PART B – The musculo-skeletal system applied torture methods is a prerequisite for the examination. Assessment of the musculo-skeletal system should in general include: • Examination of muscles and tendons: inspection, palpation (tone, stretch range, tenderness, changes in tissue texture) and assessment of function (strength, endurance) • Examination of peripheral joints and bones: inspection, palpation and assessment of joint function (range of movement and stability) • Examination of the spine and pelvic girdle: inspection, palpation and range of 15 movement in the cervical, thoracic and lumbar spine • Neurological examination: muscle strength, tendon reflexes, and sensibility. Some symptoms/symptom constellations may be related to the use of specific torture methods, e.g. pain in the feet and lower legs, and impaired walking after falanga (Rasmussen 1990), but symptoms and findings in the musculo-skeletal system in the later stages are in general unspecific and cannot – on their own – document exposure to torture. (See § 184 in the Istanbul Protocol.) I. POSSIBLE LESIONS IN THE MUSCULO-SKELETAL SYSTEM AFTER PHYSICAL TORTURE 1. SOFT TISSUE INJURIES An acute stretch of a muscle may cause a partial or even complete tear of the muscle-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. The initial pathology shows many similarities in strains and contusions. • 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 in- flammatory 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. Regenerating muscle cells and fibroblasts mounting a scar response are seen in the injured area. 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. In animal models, the muscle is largely healed after approximately two weeks. It is not known whether the healing in human muscles is substantially different. It is possible that the healing process in human muscles takes longer, as suggested by the