoulder joint capsule. Marginal osteophytes extended horizontally from the edges of eight vertebral bodies and were more prominent on the left side of the lumbar vertebrae where, on some vertebrae, the osteophytes curled slightly towards the adjacent intervertebral space as described by Rogers & Waldron (1995) (Figure 3). A Schmorl’s node was noted on the superior surface of L-4. Osteophytes demarcated the left acetabular rim (Score ¼ 2), while a tongue of osteophytes extended from the inferior tip of the acetabulum. Small surface osteophytes and active porosity were also observed. Marginal osteophytes outlined the left auricular surface (Score ¼ 2), but the joint was not grossly affected by normal age degeneration. Both pubic bones were recovered, but were incomplete (Figure 4). The superior ramus was absent from the right pubic bone. The medial portion of the distal segment of the left pubic face was recovered and both rami were absent. The attachment of the site of the ventral pubic ligament adductor muscle group was visible on Figure 2. Skeletal inventory of Burial 32. Figure 3. Fourth lumbar vertebra showing osteophytes and Schmorl’s node. Copyright # 2009 John Wiley & Sons, Ltd. Int. J. Osteoarchaeol. 20: 280–290 (2010) M. A. Judd 284 Figure 4. Anterior view of right and left pubic bones. the right pubis, as was the gracilis attachment. The pubic symphyseal faces exhibited macroporosity, were completely flat and smooth, and had a sheen (Figure 5) so that they had the appearance of the eburnation associated with osteoarthritis (Rogers & Waldron, 1995: 13). Discussion Pubic bone anatomy In order to diagnose this unique anomaly, it is essential to understand the anatomy of the pubic symphysis and its relationship to the pelvic basin. The symphyseal faces of the pubic bones are jacketed by a thin layer of hyaline cartilage, are tightly bound together and are separated by a fibrocartilaginous disc that forms the symphysis. The disc has some mobility, about 2 mm, and in females this becomes more flexible during pregnancy when the hormone relaxin causes the symphyseal space to expand up to 1 cm before returning to normal (Gamble et al., 1986). However, chronic overloading can also facilitate an increase in space and once 1 cm is reached joint laxity and instability result. The abdominal muscles (rectus abdominus and external and internal oblique) attach distally to the pubic symphysis, inguininal ligament and conjoined tendon. The superior and inferior rami of the pubic bones are the site of origin for the adductors (pectineus, adductor longus, adductor brevis, adductor magnus and gracilis). The pubic symphysis and sacroiliac joints respond to movement, but any abnormal force disrupts the stability of the pelvic ring. This disruption is transmitted throughout the pelvic ring placing additional stress on the other joints and affects ability to stand and bear weight (Major & Helms, 1997). Differential diagnosis Figure 5. Medial view of right pubic symphyseal face. Copyright # 2009 John Wiley & Sons, Ltd. The incomplete and fragmentary nature of this individual severely impedes the interpretation of the pathological process(es) manifest on bone. However, sufficient skeletal evidence is present to discriminate against some disease processes. The mobility of the pubic symphysis increases during childbirth due to the hormone relaxin that permits widening to facilitate the development and birth of the child. This is normally a temporary adjustment and the symphyseal disc returns to its normal size within 3–6 months after birth, although there are exceptions (Resnick, 2002a, p. 2127; Seth et al., 2003). When the width of the joint space does not return to its normal 7 mm or less, bone erosion, resorption and eburnation may occur (Resnick, 2002a, p. 2130). As this individual was identified as a male, complications resulting from childbirth are not relevant here. Int. J. Osteoarchaeol. 