PHR Toolkits
Physicians for Human Rights Tools & Resources
Skip to content
  • Home
  • Toolkits
    • Asylum and Detention
    • Essential Medicines
    • Health & Human Rights Education
    • Health Access in Massachusetts
    • International Forensic Investigation Course
    • Istanbul Protocol Model Medical Curriculum
    • Medical Neutrality Protection Act
    • Medical Professionalism
    • Student Chapter Toolkit
  • Categories
    • Subjects
    • Issues
    • Uses
  • Downloads & Materials
    • Campaign Specific
    • Forms & Letters
    • Letterhead & Stationery
    • Logos & Graphics
    • Model Curriculum
    • Posters & Stickers
    • Slideshows & Media
    • General/Other
  • Resources & Links
    • Physicians for Human Rights
    • National Student Program
    • Articles
    • Books
    • Reports
    • Social Media
    • Networks, Groups & Forums
    • Online Tools
    • Important Organizations
    • Blogs of Interest
    • Relevant Websites
  • PHR
  • Contact
Chest and Abdomen
Neurological Examination
Toolkits > Istanbul Protocol Model Medical Curriculum > Module 5: Physical Evidence of Torture and Ill-Treatment > The Physical Examination > Musculoskeletal System

Musculoskeletal System

Printable Page Printable Page

Complaints of musculoskeletal aches and pains are very common in survivors of torture. They may be the result of repeated beatings, of suspension, or of other positional torture. They may also be somatic. They are non-specific, but should be documented. In accordance with the characteristics of torture, complaints are characterized as pain in the respective region of the body, limitation of joint movement, swelling, parasthesiae, numbness, loss of sensation to touch, and tendon reflex loss.

Physical examination of the skeleton should include testing for mobility of joints, the spine and the extremities. Pain with motion, contractures, strength, evidence of compartment syndrome, fractures with or without deformity, and dislocations should all be noted after documenting visible signs such as contusions, abrasions, and lacerations as described above. Trauma to muscle should be checked for, such as muscle rupture and muscle tearing. Specific clinical signs of ligament tear include swelling, bruising, muscle spasm, and painful stress test, often with joint laxity. There may be a palpable gap in the ligament. If it is completely torn, then considerable swelling and bruising occurs. Tendon ruptures, avulsions from the insertion of the bone, and dislocation of a tendon from its groove may all be observed.

Back pain is also common in survivors of torture, and there may be some local tenderness in the lumbar spine. However, these findings are non-specific and common in the general population. Fractures of the vertebral pedicles (the parts of the vertebra going away from the main body) may result from direct blunt force and, in some instances, radiography of the vertebrae may indicate recent or healed fractures.

Fractures

Fractures are caused by a loss of bone integrity due to the effect of a blunt mechanical force on various vector planes. Fractures can be caused by a direct blow, in which case the fracture is at the site of the impact, or by twisting or crushing, in which case the fracture tends to be at the weakest part of the bone. In the acute phase, local swelling, bony deformity, tenderness and loss of function will be typical findings on clinical examination. In the chronic phase, various degrees of bony deformity, pain with activity and loss of function may be found. A direct fracture occurs at the site of impact or at the site where the force was applied. In an indirect fracture, the location, contours, and other characteristics of a fracture reflect the nature and direction of the applied force. The most frequent fractures seen in survivors of torture are of the nasal bones, the ribs, the radius, ulna and small bones of the hand, the transverse process of vertebrae, and those of the coccyx. The hyoid bone and laryngeal cartilage may be fractured in partial strangulation or from blows to the neck.

If a person alleges that a bone was fractured during torture and a callus is palpable, that should normally be sufficient to document. X-rays are unlikely to add anything. Generally, even with an X-ray, it is only possible to say that a bone was fractured within a wide time-frame, but very rarely that the fracture was caused by torture. Mal-united fractures are highly supportive of a history of torture with no immediate medical treatment.

Routine radiographs are recommended at the initial examination, if facilities are available. Injuries to tendons, ligaments, and muscles are best evaluated with MRI, but arthrography (arthroscopy) can also be performed. In the acute stage, MRI can detect hemorrhage and possible muscle tears. Muscles usually heal completely without scarring, so later imaging studies will be negative. MRI or scintigraphy may detect bone injury such as a subperiosteal haematoma, which may not be detected on routine radiographs or CT. Radiographic aging of relatively recent fractures should be performed by an experienced trauma radiologist.

Chest and Abdomen
Neurological Examination
Printable Page Printable Page
  • Search

  • 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
  • Twitter Flickr Facebook LinkedIn YouTube Change.org
  • Toolkit Administration

    • Register
    • Log in
  • PHR Links

    • Physicians for Human Rights
    • About PHR
    • Blog
    • Press Room
    • Library
    • Student Program
    • Donate
    • Join
    • Subscribe
    • Take Action
    • Contact
  • RSS Press Releases

    • Trump’s Texas Visit Highlights Damage Caused by Anti-Immigrant Policies, COVID-19 Failures
    • U.S. Immigration and Customs Enforcement (ICE) Endangered Detained Immigrants, Violated Human Rights During Pandemic: Physicians for Human Rights (PHR) Investigation
    • El Servicio de Inmigración y Control de Aduanas (ICE) de los Estados Unidos puso en peligro y violó los derechos humanos de los inmigrantes detenidos durante la pandemia: Investigación de Physicians for Human Rights (PHR)
    • Court Delivers Justice for Several Survivors of Post-Election Sexual Violence in Kenya
    • By Design or Neglect, Syrian Government Has Damaged Health System, Suppressed COVID-19 Data in Daraa: PHR Report
  • RSS Blog

    • Trump’s Texas Visit Highlights Damage Caused by Anti-Immigrant Policies, COVID-19 Failures
    • U.S. Immigration and Customs Enforcement (ICE) Endangered Detained Immigrants, Violated Human Rights During Pandemic: Physicians for Human Rights (PHR) Investigation
    • El Servicio de Inmigración y Control de Aduanas (ICE) de los Estados Unidos puso en peligro y violó los derechos humanos de los inmigrantes detenidos durante la pandemia: Investigación de Physicians for Human Rights (PHR)
    • Court Delivers Justice for Several Survivors of Post-Election Sexual Violence in Kenya
    • By Design or Neglect, Syrian Government Has Damaged Health System, Suppressed COVID-19 Data in Daraa: PHR Report
  • RSS In the News

    • Trump’s Texas Visit Highlights Damage Caused by Anti-Immigrant Policies, COVID-19 Failures
    • U.S. Immigration and Customs Enforcement (ICE) Endangered Detained Immigrants, Violated Human Rights During Pandemic: Physicians for Human Rights (PHR) Investigation
    • El Servicio de Inmigración y Control de Aduanas (ICE) de los Estados Unidos puso en peligro y violó los derechos humanos de los inmigrantes detenidos durante la pandemia: Investigación de Physicians for Human Rights (PHR)
    • Court Delivers Justice for Several Survivors of Post-Election Sexual Violence in Kenya
    • By Design or Neglect, Syrian Government Has Damaged Health System, Suppressed COVID-19 Data in Daraa: PHR Report

Physicians for Human Rights, 2 Arrow Street, Suite 301, Cambridge, MA 02138  |  Tel 617.301.4200  |  Fax 617.301.4250
© Physicians for Human Rights (PHR) 2010