(e) Planter fasciitis. May occur as a further complication of this injury. In cases of falanga, irritation is often present throughout the whole aponeurosis, causing chronic aponeurositis. Studies on the subject have shown that in prisoners released after 15 years of detention and who claimed to have been subjected to falanga application when first arrested, positive bone scans of hyperactive points in the calcaneus or metatarsal bones were observed.87 diagnostic. Falanga may produce chronic disability. Walking may be painful and difficult. The tarsal bones may be fixed (spastic) or have increased motion. Squeezing the plantar (sole) of the foot and dorsiflexion of the great toe may produce pain. On palpation, the entire length of the plantar aponeurosis may be tender and the distal attachments of the aponeurosis may be torn, partly at the base of the proximal phalanges, partly at the skin. The aponeurosis will not tighten normally, making walking difficult and muscle fatigue may follow. Passive extension of the big toe may reveal whether the aponeurosis has been torn. If it is intact, the beginning of tension in the aponeurosis should be felt on palpation when the toe is dorsiflexed to 20 degrees; maximum normal extension is about 70 degrees. Higher values suggest injury to the attachments of the aponeurosis.83, 84, 85, 86 On the other hand, limited dorsiflexion and pain on hyperextension of the large toe are findings of Hallux rigidus, which results from dorsal osteophyte at the first metatarsal head and/or base of the proximal phalanx. 204. occur: 205. Radiological methods such as MRI, CT scan and ultrasound can often confirm cases of trauma occurring as a result of the application of falanga. Positive radiological findings may also be secondary to other diseases or trauma. Routine radiographs are recommended as the initial examination. MRI is the preferred radiological examination for detecting soft tissue injury. MRI or scintigraphy can detect bone injury in the form of a bruise, which may not be detected by routine radiographs or CT.88 3. Numerous complications and syndromes can Suspension 206. Suspension is a common form of torture that can produce extreme pain, but which leaves little, if any, visible evidence of injury. A person still in custody may be reluctant to admit to being tortured, but the finding of peripheral neurological deficits, diagnostic of brachial plexopathy, virtually proves the diagnosis of suspension torture. Suspension can be applied in various forms: (a) Closed compartment syndrome. This is the most severe complication. An oedema in a closed compartment results in vascular obstruction and muscle necrosis, which may result in fibrosis, contracture or gangrene in the distal foot or toes. It is usually diagnosed by measuring pressures in the compartment; (a) Cross suspension. Applied by spreading the arms and tying them to a horizontal bar; (b) Crushed heel and anterior footpads. The elastic pads under the calcaneus and proximal phalanxes are crushed during falanga, either directly or as a result of oedema associated with the trauma. Also, the connective tissue bands that extend through adipose tissue and connect bone to the skin are torn. Adipose tissue is deprived of its blood supply and atrophies. The cushioning effect is lost and the feet no longer absorb the stresses produced by walking; (b) Butchery suspension. Applied by fixation of hands upwards, either together or one by one; (c) Reverse butchery suspension. Applied by fixation of feet upward and the head downward; (d) “Palestinian” suspension. Applied by suspending the victim with the forearms bound together behind the back, the elbows flexed 90 degrees and the forearms tied to a horizontal bar. Alternatively, the prisoner is suspended from a ligature tied around the elbows or wrists with the arms behind the back; (c) Rigid and irregular scars involving the skin and subcutaneous tissues of the foot after the application of falanga. In a normal foot, the dermal and sub-dermal tissues are connected to the planter aponeurosis through tight connective tissue bands. However, these bands can be partially or completely destroyed due to the oedema that ruptures the bands after exposure to falanga; (e) “Parrot perch” suspension. Applied by suspending a victim by the flexed knees from a bar passed below the popliteal region, usually while the wrists are tied to the ankles. (d) Rupture of the plantar aponeurosis and tendons of the foot. An oedema in the post-falanga period may rupture these structures. When the supportive function necessary for the arch of the foot disappears, the act of walking becomes more difficult and foot muscles, especially the quadratus plantaris longus, are excessively forced; 207. Suspension may last from l5 to 20 minutes to several hours. “Palestinian” suspension may produce permanent brachial plexus injury in a short period. The “parrot perch” may produce tears in the cruciate ligaments of the knees. Victims will often be beaten while suspended or otherwise abused. In the chronic phase, it is usual for pain and tenderness around the shoulder joints to persist, 83 G. Sklyv, “Physical sequelae of torture”, in Torture and Its Consequences: Current Treatment Approaches, M. Başoglu, ed. (Cambridge, Cambridge University Press, 1992), pp. 38-55. 84 See footnote 76. 85 K. Prip, L. Tived, N. Holten, Physiotherapy for Torture Survivors: A Basic Introduction (Copenhagen, International Rehabilitation Council for Torture Victims, 1995). 86 F. Bojsen-Moller and K. E. Flagstad, “Plantar aponeurosis and internal architecture of the ball of the foot”, Journal of Anatomy, vol. 121 (1976), pp. 599-611. ^ 87 V. Lök and others, “Bone scintigraphy as clue to previous torture”, The Lancet, vol. 337, No. 8745 (1991), pp. 846-847. See also M. Tunca and V. Lök, “Bone scintigraphy in screening of torture survivors”, The Lancet, vol. 352, No. 9143 (1998), p. 1859. 88 See footnotes 76 and 83 and V. Lök and others, “Bone scintigraphy as an evidence of previous torture”, Treatment and Rehabilitation Center Report of the Human Rights Foundation of Turkey (Ankara, 1994), pp. 91-96. 39