BACKGROUND AND INTRODUCTION: In 1991, a deceased human male was found frozen in 
a glacier pool in the Italian Alps in north west Italy, and is now carefully 
preserved in the South Tyrol Museum of Archaeology, in Bolzano, Italy. The 
bodily tissues of the 5,300 year old male (colloquially referred to as the 
Iceman or Ötzi) were well preserved despite damage related to freezing, and 
glacial movement. Associated articles of well-preserved clothing, tools, weapons 
and other devices were also present and have been studied in detail. Clinical 
examination and imaging investigations have also shown that the Icemen had 
experienced possible illnesses in his lifetime and had identifiable areas of 
arthritis and musculoskeletal injury. This report includes some key observations 
on the musculoskeletal state of Ötzi and reference to the involvement of tattoo 
markings. Some aspects about the aetiology of his abnormalities and inflammatory 
arthritis are considered along with possible treatments that he might have 
employed.
METHODS AND RESULTS: We (WFK and MK) undertook a clinical musculoskeletal 
examination of the Iceman, details of which with available photographs and 
radiographic imaging pertaining to the musculoskeletal findings of the Iceman 
are reported here. The skin of the Iceman has numerous linear carbon tattoos, 
which are not of a decorative type. These have been presumed to possibly be 
"medicinal" tattoos administered for therapeutic reasons and may have been used 
in acupuncture-like treatment of pain. Spinal imaging identified areas of spinal 
damage and our observations have provided clues as to possible sites of spinal 
initiated pain and hence sites for administration of the "medicinal" tattoos. We 
observed body areas of the Iceman, in which imaging demonstrated arthritis and 
other forms of long-term musculoskeletal damage, but which do not have adjacent 
or corresponding "medicinal" tattoos. We contend that the back and leg 
"medicinal" tattoos correspond directly to sites of chronic right knee and right 
ankle pain, and left thoracolumbar pain. They also correspond to lower lumbar 
and sciatic referred radicular pain which may have a contributory cause related 
to the presence of a transitional lumbar 5 vertebra. Using recent published data 
(Keller et al. in Nature Commun 3:698, 2012. doi: 10.1038/ncomms1701 ) of the 
genome structure of the Iceman, we suggest some potential causes of the 
osteoarthritis or inflammatory joint injury may relate to presence of coronary 
heart disease (CHD) and Lyme disease (Borrelia burgdorferi) infection. We 
speculate on possible medical applications of natural products for 
self-medication.
CONCLUSIONS: These observations highlight several diagnostic features of 
musculoskeletal conditions in the Iceman with the possibility that tattoos may 
have been used for diagnosis or location of his painful states. The origins of 
his musculoskeletal conditions are unclear but there are indications that Lyme 
disease and CHD may have been factors. The associations or use of natural 
products may give insights into their applications at the time of the life of 
the Iceman.