Arising on the bank of the Severn, just south-east of Shrewsbury, Atcham took its name around the close of the Middle Ages, through a process of contraction from Attingham or Ettingham, referring to a site where Eata's folk settled. St. Eata was a seventh century Northumbrian bishop and, while the place-name might refer to some other Eata, the only English church dedicated to that saint is at Atcham, which makes it likely the bishop is intended in the place-name; this, however, does not necessarily imply that Eata himself ever lived there. On grounds of its dedication, the church is assumed to be a Saxon foundation, although not mentioned in Domesday and its oldest surviving fabric dates to the eleventh century; that the chronicler Orderic reported having been baptized in the church in 1075 exemplifies how we cannot always rely on Domesday to give a full picture of a community. Although Eata is not known to have ventured to that part of the country, aerial photography has revealed, to the north of the village, the ground-plan of a building that looks very similar to a Saxon episcopal palace excavated at Hexham, the later seat of Eata's bishopric. The nature of the connection remains a mystery, but may have something to do with Attingham having, according to Domesday, long been held by the Shrewsbury church of St. Alkmund's, founded by Æthelflæda of Mercia and dedicated to a Northumbrian prince.

A Domesday manor, Atcham was acquired around the mid-twelfth century by the Abbey of Lilleshall, many of the former endowments of St. Alkmund's being transferred to it in the years that followed. The abbots, perhaps with an eye to converting the village into a market town, had initiated construction of a bridge there in the early years of the thirteenth century, though in 1221 Shrewsbury's burgesses complained the abbot persisted in charging a toll for passage levied on carts but had not put the money towards bridge completion; the abbots also built a fulling mill. The Extensive Urban Survey report authors see the bridge construction as a component in a plan to develop Attingham into a market centre, but this is not intimated in the record of the dispute between Shrewsbury and the abbey, which rather suggests a generally-felt need to replace the ferry with a bridge on what was evidently an important crossing of the Severn. Rather, we might argue that the bridge, once completed (presumably after 1322) would have created the improved conditions that made establishment of commercial events a more viable venture.

No market charter is known and no market ever mentioned – we might have expected Shrewsbury to challenge any such, unless its business was too modest to offer any real competition – but a three-day fair in September was approved in 1269 and a second in 1276 for May; the saint's-day of the parish church, often chosen as the focus for a local fair, if at a suitable season, was in late October, not an optimal time for a fair, unless perhaps one dealing mainly in livestock, though some were held in the later months of the year. In 1304 we hear of burgesses there, in the context of a tallage levied from them by the abbot; this is a likely indicator of the existence of a commerce-based settlement. In 1315 the bridge was apparently in need of repair and the king granted the right to collect pontage on all commercial goods crossing it; the grant was made to the vicar of Attingham (probably as representative of the abbey) and to John de Berewico, possibly the tenant of a manor to the north of Atcham.

Atcham was built around an east-west through-road leading to Shrewsbury, which met the river on the west side of the village; the crossing there was served by a ferry before a bridge was built. Where the fairs – and market if there were one – were held is uncertain, but it may have been in a widened stretch of that road just east of the bridge, from which point a street headed south to the church, while another road headed north to Berwick. No clear layout of burgages can be discerned from post-medieval maps, unless perhaps on the north side of the through-road. It was probably proximity to Shrewsbury that prevented Atcham from developing a market, or its fairs from becoming competitive; before the close of the Middle Ages it had reverted to a rural village.