14 A practical guide to the Istanbul Protocol – for medical doctors PART B THE MUSCULO-SKELETAL SYSTEM 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 traumas causing lesions in soft tissues (muscles, joint capsules, tendons, ligaments, nerves and vessels) and distortion/dislocation of joints and fractures (Forrest, 1999, 2002; Rasmussen, 1990). 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 irradiating pain (Edston, 1999; Moreno & Grodin, 2002; Rasmussen, 1990). 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 pel- vic girdle, and muscles of the lower extremities; tendinitis around the shoulder joint, elbow, knee and ankle joint • Tenderness and restricted range of movement in peripheral joints, cervical and lumbar spine • Tenderness in the soles and a compensatory altered gait (Forrest, 2002; Rasmussen, 1990; Skylv, 1992). The clinical examination of the musculoskeletal system may be done: 1. in order to document findings consistent with allegation of torture, and/or 2. for the purpose of rehabilitation. In documenting torture, the focus is on a description of signs supporting the use of torture, whereas in assessment for the purpose of rehabilitation, the focus should be on function and possibilities for interventions aiming at increasing function. In both instances, examination of the musculo-skeletal system is time-consuming. Most often, torture victims present widespread symptoms necessitating a thorough examination of many structures guided by the medical history; and knowledge about torture and