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Torture Methods
Ear Trauma
Toolkits > Istanbul Protocol Model Medical Curriculum > Module 4: Torture Methods and their Medical Consequences > Torture Methods > Beatings/Falanga

Beatings/Falanga

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Beating

Beating is the most common form of physical torture. When the aim is to disguise its effects, beating may be performed with heavy, flexible implements such as sandbags or lead-filled plastic pipes, which may leave short-lived bruising but no permanent scarring. Sometimes the torturers perform the beating over clothing or folded towels. The impact of the blows is still severe and such beating may cause deep muscle bruising (which may take several days to reach the surface) or internal bleeding. This has been reported to lead to acute renal failure due to release of myoglobin (see Module 5). In many countries, severe beatings, which cause widespread bruising, are discontinued after the first few days of detention so that when the victim is produced to court or released after days or weeks later, all obvious signs of beating will have faded.

Beating using a metal cable in South Africa. (Courtesy of Physicians for Human Rights)

Falanga

Falanga, also referred to as falaka, can be defined as the applications of blunt trauma to the soles of the feet. The technique has been practised throughout history. It is still very common, particularly in the Middle East, but also in the Indian subcontinent and, according to Amnesty International, in over thirty countries worldwide. In some countries, such as Turkey, it is applied almost as a routine at the time of detention and many torture survivors report having suffered it on numerous occasions.

“Falaka” (beating the soles of the feet). (Courtesy of the Human Rights Foundation of Turkey)

It may be applied by batons, whips or canes to the bare feet or with shoes still on, and the immediate effect will depend on these variables. Often the victim is made to walk round on rough paving afterwards, sometimes carrying another on his back. This last detail is clearly intended to add to the humiliation as well as the pain.

Falanga (Amnesty International) This photo was taken one week after falanga.

As with most forms of physical torture, the physical findings associated with falanga change over time. These changes can be summarised as follows:

Acute Symptoms and Signs

The immediate effect of falanga 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. 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. 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

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, and most likely a combination of trauma mechanisms are responsible.

Reduced Shock Absorbency in the Heel Pads

The footpads are situated under the weight-bearing 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 structures are easily felt through the tissues. The pathophysiology of the reduced elasticity in the heel pad is thought to be tearing of the connective tissue septa, leading to deprivation of blood supply and secondary atrophy of fat cells with loss of the shock absorbing ability.

Damaged footpads are not pathognomonic of falanga, but are also described in connection with other conditions unrelated to torture, e.g. lesions in long-distance runners and patient with fractures of the heel bone. It should also be stressed that normal footpads at clinical examination does not rule out exposure to falanga.

Changes in the Plantar Fascia

The plantar fascia springs from the calcaneus and proceeds to the forefoot. It is tightened during foot of supporting the longitudinal arches of the foot, assisting the foot muscles during walking. Changes in the plantar fascia are present in some torture victims after falanga and are probably due to the repeated direct traumas to this superficial structure. After falanga, the fascia may appear thickened with an uneven surface at palpation, and tenderness may be found throughout the whole length of the fascia, from its spring to the insertion. Disruption of the plantar fascia has been reported, based on the finding of increased passive dorsiflexion in the toes at clinical examination.

Closed Compartment Syndrome

The plantar muscles of the foot are arranged in tight compartments—an anatomical arrangement which makes it possible for a closed compartment syndrome to develop. A closed compartment syndrome is defined as a painful ischaemic, circulatory disturbance in connection with an increase in pressure and volume inside a well-defined muscle compartment. In the acute form, with a rapidly increasing pressure, e.g. caused by bleeding inside the compartment, the symptoms are alarming and the consequences severe with necrosis of involved tissues if left untreated.

Chronic compartment syndromes may occur as a result of an increase in the muscle bulk and/or a narrowing of the compartment. Clinically, this condition presents itself with pain that intensifies with load and which finally makes continued muscle activity impossible. The pain subsides after a short period of rest, but recurs if muscle activity is resumed—a picture not unlike that seen in impaired walking after falanga.

In a MRI study comparing torture victims exposed to falanga with healthy volunteers, significant thickening of the plantar fascia was found in all victims. Apart from this, morphological changes were present in the fascia, possibly representing scar tissue formation. No signs of detachment of the plantar fascia, closed compartment syndrome or changes in the heel pads were shown in this study.

Neurogenic Pain

The skin of the soles in the normal foot is apart from the arch area, very thick and firmly tied to the underlying tissues. It is very rich in sensory nerve endings, which register touch and pressure. Peripheral nerve lesion affecting the small nerves of the soles is a very possible consequence of falanga. Neurogenic pain due to nerve lesion is therefore a possible contributing pain mechanism.

