Complaints of musculoskeletal aches and pains are very common in torture survivors, immediately as well as later. They may be the result of repeated beatings, suspension, other positional torture or the general physical environment of detention. They may also be psychosomatic or somatic in nature, but should still be documented. Pain may be specific to the torture mechanism or non-specific and generalized.
Physical examination should include testing for mobility of the joints, spine and extremities.
Clinicians should note: pain on palpation or with motion, muscle strength, contracture, evidence of compartment syndrome, fractures with or without deformity and dislocations. In the case of severe beatings, muscle tissue breakdown may lead to myoglobin release into the blood circulation in large amounts, potentially leading to acute kidney failure. The urine myoglobin level may be tested when and if available in severely beaten survivors during the acute phase.
Suspected dislocations, fractures and osteomyelitis should be evaluated radiologically. Injuries to tendons, ligaments and muscles are best evaluated with MRI, although arthrography can also be performed. In the acute stage, this can detect hemorrhage and possible muscle tears. Muscles usually heal completely without scarring; thus, later imaging studies will be negative. MRI and CT images of denervated muscles and chronic compartment syndrome may demonstrate muscle fibrosis. Bone bruises can be detected by MRI or scintigraphy Bone bruises usually heal without leaving traces. Vitamin D deficiency due to lack of sunlight and poor diet can also be a cause of musculoskeletal pain and responds to replacement therapy.
Symptoms related to the musculo-skeletal system are the most frequently reported physical complaints at the time of torture, as well as at later stages. The associated signs and symptoms in the acute phase are similar to those following other types of acute trau- mas causing lesions in soft tissues (muscles, joint capsules, tendons, ligaments, nerves and vessels) and distortion/dislocation of joints and fractures.
Pain is the dominant symptom in relation to the musculo-skeletal system in the chronic phase. The clinical picture is one of localised or diffuse pain in muscles, joint pain, pain related to the spine and pelvic girdle, and neurological complaints mainly in the form of sensory disturbances and radiating pain.
Examination of the torso, in addition to noting lesions of the skin, should be directed towards detecting regions of pain, tenderness or discomfort that would reflect underlying injuries of the thoracic muscles and skeleton or abdominal organs. The examiner must consider the possibility of intramuscular, retroperitoneal and intra-abdominal haematomas, as well as laceration or rupture of an internal organ. Radiological techniques are required to confirm such injuries. Blood tests and urinalysis may be useful screens for such injuries. Routine examination of the cardiovascular system, lungs and abdomen should be performed in the usual manner. Pre-existing respiratory disorders are likely to be aggravated in custody and new respiratory disorders frequently develop.
Acute stretching of the muscle can cause partial or complete tear of the muscle tendon unit
Typical findings in the musculo-skeletal system in the chronic phase are:
Increased muscle tone
Tender and trigger points, especially in the muscles of the neck and shoulder girdle, muscles in the low back and pelvic girdle, and muscles of the lower ex- tremities; tendinitis around the shoulder joint, elbow, knee and ankle joint
Tenderness and restricted range of move- ment in peripheral joints, cervical and lumbar spine
Tenderness in the soles and a compensatory altered gait
Assessment of the musculo-skeletal system should in general include:
Examination of muscles and tendons: in- spection, palpation (tone, stretch range, tenderness, changes in tissue texture) and assessment of function (strength, endurance)
Examination of peripheral joints and bones: inspection, palpation and assess- ment of joint function (range of movement and stability)
Examination of the spine and pelvic girdle: inspection, palpation and range of movement in the cervical, thoracic and lumbar spine
Neurological examination: muscle strength, tendon reflexes, and sensibility.
Acute stretch of a muscle may cause a partial or even complete tear of the mus- cle-tendon unit. These injuries are usually designated as stretch-induced injuries or muscle strains. A direct, non-penetrating blow to the muscle belly is another common mechanism for muscle injuries. Such muscle contusions may cause significant damage to the structure and function of the muscle.
Immediately following the injury, there is disruption of the architecture due to ruptured muscle fibres, as well as injury to the connective tissue framework and haematoma formation. Within two-three days, an intense inflammatory response develops. Pain and disability in the acute phase are, at least in part, due to this inflammation, and biomechanically the muscle is most impaired at this point.
