Lower limbs
Scars on the knees and shins are common in many people, especially those who have played contact sports. Thus lesions in this part of the body can rarely be significant, though they might be consistent with allegations of torture (see section 4.6). Additionally, tropical ulcers in childhood can leave large, irregular scars primarily around the lower legs. Lesions on the upper thighs and particularly those inside the thighs are much more important, as they are less likely to be the result of disease or accidental causes.
Feet
Falanga (repeated applications of blunt trauma to the soles of the feet) is a common method of torture. The immediate effect of is bleeding and oedema in the soft tissues of the feet, as well as severe pain and swollen feet which can last for days or weeks after the torture. Some may describe pain on walking several years later, or burning pain in the foot radiating up to the calf or even the thigh in bed at night. There may be some tenderness of the sole of the foot on palpation. However, the recognised syndromes of permanent damage to the foot probably only occur in those whose feet were beaten most severely.
The majority of torture victims submitted to falanga complain of pain and impaired walking. The cardinal symptom is pain in the feet and calves, and two types of pain are usually present:
A deep, dull cramping pain in the feet, which intensifies with weight bearing and muscle activity spreading up the lower legs
A superficial burning, stinging pain in the soles, often accompanied by sensory disturbances and frequently also a ten- dency for the feet to alternate between being hot and cold, suggestive of auto- nomic instability
Because of the pain, walking is impaired in most falanga victims. Walking speed and walking distance are reduced. Typically, the torture victim is only able to walk a lim- ited distance, during which the pain will in- crease and make continued muscle activity impossible. After rest, the pain subsides and the victim can resume walking. At clinical examination, changes are also confined to the soft tissues. Swelling of the feet, discoloration of the soles due to haematoma formation and various degrees of skin lesions are typical and diagnostic findings. Extensive ulcerations and gangrene of toes due to ischaemia have been described, but are not common. Fractures of tarsals, meta- tarsals and phalanges are described as occurring occasionally. The acute changes disappear spontaneously within weeks, as the oedema and extravasation of blood resolve, but the induced soft tissue lesions may be permanent.After falanga, the heel pad may appear flat and wide, with displacement of the tissues laterally during weight loading. This is ob- served at inspection from behind, with the torture victim in the standing position. At palpation, the elasticity in the heel pad is reduced and the underlying bony struc-tures are easily felt through the tissues. The pathophysiology of the reduced elasticity in the heel pad is thought to be tearing of the connective tissue septa, leading to deprivation of blood supply and secondary atrophy of fat cells with loss of the shock absorbing ability. As a consequence of the altered function of the foot, altered gait and frequently concurrent exposure to other forms of torture involving the lower extremities, a chain re- action of muscular imbalance occurs. The various muscle groups of the lower legs are often painful due to increased muscle tone, tight muscles and fasciae, tender and trigger points, and musculo-tendinous inflammation.
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