20: 280–290 (2010) Pubic Symphyseal Face Eburnation Age hastens the degeneration of any joint, the pubic symphyseal joint being no exception. Agerelated changes may include joint narrowing, marginal osteophytes and subchondral cysts. While marginal lipping and surface destruction of the pubic face are associated with the aging process, the excessive flattening and polishing of the face observed here is not mentioned in Todd’s (1920, 1921) seminal papers on the aging process using the pubis or in any of the later methods developed from Todd’s work (Gilbert & McKern, 1973; Meindl et al., 1985; Katz & Suchey, 1986; Suchey et al., 1986; Brooks & Suchey, 1990; Klepinger et al., 1992; Sakaue, 2006). Among individuals over 50 years of age, Todd (1920) noted erosive change, possibly with some osteophytic growth on the face and destruction of the vertebral margin. Brooks & Suchey (1990) described the pubic face in the final (Phase VI) as being pitted or porous with disfigurement due to erratic ossification. Acsadi & Nemeskéri (1970, p. 126) referred to features of the aged pubic face as being ‘‘. . .partly concave, sunken inwards, porous and shriveled’’. As a caveat, they state that age changes must be considered on an individual basis rather than be limited within a set range (Acsadi & Neméskeri, 1970, p. 126). Flattening and eburnation of the pubic face, if observed by any of these previous researchers, was not considered to be part of normal age-related changes associated with the human pubic face. It is noteworthy, however, that some researchers studying non-human primates (macaques) observed smooth, knife-like flat surfaces prior to the normal age-associated ankylosis of the male pubic symphysis (Rawlins, 1975). Because the pubic symphyseal joint is nonsynovial it is not susceptible to synovial fluid damage or disease processes initiated by synovial fluid/membrane inflammation such as rheumatoid arthritis (Gamble et al., 1986; Alicioglu et al., 2008). However, the pubic symphyseal faces of Individual 32 indicated an advanced stage of some pathological process and the constellation of skeletal modifications associated with spondyloarthropathies needs to be evaluated. Aside from a single Schmorl’s node and osteophytic spikes, no pattern distinctive of the seronegative spondyloarthropathies, such as ankylosing spondylitis, psoriatic arthritis and rheumatoid arthritis Copyright # 2009 John Wiley & Sons, Ltd. 285 (as described by Rogers & Waldron, 1995) were observed. Differential signs for diagnosing the spondyloarthropathies were summarised by Arriaza (1993) and aside from Reiter’s syndrome, the pubis is rarely involved. Psoriatic arthritis, associated with soft tissue psoriasis, is differentiated from other spondyloarthropathies by the destruction of distal and middle phalanges resulting in complete obliteration of the distal phalanges or a characteristic ‘cup-and-pencil’ morphology (Rogers & Waldron, 1995, p. 70– 73; Ortner, 2003, p. 580). Rheumatoid arthritis is typically polyarticular and symmetrical, favouring the erosion and deformation of the upper extremity and appendage joints. The diarthrodial joints of the cervical vertebrae may also be affected (Rogers & Waldron, 1995, p. 55–63; Ortner, 2003, p. 562–563). This disease process commences with an infection of the synovial fluid and membrane, rather than the fibrocartilagenous joints. The fusion of the sacroiliac is the hallmark of ankylosing spondylitis; vertical bony outgrowths from the vertebral body margins, syndesmophytes, that ascend the spine resulting in ankylosis are also common (Rogers & Waldron, 1995, p. 65; Jajic et al., 2000; Ortner, 2003, p. 572). Cartilaginous joints gradually ossify in these processes leading to complete ankylosis. Spurring or whiskering at ligament or tendon attachment sites on postcranial elements and bilateral synovial joint destruction are secondary features observed in the skeleton (Resnick, 2002b, p. 1023). Radiological studies found that individuals diagnosed with ankylosing spondylolitis who exhibited symphyseal changes, manifest as surface erosion and adjacent eburnation, also bore the hallmark sacroiliac changes which were more advanced in all cases (Jajic et al., 2000). This was not the case here. The pubic symphyseal faces did not show any marginal osteophytic outgrowths that would have initiated joint fusion. Furthermore, the sacroiliac joint did not exhibit the early stages of articular destruction that signal the beginnings of marginal ankylosis, nor were exuberant vertical syndesmophytes observed on any of the vertebral elements. The presence of enthsophytes projecting from the subscapularis insertion, the shoulder joint Int. J. Osteoarchaeol. 