PART B – The musculo-skeletal system 2. FALANGA Acute symptoms and signs The immediate effect of falanga (repeated applications of blunt trauma to the soles of the feet) is bleeding and oedema in the soft tissues of the feet, as well as severe pain. 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 (Allden et al., 2001; Amris & Prip, 2001a). Extensive ulcerations and gangrene of toes due to ischaemia have been described, but are not common. Fractures of tarsals, metatarsals and phalanxes are described as occurring occasionally (Forrest, 2002). The acute changes disappear spontaneously within weeks, as the oedema and extravasation of blood resolve, but the induced soft tissue lesions may be permanent. Symptoms and signs in the chronic phase 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 tendency for the feet to alternate between being hot and cold, suggestive of autonomic instability 23 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 limited distance, during which the pain will increase and make continued muscle activity impossible. At rest, the pain subsides and the victim can resume walking. Theories explaining the persistent pain and foot dysfunction after falanga The aetiology and pathogenesis of the persistent pain and disability after falanga is not fully understood. Several theories have been put forward (Allden et al., 2001; Amris & Prip, 2001b; Bro-Rasmussen & Rasmussen, 1978; Rasmussen, 1990; Skylv, 1993), and most likely a combination of trauma mechanisms are responsible. Reduced shock absorbency in the heel pads The footpads are situated under the weightbearing bony structures, at which in particular the heel pads act as the first in a series of shock absorbers. The heel pad is normally a firm elastic structure covering the calcaneus. It has a complex internal architecture consisting of closely packed fat cells surrounded by septa of connective tissue, which also contain the nerve and vessel supply to the tissues. Because of its structure, the heel pad is under constant hydraulic pressure and maintains its shape during weight load in the standing position. After falanga, the heel pad may appear flat and wide, with displacement of the tissues laterally during weight loading. This is observed 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-