Impaired Walking

Deviations from the normal gait pattern are very frequent after exposure to falanga. Many torture victims develop a compensatory 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 for Falanga

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 feet does not rule out the possibility of this specific torture method. Special investigations that may aid in correlating allegations of falanga include x-rays, scintography and MRI (see Module 5). Treatment in the chronic phase often includes gentle massage to the muscles of the feet, calves and thighs, re-education of the walking pattern and supportive footwear, especially designed to offer cushioning of the heels.

Torture Methods
Ear Trauma
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  • Istanbul Protocol Model Medical Curriculum

    • Preface
      • Copyright and Acknowledgements
      • Resources
      • Glossary
    • Introduction
      • Curriculum Materials
      • Summary of Content
      • How to Use These Educational Resources
    • Module 1: International Legal Standards (Overview)
      • Torture
        • What is Torture
        • Purpose of Torture
        • History of Torture
        • Other Definitions
        • Cruel Inhuman & Degrading Treatment & Punishment (CID)
        • Prohibition of Torture in International Law
        • The United Nations Convention Against Torture and Other Cruel, Inhuman or Degrading Treatment or Punishment 1984
        • Torture in the World Today
        • Country-Specific Legal Standards and Torture Practices
        • The Perpetrators
        • Common Situations for Torture Allegations
        • Where Does Torture and Ill-treatment Occur?
        • Obligation to Investigate and Bring Justice
        • Formal Inspection of Detention Facilities
        • Official Complaints to Human Rights Bodies and Other Organizations
        • Recently Released Detainees
        • NGO Information Gathering
        • Late Allegations
      • Prevention and Accountability
        • Prevention
        • Accountability
        • Reparation
      • International Supervisory Machinery and Complaints Procedures
        • The Human Rights Committee
        • The UN Committee against Torture
        • Regional Mechanisms
        • Other monitoring mechanisms
        • The UN Special Rapporteur on Torture and other Cruel, Inhuman and Degrading Treatment or Punishment
        • International criminal courts and tribunals
        • The International Committee of the Red Cross (ICRC)
      • Safeguards Against Torture for Those Deprived of Their Liberty
        • Notifying people of their rights
        • Use of officially recognized places of detention and the maintenance of effective custody records
        • Avoiding incommunicado detention
        • Humane conditions of detention
        • Limits on interrogation
        • Access to a lawyer and respect for the functions of a lawyer
        • Access to a doctor
        • The right to challenge the lawfulness of detention
        • Safeguards for special categories of detainees
      • Module 1 Presentation: International Legal Standards
      • Self-Assessment and Quiz
        • Module 1 Answers
    • Module 2: Istanbul Protocol Standards for Medical Documentation of Torture and Medical Ethics
      • The Istanbul Protocol
        • About the Istanbul Protocol
        • Brief History
        • International Recognition of the Istanbul Protocol
      • An Overview of the Istanbul Protocol
        • Legal Investigation of Torture
        • General Considerations for Interviews
        • Physical Evidence of Torture
        • Psychological Evidence of Torture
        • Interpretation of Findings and Referrals
        • Misuse of the Istanbul Protocol
        • Procedural Safeguards for Detainees
      • Medical Ethics
        • Introduction
        • Duties of the health professional
        • International Codes
        • Ethical rules directly prohibiting involvement in torture
        • Primary loyalty to the patient
        • Dual Obligations
        • The treatment of prisoners and detainees
        • Issues surrounding examinations of individuals in the presence of security forces
        • Abusive medical treatment
        • Consent and confidentiality
        • Security
        • Involvement of other health professionals in torture
        • Seeking further information and support
        • Country-specific legal responsibilities of health professionals for forensic documentation of torture and ill-treatment
      • General Guidelines for Gathering Evidence and Documenting Findings
        • The aims and goals of investigation
        • Multidisciplinary approach to documentation
        • Role of the health professional in the team
        • Role of the lawyer in the team
        • Role of the NGO member in the team
        • Role of judges and prosecutors
      • Documenting the allegations
        • The aim of medical documentation
        • Types of evidence
        • Medical evidence
        • Gathering of evidence
        • Essential information
        • Quality of information
        • Comparing records