20: 280–290 (2010) M. A. Judd 286 capsule and the adductor insertion as well the periarticular osteophytes of the humeral head and tarsals, warrant that DISH (diffuse idiopathic skeletal hyperostosis) also be considered. DISH typically affects people over 50 years of age and is diagnosed by three criteria: flowing ‘candle-waxlike’ ossification of the anterolateral borders of four consecutive thoracic vertebrae; absence of vertebral body degenerative changes; and absence of spinal facet joint involvement (Rogers & Waldron, 1995, p. 47; Belanger & Rowe, 2001). There was no sequence of four fused vertebrae among the eight vertebrae that survived nor was prolific ossification of the anterior longitudinal ligament present on individual vertebrae. Had this disease process affected this individual, these osseous changes would have been present in these advanced stages due to the age of the individual. Finally, the pubic symphyseal face is not involved in DISH (Rogers & Waldron, 1995, p. 47–54; Belanger & Rowe, 2001). The symptoms and etiologies of osteomyelitis pubis, osteitis pubis and septic arthritis of the pubic symphysis are similar (Ross & Hu, 2003). Causes of the infection have been attributed to blunt trauma, intravenous drug use and abortion, among others, but strenuous muscular exertion is also implicated (Karpos et al., 1995; Ross & Hu, 2003; Meirovitz et al., 2004). The presence of a bacterial infection is only distinguished by positive cultures, in addition to clinical symptoms such as fever and chills (Karpos et al., 1995; Pauli et al., 2002; Ross & Hu, 2003; Meirovitz et al., 2004). When assessing skeletalised remains we are limited to the skeletal changes, such as the presence of a sequestrum indicating osteomyelitis pubis, which was not observed here. Fractures to the pubic bone cannot be ruled out as only body portions of the pubic bone and a partial ilium survived. These injuries could include, but are not limited to, straddle fractures, intra-articular fractures and dislocations, which are often associated with high-impact collisions (Frakes & Evans, 2004). Clinically, diastasis resulting in instability occurs when the symphyseal space becomes greater than 1 cm. Ligamentous damage of the sacroiliac is assumed if the symphyseal space surpasses 2.5 cm (Gamble et al., 1986). Fatigue fractures normally occur on the medial ramus and the junction between the Copyright # 2009 John Wiley & Sons, Ltd. inferior pubic ramus and ischial ramus as a result of tension created by the adductor, resulting in micro-trauma with insufficient time to heal (Lee & Lee, 2005). As the pubic rami were not recovered, fracture rather than ligamentous tears or symphyseal ruptures may also predispose the pubic symphyseal faces to disfigurement and pelvic ring instability. Osteitis pubis Osteitis pubis is a localised inflammation initiated by trauma, pelvic surgery or childbirth (Harris & Murray, 1974; Gamble et al., 1986; Major & Helms, 1997; Williams et al., 2000; Rodriguez et al., 2001; Pauli et al., 2002; Alicioglu et al., 2008). Repetitive stress due to chronic overload, acute impaction trauma or sudden directional movements are implicated among athletes involved in soccer, hockey, football, kicking, skating, tennis and dancing where intensive training, sprinting, twisting, pivoting and kicking are prominent (Gamble et al., 1986; Major & Helms, 1997; Besjakov et al., 2003; Brennan et al., 2005; Kunduracioglu et al., 2007). ‘Athletic pubalgia’, or groin pain due to athletic exertion, accounts for up to 5% of all sports injuries or higher for the particular sports listed above (Cunningham et al., 2007). Infection is rarely involved and it has been proposed that ‘pubic symphysis stress injury’ may be a more appropriate term (Major & Helms, 1997). Clinically, symptoms of osteitis pubis originate with groin pain and in later stages pain extends to the pelvic girdle and lumbar spine when sneezing, defecating, walking and changing positions, making daily life intolerable (Kunduracioglu et al., 2007). In addition to rest and physical therapy, the condition is now treated with medication and corticosteroid injections directly into the symphysis; surgical procedures are uncommon and are usually limited to obstetric cases (Williams et al., 2000). Clinically, the soft tissue markers of osteitis pubis that include secondary cleft, microtears, width of joint space and bone edema, are diagnosed by CT or MRI (Major & Helms, 1997; Brennan et al., 2005; Cunningham et al., 2007; Kunduracioglu et al., 2007; Alicioglu et al., 2008). Magnetic resonance imaging (MRI) has Int. J. Osteoarchaeol. 