Over the past two decades, many articles have been published on entheseal changes (usually called ‘Musculoskeletal Stress Markers’) as activity markers in past societies. Over-simplified methods and over-interpretation of past activities have generated strong critiques of research results in this area of enquiry. While some significant improvements regarding the recording systems for entheseal changes have been applied more recently, many bioarchaeologists appear not yet to be fully aware of the multi-factorial aetiology of these alterations. In this article, we review the anatomical and clinical literature to discuss some of the difficulties associated with the recording of entheseal changes and the multiple factors leading to their appearance in the human skeleton. Thus far, fibrocartilaginous entheses appear to hold more promise for activity-related reconstruction than do fibrous ones, but these relationships remain an area of active research interest. Copyright © 2012 John Wiley & Sons, Ltd.