      • Module 2 Presentation: Istanbul Protocol Standards for Medical Documentation of Torture and Medical Ethics
      • Self-Assessment and Quiz
        • Module 2 Answers
    • Module 3: Interview Considerations
      • Preliminary Considerations
        • Purpose of Medical Evaluations
        • Interview Settings
        • Trust
        • Informed Consent
        • Confidentiality
        • Privacy
        • Empathy
        • Objectivity
        • Safety and Security
        • Procedural Safeguards for Detainees
        • Risk of Re-traumatisation
        • Gender Considerations
        • Interviewing Children
        • Cultural and Religious Awareness
        • Working with Interpreters
        • Transference and Counter-Transference Reactions
      • Conducting Interviews
        • Types of questions
        • Cognitive Techniques
        • Summarising and clarifying
        • Difficulties Recalling and Recounting
        • Assessing Inconsistencies
      • Interview Content
        • Identification and Introduction
        • Psychosocial History (Pre-Arrest)
        • Past Medical History
        • Summary of Detention(s) and Abuse
        • Circumstances of Detention(s)
        • Prison/Detention Place Conditions
        • Allegations of Torture and Ill-treatment
        • Review of Symptoms
        • Psychosocial History (post-arrest)
        • Assessments of Physical and Psychological Evidence
        • Physical Examination
        • Closing
        • Indications for Referral
      • Module 3 Presentation: Interview Considerations
      • Self-Assessment and Quiz
        • Module 3 Answers
    • Module 4: Torture Methods and their Medical Consequences
      • Introduction
      • Torture Methods
        • Beatings/Falanga
        • Ear Trauma
        • Eye Trauma
        • Restraint, Shackling and Positional Torture
        • Suspension
        • Crushing and Stretching Injuries
        • Burning
        • Electrical injuries
        • Asphyxiation
        • Violent Shaking
        • Sexual Assault
        • Sexual Humiliation
        • Prolonged Isolation and Sensory Deprivation
        • Sleep Deprivation
        • Temperature Manipulation
        • Sensory Bombardment
        • Threats of Harm
      • Psychological Consequences of Torture
        • Introduction
        • The Paradox of Psychological Consequences of Torture
        • The Psychological Consequences of Torture
        • Social, Political and Cultural Context
        • Risk factors for Trauma and Torture-Related Disorders
        • Psychological Symptoms
      • Module 4 Presentation: Torture Methods and their Medical Consequences
      • Self-Assessment and Quiz
        • Module 4 Answers
    • Module 5: Physical Evidence of Torture and Ill-Treatment
      • Physical Evidence of Torture
        • Medical history
      • The Physical Examination
        • Dermatologic Evaluation
        • Head and Neck
        • Chest and Abdomen
        • Musculoskeletal System
      • Neurological Examination
        • Head Trauma and Post-traumatic Epilepsy
        • Nerve Damage
      • Examination of Women
        • Examination Following a Recent Assault
        • Examination After the Immediate Phase
        • Follow-up
        • Genital Examination of Women
      • Genital Examination of Men
      • Perianal Examination
      • Medical Photography
        • Assessment for Referral
      • Diagnostic Tests
      • Module 5 Presentation: Physical Evidence of Torture and Ill-Treatment
      • Self-Assessment and Quiz
        • Module 5 Answers
    • Module 6: Psychological Evidence of Torture and Ill-Treatment
      • The Central Role of the Psychological Evaluation
        • Conducting the Psychological Evaluation
        • Psychological Findings and Diagnostic Considerations
        • Components of the Psychological/Psychiatric Evaluation
      • Children and Torture
        • Introduction
        • Developmental Considerations
        • Clinical Considerations
        • Role of the Family
      • Apendix I: Sample Psychological Evaluations
        • Psychological Evaluation #1
        • Psychological Evaluation #2
      • Apendix II: ICD-10
      • Module 6 Presentation: Psychological Evidence of Torture and Ill-Treatment
      • Self-Assessment and Quiz
        • Module 6 Answers
    • Module 7: Case Example #01
      • Introduction
      • Preliminary Considerations
      • Materials
      • Module 7 Presentation: Case Example #01
      • Self-Assessment and Quiz
        • Module 7 Answers
    • Module 8: Case Example #02
      • Introduction
      • Preliminary Considerations
      • Materials
      • Module 8 Presentation: Case Example #02
      • Self-Assessment and Quiz
        • Module 8 Answers
    • Module 9: Report Writing and Testifying in Court
      • Written Reports
        • General Considerations
        • Content of Written Reports
        • Conclusions
        • Inconsistencies
      • Providing Testimony in Court
      • Appendix: Court Testimony Guidelines and Maxims
      • Module 9 Presentation: Report Writing and Testifying in Court
      • Self-Assessment and Quiz
        • Module 9 Answers
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