20: 280–290 (2010) Pubic Symphyseal Face Eburnation demonstrated that adductor microtears initiate an expansion of a secondary cleft within the symphyseal disc, and the accumulation of fluid restricts healing between the tendon and pubic bone. Continued activity irritates the tear, with inflammation and imbalance of the pubic bones resulting in osteitis pubis (Major & Helms, 1997; Cunningham et al., 2007). Plain radiographs and computerised axial tomography (CT) scans reveal skeletal responses that include subchondral sclerosis and resorption, marginal degeneration, offset pubic bones, eburnation, marked origins or avulsions of the gracilis muscle and osteophytic formation with changes affecting each side equally (Scott et al., 1979; Major & Helms, 1997; Resnick, 2002a, p. 2130; Besjakov et al., 2003). The sacroiliac joint may also be involved as any laxity resulting in subchondral sclerosis around the anterior-inferior auricular surface and apex of one or both joints also affects the stability of the pubic symphysis (Harris & Murray, 1974; Major & Helms, 1997; Resnick, 2002a, p. 2130). Resnick (2002a, p. 2128) defines osteitis condensans ilii and osteitis pubis by the presence of eburnation: The major radiographic findings associated with physiologic and pathologic changes during pregnancy occur at the sacroiliac joints and symphysis pubis. Bony eburnation about the sacroiliac joint is termed osteitis condensans ilii, whereas that at the symphysis pubis is termed osteitis pubis. Although either of the two conditions may be apparent in nulliparous women or even men, both are observed more frequently in multiparous women and most appropriately are discussed here. Sports in ancient Egypt The funerary program at HK27C showed blurring of Nubian and Egyptian material culture and funerary elements and, perhaps in the final phase, ethnic identity (Friedman, 2007). However, dental non-metric traits indicated that the group was not genetically affiliated with other Nubian groups from the southerly Nubian heartland near Kerma, but were indeed Nubian rather than Egyptian (Irish, 2007). Their presence Copyright # 2009 John Wiley & Sons, Ltd. 287 near Aswan during this tempestuous period of Egyptian-Nubian relations is enigmatic, but may be anchored to a social ‘package’ valued by the Egyptians. Nubians figured prominently in Egyptian cultural history and were legendary for their athletic prowess, particularly with archery, and were recruited as mercenaries as early as the Old Kingdom (Fischer, 1962). The HK27C group was not likely to be involved with the military as the demographic profile was balanced by sex and age and injuries associated with interpersonal violence and warfare were negligible (Judd, 2007). Similarly, heavy labour was not indicated by the patterns of osteoarthritis, Schmorl’s nodes, injuries or musculoskeletal stress markers observed in this collection. However, the prominent muscle insertions on the innominates and the distortion of the pubic symphyses on the remains of eight adult females of varying ages and two older males (including Individual 32), out of thirteen and three individuals respectively, suggested that during their lifetime some people from HK27C regularly participated in an activity or cluster of activities that commanded concentrated levels of physical endurance and dexterity (Judd, 2007). The clinical literature reviewed above proposed that regular participation in certain sports was the most common source of pelvic injuries resulting in osteitis pubis, as well as osteomyelitis pubis and septic arthritis. Sports and exercise figured prominently amongst Egyptians for the positive physical benefits and entertainment value. Young people were trained in acrobatics, dancing, juggling and pole climbing, which in addition to entertainment were central to cultic and funerary ceremonies (Janssen & Janssen, 1990, p. 55–56; Decker, 1992, p. 136–146). The Middle Kingdom offers a cornucopia of tomb paintings, reliefs and statuettes that depict these wholesome exercises with the tombs at Beni Hasan being most prolific (Newberry, 1894; Wilson, 1931). Physical stamina and good health were the very essence of Egypt. The pharaoh was the human embodiment of Egypt, identified as a single entity by the Egyptians as well as their adversaries. Egypt’s prosperity hinged on the health and fitness of the pharaoh; any hint of decline in the pharaoh’s physical or mental status Int. J. Osteoarchaeol. 