Jaime Ullinger1, Mary Elizabeth Kovacik2, Dennis P. Van Gerven3, Bert DeVries4, and Susan Guise Sheridan2
1Department
of Anthropology, Ohio State University;
The nature of lower limb activity has been extensively studied in skeletal remains from Byzantine St. Stephen’s monastery in Jerusalem.
Previous studies have shown markers of repetitive kneeling on the bones of these monks. The hip, knee and ankle all exhibit modification
suggesting repetitive activity consistent with daily prayer, as noted by ancient sources. Alterations of the foot were examined to flesh out
the lower limb activity markers. As defined by Ubelaker (1979), these “kneeling” facets are found on all metatarsals (first through fifth),
although they are primarily located on the second, third, and fourth metatarsals.
For this monastic collection, there was no significant difference between right and left metatarsals (x2=0, p=1.0). Twenty-three of 227
(10.1%) total right metatarsals demonstrated “kneeling” facets; approximately 20% of the second and third metatarsals had them. Many of
the metatarsals also exhibited osteoarthritis on the first metatarsophalangeal joint. Lipping, surface porosity, osteophytic growth and
eburnation were examined on the distal joint of the first metatarsals. Many of the toes exhibited some modification, including 20.8%
(11/53) of right first metatarsals with eburnation. The eburnation, porosity, and osteophytic growth occurred on the plantar surface of the
foot, while the “kneeling” facets were located on the dorsal surface.
These findings suggest that at least some of the monks were engaged in sustained, repetitive hyperdorsiflexion of the foot. This,
combined with the presence of facets and imprints on the femur, tibia, and talus, lead to a better understanding of the daily postures of this
monastic community.
2Department
of Anthropology, University of Notre Dame;
Table 1. Metatarsophalangeal joint surface changes
Score
Lipping
Surface
Porosity
Eburnation
Surface
Osteophytes
1
barely discernible
pinpoint
barely
discernible
barely
discernible
2
sharp ridge
coalesced
polish only
clearly present
3
extensive spicule
formation
pinpoint &
coalesced
polish with
grooves
--
4
ankylosis
--
--
--
Table 2. Metatarsal facet frequencies for each collection
Site
The monks of Byzantine St. Stephen’s, a monastery in Jerusalem, have been thoroughly studied for the past decade. The skeletal
remains date from 5th-7th centuries AD and constitute one portion of a biocultural synthesis, which has reconstructed several aspects of
the monks’ lives, including habitual, repetitive kneeling (Sheridan 1999, Driscoll and Sheridan 2000). Several studies have
examined the nature of repetitive kneeling in the skeletal remains from St. Stephen’s, including the examination of
musculoskeletal lesions (Hayden et al. 2004), non-metric features of the distal femur and proximal tibia (Kovacik et
al. 2004), “squatting facets” (Ullinger et al. 2004) and morphological features of the femoral neck
(Jennings et al. 2004). This study of the foot adds to the growing knowledge of lower limb activities
in the Byzantine monks. The metatarsals from St. Stephen’s were compared to pedal bones from
Umm el-Jimal, a contemporary non-monastic site in Jordan, and Early Bronze Age II-III (2850
– 2300 BC) remains from Bab edh-Dhra’, Jordan.
Metatarsal Facets
Location
Bab edh-Dhra
Umm el-Jimal
Ayalan *
Hawikuh *
Mobridge *
Nanjemoy *
Eskimo *
Terry *
Jordan
Jordan
Ecuador
New Mexcio, US
South Dakota, US
Maryland, US
Alaska, US
Midwest, US
St. Stephen's
Jerusalem
Time Period
n
+
%
2850-2300 BC
2nd - 6 th C AD
700-1550 AD
-1750 AD
Late Woodland
modern
19-20th C AD
430
179
544
940
345
1322
1972
500
30
14
106
55
4
22
40
2
6.9
7.8
19.5
5.8
1.2
1.7
2.0
0.4
5-7th C AD
453
46
10.1
* collections drawn from Ubelaker, 1979
Joint Surface Changes: The Byzantine St. Stephen’s collection
showed considerably greater degenerative joint disease when
compared to the Jordanian collections. Over half of the first
metatarsals from Bab edh-Dhra’ and Umm el-Jimal had barely
discernible lipping, while more than half from Byzantine St. Stephen’s
had severe lipping with sharp ridge formation. Forty percent (11/27)
of the monks’ first left metatarsals had surface porosity, compared to
12.0% for Bab edh-Dhra’ (x2=8.9, p=0.01). However, there was there
was no difference between the monks and their Byzantine
contemporaries at Umm el-Jimal (x2=2.8, p=0.2).
