PART B – The musculo-skeletal system tory altered gait with loading of the lateral border (supinating the foot) or loading of the medial border (pronating the foot) to avoid pain at heel strike. The unwinding of the foot is likewise abnormal. Maximal extension and weight loading of the first toe is typically avoided at take-off. Stride and walking speed are reduced. The gait is broad, stiff and insecure as seen in patients with peripheral neuropathy from other causes. Postural reflexes are elicited from the soles, and, together with the ability to register distribution of pressure, these reflexes are essential for balance and walking. Nerve lesion influencing the proprioception may therefore also contribute to the overall picture. 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 reaction 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. Clinical examination The clinical examination of torture victims exposed to falanga should include: 1. Inspection and palpation of the soft tissues of the feet: heel pads, plantar fascia, skin 2. Assessment of foot function and gait 3. Examination of soft tissues and joints in the lower extremities 4. Neurological examination. It should be stressed once again that none of the findings at clinical examination in the late phases after falanga are pathognomonic, and that a normal examination of the 25 feet does not rule out the use of this specific torture method. (See §§ 203-205 in the Istanbul Protocol.) 3. NEUROLOGICAL Acute central nerve neurological problems are associated with severe beating to the head. Of 200 torture victims, 58% had received severe beating to the head and 1/4 of those consequently lost consciousness (Rasmussen, 1990). Headaches were the most frequently reported symptom, present in more than 50% of the examined persons. A significant correlation between severe beating to the head and headaches was found. Likewise, there was a significant association with the symptom vertigo present in 20% of the persons. Violent shaking may produce cerebral injuries identical to those seen in the shaken baby syndrome: cerebral oedema, subdural haematoma and retinal haemorrhages. The first fatal instance of “shaken adult syndrome” was reported by Pounder and Path (1997). Acute peripheral nerve symptoms are most often reported as a result of handcuffs or tight ropes at the wrist. Lesions of the brachial plexus, especially the lower roots, have been mentioned after suspension, and damage to the long thoracic nerve has been reported after “Palestinian hanging” (Forrest, 2002). Many of the long-lasting symptoms, such as loss of concentration, headaches, memory disturbances and vertigo, could be explained by chronic, organic brain damage (Abildgaard et al., 1984) and call for a neurophysiological evaluation in order to evaluate the specific symptoms. It should, however, be borne in mind that many of these symptoms are also related to PTSD.