16 A practical guide to the Istanbul Protocol – for medical doctors clinical symptoms that often last for several weeks (Almekinders, 1999). 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 (Skylv, 1992). 2. MUSCLE TONE Applying a digital pressure to a muscle, resistance in the tissue opposing deformation occurs. Variations in this resistance are referred to as muscle tone or muscle tension and are described in a continuum from high (hypertone) to low (hypotone). Several causes may lead to deviations in muscle tone, and traditionally these are grouped into three main categories: 1. Organically-determined, e.g. neurological disorder 2. Mechanically-determined, e.g. overload 3. Psychologically-determined, e.g. prolonged stress conditions 3. STRETCH RANGE OF MOVEMENT A normal muscle may be stretched to its full length with a springy, elastic resistance at the end of range. Stretching of a short, tight muscle evokes pain and – depending on the muscles involved – causes reduced range of movement in the corresponding joint. A restricted range of movement in muscles may be caused by: 1. Sustained activation of the contractile mechanism of the muscle fibres, e.g. painful trigger points or 2. Reduced elasticity in the passive tissue components, e.g. shortening due to fibrosis (muscle contracture). 4. TENDER AND TRIGGER POINTS A tender point is a hyperirritable spot in a muscle that is painful on compression. Tender points should be distinguished from trigger points, which are hyperirritable spots in a muscle or its fascia that are painful on compression and give rise to a characteristic and well-defined pattern of referred pain. 5. MUSCULO-TENDINOUS INFLAMMATION Inflammation represents the body’s response to tissue injury caused by pressure, friction, repeated load or overload and external trauma. Whatever the nature of the underlying cause, the inflammatory response leads to impaired and painful mobility of the affected part. Inflammatory reactions in the musculo-skeletal system may occur in joints, tendons, tendon and muscle attachments, bursae and the periosteum. Inflammation of muscle-tendon attachment to bone (teno-periostitis) is clinically characterised by localised tenderness to pressure over the affected attachment and an increase in pain at the site of attachment, when the muscle group concerned is contracted against resistance (isometric testing). Inflammation of tendons (tendinitis) and bursae (bursitis) is clinically characterised by tenderness, and in the acute phase swelling and crepitus may be present.