20: 280–290 (2010) M. A. Judd 288 signalled a corresponding collapse of the Egyptian polity. The king’s fitness was therefore physically tested on the 30 year anniversary of his rule with the Jubilee Run (Festival of Sed) that originated during the Pre-Dynastic period (Decker, 1992, p. 30–35). Physical training was requisite for the heir to the throne, for example Sesostris, who was often accompanied by an ageset of other males who were sponsored by the king. Stories passed down by Egyptian priests recounted that the young man began each day with a 30 km run followed by specialised training in archery, chariotry, fencing, weight-training, wrestling and stick fighting (Janssen & Janssen, 1990, p. 138). Wrestling was the sport of ‘kings’ and peaked in popularity during the Middle Kingdom, although representations appeared in tombs as early as 2300 BC (Carroll, 1988). Over 400 scenes garnished the Middle Kingdom tombs at Beni Hasan as well as the later depictions at Medinet Habu near Luxor (Newbury, 1894; Wilson, 1931; Decker, 1992, p. 71–82; Crowther, 2007, p. 29). Interestingly, many of the participants in tomb paintings of the Middle and New Kingdoms were Nubians who were renowned for their skills in stick-fighting, archery and wrestling (Wilson, 1931; Fischer, 1961, 1962; Carroll, 1988; Janssen & Janssen, 1990, p. 139; Filer, 1997). During the New Kingdom reign of Ramesses III, following the Egyptian destruction of the Nubian Empire ca. 1550 BC, sport spectacles between Egyptians and foreigners were choreographed to delight the court and to humiliate the tribute-bearing foreign ambassadors (Wilson, 1931; Decker, 1992, p. 79– 81). The Nubians were not necessarily recruited for a fair game, but served as stabled actors in a mock-battle arranged to ensure the victory of the king over the enemy and thus reaffirm the power of Egypt and the pharaoh (Wilson, 1931; Crowther, 2007, p. 29). was maintained, indicating that the individual was not demobilised due to pain. An injury likely resulting from intense movements, such as running, kicking, twisting or leaping commonly associated with sports or other physical performance should be considered in view of the occurrence of this type of injury among modern athletes. This is particularly significant among the C-Group Nubians interred at Hierakonpolis, as their presence in Egyptian territory during a period of animosity is puzzling. It may be that the unique skills of some individuals, such as those associated with athletics or entertainment, were the necessary collateral required to maintain the community’s existence without fear of Egyptian interference. This interpretation is grounded in the artistic representations of sport in ancient Egypt and Nubia, as well as in modern clinical cases that serve as models to explain the etiology of the lesion observed. In the absence of associated artefacts, historical documentation and observation, we are left with these sources of information to make sense of the human remains, the malleable material that responded to this individual’s activities during their lifetime. Acknowledgements Special thanks to Joel D. Irish and Renée Friedman for inviting me to assess the paleopathology at Hierakonpolis for the 2007 season. The crew and local staff from the Hierakonpolis Expedition are also acknowledged. Travel funding was from National Geographic Society (#8116-06) and Wenner-Gren Foundation (#7557) grants to Irish. The author thanks Jim Cray, Joel Irish, Terry O’Connor and the two anonymous reviewers for their thorough reviews and helpful suggestions that greatly improved the paper. 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