Within the first week, evidence of muscle regeneration may be found. The combined regenerative and scar response results in a healed muscle that has fewer and smaller muscle fibres in the injured area, as well as an increased amount of collagenous tissue between the fibres.
The majority of muscle lesions heal leaving no specific gross findings, but very often torture victims present with muscular dysfunction in the chronic phases. Typical, but unspecific, findings are: increased muscle tone, restricted stretch range of movement, tender and trigger points, and musculo-tendinous inflammation. The range of muscle movement may be restricted because of painful trigger points or reduced elasticity due to muscle contracture/fibrosis. A tender point is a hyperirritable spot that is painful on compression. A trigger point is painful on compression and also gives rise to a characteristic pattern of referred pain. Inflammatory reactions in musculo-skeletal system can occur in joints, tendons, muscle, bursae and periosteum. Inflammation of muscle-tendon attachment to bone (teno-periostitis) is characterised by localised tenderness as well as when the connected muscle group is contracted against resistance (isometric testing). With tendinitis and bursitis, there can be tenderness, swelling and crepitus.
Exceeding normal range of movement or adding excess weight on a joint as happens with some forms of torture, can lead to pain, swelling and joint dysfunction. Full recovery may take months. Clinically, reduced range of movement of joints, joint laxity and instability can be found.
Suspension by the limbs, prolonged squatting or standing, prolonged back loading positions, restricted movement due to confinement etc. leave relatively few and unspecific findings, despite subsequent frequently severe, chronic physical disability.
Suspension by the arms, an often-applied torture method, is practised either separate- ly or in combination with other forms of torture, such as beatings and electrical torture. The torture victim is most often tied at the wrists and left hanging for a prolonged pe- riod of time by one or both arms. This form of torture is extremely painful and causes an immense overload of the shoulder joint and surrounding soft tissues.
In Palestinian hanging, the shoulder joint is maximally extended, inward rotated and the entire body weight loading the weak anterior aspect of the shoulder joint placing traction on the brachial plexus. Typically, the lower plexus, and thereafter the middle and the upper plexus fibres if the traction force is severe enough, will be damaged.
If the suspension is of the “crucifixion” type, the shoulder joints being in abduction, the traction force will primarily be placed on the middle plexus fibres, which are likely to be the first ones damaged.
Symptoms in the acute phase are severe pain in the neck and shoulder girdle and in the shoulder joints, and loss of function in the upper extremity. Occasionally, one or both shoulder joints may dislocate during the torture.
Neurological complaints indicative of plexus lesion are frequent: radiating pain and re- duced muscle strength in the upper extremities, accompanied by sensory disturbances, typically in the form of paraesthesia and reduced sensibility. At neurological examination, common findings are reduced muscle strength, most prominent distally, loss/reduction of tendon reflexes and sensory disturbances along the sensory nerve pathways).
In the chronic phase, many torture victims who have been exposed to suspension by the arms, in particular Palestinian hanging, develop chronic disability with pain, reduced shoulder function and permanent neurological deficit, indicative of partial lesion of the brachial plexus, most often involving sensory modalities. In the late stages, typical complaints are pain in the neck and shoulder girdle, deep pain in the shoulder joints during activity, especially in connection with overhead movements (abduction, inward rotation) and lifting, reduced range of movements in the shoulder joints, feeling of instability in the shoulder joints or popping, locking sen- sations on movement.
Neurological symptoms are likewise frequent: radiating pain, muscle weakness with a feeling of heaviness in the upper extremities and various sensory disturbances, including vasomotor and sudomotor changes.
At clinical examination, most of the findings are unspecific and confined to the soft tis- sues: typical findings are tender and trigger points in the neck and shoulder girdle, muscular imbalance with musculo-tendinous inflammation. At joint examination, a reduced range of active movement in the shoulder joint is common. Signs of habitual luxation/subluxation are rare, but upon specific testing, various degrees of instability may be present.
At neurological examination, brachial plexus injury will manifest itself as sensory and motor deficit, depending on the severity of the nerve lesion. Reduced muscle strength, which often is asymmetrical and most pronounced distally as well as reduction/loss of tendon reflexes are signs of motor involvement. Sensory disturbances, which might involve different sensory modalities, are signs of sensory involvement.
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