There was a highly significant difference in eburnated right first
metatarsals among the groups. Only 1% (1/74) from Bab edh-Dhra’
Table 3. Comparison of metatarsal facets to St. Stephen’s
Collection
Site
Kneeling facets are located at the
distal end of the superior metatarsal
surface, and are described as “usually
flat with sharply defined proximal
borders” (Ubelaker 1979). Facets were
examined on all right and left, first
through fifth metatarsals. Figure 1
illustrates facets on two second left
metatarsals. Of the 771 metatarsals (1st
through 5th) from Byzantine St.
Stephen’s, 453 specimens could be
scored. For Umm el-Jimal, 179 of the
334 were scorable, and 430 of 715
could be used from the Bab edh-Dhra’
collection.
Bab edh-Dhra
Umm el-Jimal
Ayalan *
Hawikuh *
Mobridge *
Nanjemoy *
Eskimo *
Terry *
Facets
Location
Jordan
Jordan
Ecuador
New Mexcio, US
South Dakota, US
Maryland, US
Alaska, US
Midwest, US
Time Period
x2
p
2850-2300 BC
2nd - 6 th C AD
700-1550 AD
-1750 AD
Late Woodland
modern
19-20th C AD
2.8
0.3
16.6
8.2
28.1
28.1
71.6
46.5
0.09
0.6
4.7E-05
0.004
1.2E-07
1.2E-07
2.5E-17
9.1E-12
* collections drawn from Ubelaker, 1979
Table 4. Metatarsal facet comparisons by side for each collection
Collection
Figure 1. Kneeling facets on the posterior
end of second left metatarsals [EBND 11.13
& EBND 27.126].
The first metatarsals were studied in
further detail. They were scored for the
presence of lipping, surface porosity, eburnation, and osteophytic growth on the
metatarsophalangeal joint surface. All data were collected according to Buikstra
and Ubelaker (1994). Table 1 describes the various stages of joint surface
change scored for the present study.
MT1
x2
p
Bab edh-Dhra
Umm el-Jimal
Ayalan *
Hawikuh *
Mobridge *
Nanjemoy *
Eskimo *
Terry *
1.2
-0.1
1.5
--0
--
0.3
-0.7
0.2
--1.0
--
St. Stephen's
0.6 0.4
* collections drawn from Ubelaker, 1979
MT2
x2
p
0
1.0
1.6
0
--0.3
--
0
MT3
x2
p
1.0
0.3
0.2
1.0
--0.6
--
-1.0
0
0
-0
1.1
--
-0.3
1.0
1.0
-1.0
0.3
--
1.0
0.4 0.5
MT4
x2
p
--1.5
2.1
-0.6
0
--
--0.2
0.2
-0.5
1.0
--
0
1.0
Table 5. Comparison of right metatarsal facets to St. Stephen’s
MT5
x2
p
2.0 0.2
---- -----9.7
0
-----
0
of Anthropology, University of Colorado-Boulder;
Kneeling Facets: Results of metatarsal facet occurrence at
Byzantine St. Stephen’s were compared to a variety of collections.
Forty-six (10.1%) of the 453 scorable monastic metatarsals
demonstrated kneeling facets. Ubelaker (1979) reported that an
Ecuadorian (Ayalan) community had facets on 19.5% (106/544) of the
metatarsals examined. Regional counterparts to the Byzantine St.
Stephen’s collection showed lower frequencies, with Bab edh-Dhra'
demonstrating 6.9% (30/430) and Umm el-Jimal at 7.8% (14/179).
Markedly reduced numbers were found in several North American
collections, both ancient and modern (Table 2).
As seen in Table 3, there was a significant difference between the
frequency of total kneeling facets for the monks, compared to all the
North American collections, and the Ayalan group. However, no
significant differences were found when compared to their regional
counterparts at Bab edh-Dhra' and Umm el-Jimal. To avoid
duplicating individuals, right metatarsals were selected for
comparisons, as no significant side difference in kneeling facets was
found for any of the collections (Table 4).
There were no significant differences in facet frequency for the
Byzantine St. Stephen’s right first metatarsals when compared to the
other collections (Table 5). No kneeling facets were found in the first
metatarsals from Umm el-Jimal. There were more facets on the third
and fourth metatarsals for both Byzantine groups (St. Stephen’s and
Umm el-Jimal) compared to Bab edh-Dhra’.
Adapted from Buikstra & Ubelaker (1994)
Collection
3Department
1.0
Collection
Bab edh-Dhra
Umm el-Jimal
Ayalan *
Hawikuh *
Mobridge *
Nanjemoy *
Eskimo *
Terry *
RMT 1
RMT 2
RMT 3
RMT 4
p
x
p
x
p
x
p
x2
p
1.4
-8.4
0.9
--5.1
--
0.2
-0
0.4
--0
--
2.0
0
3.4
2.8
--22.1
--
0.2
1.0
0.1
0.1
--0
--
-0.6
0.4
1.5
-2.6
4.1
--
-0.4
0.5
0.2
-0.1
0
--
2.9
0.8
1.3
0.4
-0
6.0
--
0.1
0.4
0.3
0.5
-1.0
0
--
1.1
--0
-0
---
0.3
--1.0
-1.0
---
* collections drawn from Ubelaker, 1979
2
2
2
of History, Calvin College
were eburnated, while 21.0% (11/53) of the monks demonstrated clear bone-on-bone contact (x2=13.6, p=0.0002). No right first metatarsals
from Umm el-Jimal exhibited eburnation.
