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Torture victims experience persistent pain and gait abnormalities. There is still a lack of data regarding the diagnostic value of imaging. For agencies who lend aid to these victims, documentation and proof of torture are pivotal. Especially in cases where victims seek help years after the torture occurred, the imaging modalities of bone scintigraphy, magnetic resonance imaging, and ultrasonography can be quite advantageous.Torture is defined as a systematic and deliberate infliction of physical or mental suffering by individuals acting alone or on orders of authority, to force another person to yield information or for any other reason.1 Unfortunately, torture is still practiced throughout the world. Obtaining proof of torture is difficult after a length of time has passed. This article outlines some imaging modalities that may help confirm victims’ claims of torture by falanga.

Falanga, also called falaka or bastinado, is the repetitive beating of the soles of the feet by blunt force.2 This method of torture has origins in the Middle East, but has been documented in India, Algeria, Uganda, Chile, Peru, Iran, Bangladesh, and Azerbaijan.2 Victims of falanga often experience chronic pain in the plantar fascia (arch) area of their feet which can leave them with a profound limp. Some physical signs include a “smashed” heel and fixed dorsiflexion of the great toe due to the destruction of the plantar aponeurosis.3

A study from the Centre for Trauma Victims in Stockholm, Sweden, compared the similarities in torture among 160 patients from the following countries; Bangladesh (53), Iran (21), Peru (16), Syria (24), Turkey (25), and Uganda (21).4 The rate of chronic foot pain reported due to falanga was consistent with the exception of Peru that had reported a lower incidence of this form of torture4 Falanga remains one of the most common forms of torture today due to the lack of physical evidence left after initial injury.3 This is problematic in the medico-legal world for investigators to validate victims’claims of torture when seeking asylum.

Bone Scintigraphy
A bone scintigraphy (bone scans) are nuclear imaging tests that help diagnose and track several types of bone disease, the contrast (technetium) binds to osteoblasts which demonstrate activity in any injury, neoplastic, or metabolic diseases of bone.5 Bone scintigraphy is a sensitive indicator of traumatic events and can reveal small fractures not seen on conventional x-ray.6

The Human Rights Foundation of Turkey (HRFT) was established to help the victims of torture during the period of the military regime in the 1980s.7 The challenge of proving torture after a long period of captivity lead to the use of bone scintigraphy when no standard radiographic findings were evident. Researchers from both the HRFT and the International Rehabilitation Council for Torture Victims (Denmark) noted that positive bone scan findings of the feet were found in a victim twelve years after falanga had occurred.7 The mean duration of detectable bone lesions post-torture in this study was 5.5 years.7

Magnetic Resonance Imaging
Magnetic Resonance Imaging (MRI) is a technique that uses a magnetic field and radio waves to create detailed images of the organs and tissues within the body.8 This is an excellent imaging modality to evaluate pathology of soft tissue, bones, and joints. A study performed in 2000 by the Rehabilitation Center for Torture Victims (RCT) Denmark used MRI to evaluate victims of falanga.9 There were 12 subjects, 11 from the Middle East and 1 from South America. MRIs were taken of the victims’ feet and compared to the control groups’ images.9 The results showed only thickening of the plantar aponeurosis (arch) particularly along the central band, as compared to the control group.9 No differences were noted in the plantar musculature or plantar (heel) fat pad.9 This is one of the first studies conducted using MRI regarding falanga evaluation. Additional studies will help to evaluate the reliability of MR imaging to confirm torture.

Ultrasonography
Ultrasound produces sound waves that are beamed through the body and cause return echoes that allow for visualization of anatomic structures beneath the skin.10 One study, using a Doppler ultrasound to evaluate whether or not vascular damage can be detected in falanga victims was unable to differentiate torture victims from the (normal) control group.11 The use of ultrasound was successful, however, in identifying hypertrophy of the plantar aponeurosis in falanga victims as compared to the control group.12 These findings are very similar to the MRI results in terms of soft tissue changes post torture. Ultrasound is a less expensive and more easily accessible imaging option as compared to both bone scan and MRI.

Conclusion
The aftermath of torture can lead to crippling physical and emotional scars. These victims experience persistent pain and gait abnormalities. There is still a lack of data regarding the diagnostic value of imaging. For agencies who lend aid to these victims, documentation and proof of torture are pivotal. Especially in cases where victims seek help years after the torture occurred, the imaging modalities of bone scintigraphy, magnetic resonance imaging, and ultrasonography can be quite advantageous.

Bone scintigraphy seems to reliably reveal the osseous effects of falanga even years after the beatings. MRI and ultrasonography are also promising and should be further explored to see their potential benefits.

References

1. Altun, Gurcan, and Gulay Durmus-Altun. "Confirmation of Alleged Falanga Torture by Bone Scintigraphy?Case Report." International Journal of Legal Medicine 117.6 (2003): 365-66. Web

2 .Byard, Roger W., and Bhupinder Singh. "Falanga Torture: Characteristic Features and Diagnostic Issues." Forensic Science, Medicine, and Pathology 8.3 (2012): 320-22. Web.

3 .Forrest, Mr D.m. "Examination for the Late Physical after Effects of Torture." Journal of  Clinical Forensic Medicine 6.4 (1999): 4-13. Web.

4. Moisander, Pia A., and Erik Edston. "Torture and Its Sequel—a Comparison between Victims from Six Countries." Forensic Science International 137.2-3 (2003): 133-40. Web.

5. Bone Scan. Mayo Clinic, 02 Mar. 2002. Web.

6 .Lok, V. "Bone Scintigraphy as Clue to Previous Torture." The Lancet 337.8745 (1991): 846-47. Web.

7. Ozkalipci, Onder, Umit Unuvar, Umit Sahin, Sukran Irencin, and Sebnem Korur Fincanci. "A Significant Diagnostic Method in Torture Investigation: Bone Scintigraphy." Forensic Science International 226.1-3 (2013): 142-45. Web.

8. Magnetic Resonance Imaging. Mayo Clinic, 17 Aug. 2013. Web.

9. Savnik, A., K. Amris, H. Røgind, K. Prip, B. Danneskiold-Samsøe, F. Bojsen-Møller, E. M. Bartels, H. Bliddal, J. Boesen, and N. Egund. "MRI of the Plantar Structures of the Foot after Falanga Torture." European Radiology 10.10 (2000): 1655-659. Web.

10. Wedro, Benjamin, MD. "Ultrasonograpny." MedicineNet.com. N.p., n.d. Web. July 2014.

11. Torp-Pedersen, Soren, MD, Kirstine Amris, MD, Christian Cato Holm, MSc, Merete Konig, MD, Karen Prip, PT, and Bente Danneskiold-Samsoe, MD. "Vascular Response to Ischemia in the Feet of Falanga Torture Victims and Normal Controls." Torture 19.1 (2009): 12-18. Web.

12. Amris, Kirstine, MD, Soren Torp-Pedersen, MD, and Ole Vedel Rasmussen, MD. "Long-term Consequences of Falanga Torture." Torture 19.1 (2009): 33-40. Web.

Christine Miller, DPM, FACCWS, is Member at Large of the American Society of Forensic Podiatry and a Post-Doctoral Clinical Associate at the University of Florida College of Medicine, Jacksonville. She was formerly the Chair of Podiatric Medicine at Temple University School of Podiatric Medicine

Jessica Popelka, DPM, is with the University of Florida Health System.

Nicole Griffin Ph.D. works at Temple University.

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