The same proved true for osteophytic growth, with 29% (17/59) of the right first metatarsals at St. Stephen’s demonstrating at least
“barely discernible” osteophytes, while only 1.3% (1/75) from Bab edh-Dhra’ (x2=20.9, p<0.0005) and 4.8% (1/21) from Umm el-Jimal had
osteophytic growth (x2=5.8, p=0.02).
Previous studies have shown alterations in the lower limbs of the monks from Byzantine
St. Stephen’s consistent with historical accounts of repetitive kneeling for prayer. Liturgical
records suggest that the Byzantine monks may have been kneeling hundreds of times a
day for prayer/genuflection (Bautch 1999; Driscoll and Sheridan 2000), possibly resulting in
the presence of metatarsal modification.
Kneeling Facets: Over 10% of all metatarsals from Byzantine St. Stephen’s had
kneeling facets, which Ubelaker (1979:682) elsewhere attributed to “frequent, extreme
hyperdorsiflexion of the metatarsophalangeal joints” (Figure 2). Among the prehistoric
Native American groups cited, it was posited that these anatomical alterations resulted from
habitually grinding corn. Molleson (2000:312) reported this pattern for the Neolithic people
at Abu Hureyra, where osteophytic growth was found to be “remarkably exuberant” in older
individuals, resulting from the “demands of grain preparation and grinding.”
Joint Surface Changes: Osteoarthritis was more prevalent among the St. Stephen’s
Figure 2. Relation of the metatarsals during kneeling &
the extreme hyperdorsiflexion at the metatarsomonks than for either regional counterpart. It was markedly stronger on the plantar vs.
phalangeal joint. Adapted from Ubelaker (1979).
dorsal surface. A comparable pattern of arthritis of the first metatarsophalangeal joint
accompanied by a kneeling facet was reported in Lovell and Dublenko (1999), and was
associated with kneeling during canoe travel. The St. Stephen’s eburnation was not likely the result of hallux valgus (lateral deviation of the
great toe), as Mays (2005) reported damage on both surfaces of the joint for this disorder.
Muehleman and Kuettner (2000:691) stated that the medial groove for the sesamoid is a frequent spot for cartilage degeneration,
particularly as a result of dorsiflexion. Of interest to this study is their suggestion that “biomechanical imbalance rather than loading history”
results in plantar surface damage of the metatarsal head. This may suggest that there was sublaxation of the sesamoid, as seen in modern
clinical trails when sesamoiditis is aggravated by stair-climbing (Chou 2000). Previous studies of the St. Stephen’s calcanei also suggest
movement along uneven terrain.
Osteophytic growth is believed to be the result of repetitive stress and activity (Chou 2000). In clinical settings, it is referred to as hallux
rigidus. The condition is typically present in older individuals, as it is degenerative (Kevin Pugh, personal communication). In a study of over
100 individuals opting for surgery to correct the condition, the average age of onset was 40 (Coughlin and Shurnas 2003). The overall
average age of death for the St. Stephen’s community was mid-to-late 40s, however it was not possible to directly determine age from the
metatarsals. Thus, it is possible that if there were significantly more older monks represented by the St. Stephen’s toes compared to the two
Jordanian collections, this could explain the significantly higher frequency of osteoarthritis at the monastery.
While kneeling facets were comparable across the three Near Eastern groups in this study, osteoarthritic changes were significantly more
frequent in the metatarsophalangeal joints of the Byzantine monks. It is important to remember that these modifications were likely
exacerbated by climbing and walking the hills of Jerusalem. Nevertheless, this study compliments the data gleaned from the hips, knees,
and ankles of the monks, which when combined with the historical records, creates a strong circumstantial case that kneeling behavior took a
considerable toll on the lower limbs of the members of this monastic community.
RMT 5
x
2
4Department
National Science Foundation Research Experiences for Undergraduates
Institute for Scholarship in the Liberal Arts; University of Notre Dame
L’École Biblique et Archéologique Française de Jérusalem
Dr. Pam Stone & Chris Crain, Department of Anthropology, Western Michigan University
Dr. Kevin Pugh, Department of Orthopaedics, Ohio State University
Byzantine St. Stephen’s Project
Laboratory for Biocultural Studies
Department of Anthropology
University of Notre Dame