11/13/24, 7\:05 PM Guide | GALS examination

GALS examination

Table of contents

Introduction

Wash your hands and don PPE if appropriate.
Introduce yourself to the patient including your name and role.
Con
Brie
Gain consent to proceed with the examination.
Adequately expose the patient (ideally the patient should wear only shorts and undergarments).
Position the patient standing.

Screening questions

Part of the GALS assessment involves asking three screening questions to identify potential joint pathology,
impairment and gross motor de

Questions

First question
" D o y o u h a v e a n y p a i n o r s t i
This question screens for common symptoms present in most forms of joint pathology (e.g. osteoarthritis, rheumatoid arthritis,
ankylosing spondylitis).
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Second question
" D o y o u h a v e a n y d i
This question screens for evidence of
Third question
" D o y o u h a v e a n y p r o b l e m g o i n g u p a n d d o w n t h e s t a i r s ?"
This question screens for evidence of impaired gross motor function (e.g. muscle wasting, lower motor neuron lesions) and
general mobility issues (e.g. restricted range of movement in the joints of the lower limb).

Inspection

General inspection

Clinical signs
Perform a brief general inspection of the patient, looking for clinical signs suggestive of underlying pathology\:
Body habitus\: obesity is a signi
Scars\: may provide clues regarding previous surgery.
Wasting of muscles\: suggestive of disuse atrophy secondary to joint pathology or a lower motor neuron injury.
Psoriasis\: typically presents with scaly salmon coloured plaques on extensor surfaces (associated with psoriatic arthritis).
Objects or equipment
clinical status\:
Look for objects or equipment on or around the patient that may provide useful insights into their medical history and current
Aids and adaptations\: examples include support slings, splints, walking aids and wheelchairs.
Prescriptions\: prescribing charts or personal prescriptions can provide useful information about the patient’s recent
medications (e.g. analgesia).

Closer inspection

Ask the patient to stand in the anatomical position and turn in 90° increments as you inspect from each angle for evidence of
pathology.
Anterior inspection
Inspect the patient from the front noting any abnormalities\:
Posture\: note any asymmetry which may indicate joint pathology or scoliosis.
Scars\: note the location of any scars as they may provide clues as to the patient’s previous surgical history and/or indicate
previous joint trauma.
Joint swelling\: note any evidence of asymmetry in the size of joints that may suggest unilateral swelling (e.g. e
in
Joint erythema\: suggestive of active in
Muscle bulk\: note any asymmetry in upper and lower limb muscle bulk (e.g. deltoids, pectorals, biceps brachii, quadriceps
femoris). Asymmetry may be caused by disuse atrophy (secondary to joint pathology) or lower motor neuron injury.
Elbow extension\: inspect the patient's carrying angle which should be between 5-15°
. An increased carrying angle is known
as cubitus valgus. Cubitus valgus is typically associated with previous elbow joint trauma or congenital deformity (e.g.
Turner's syndrome). A decreased carrying angle is known as cubitus varus or 'gunstock deformity'
. Cubitus varus typically
develops after supracondylar fracture of the humerus.
Valgus joint deformity\: the bone segment distal to the joint is angled laterally. In valgus deformity of the knee, the tibia is
turned outward in relation to the femur, resulting in the knees 'knocking' together.
Varus joint deformity\: the bone segment distal to the joint is angled medially. In varus deformity of the knee, the tibia is
turned inward in relation to the femur, resulting in a bowlegged appearance.
Pelvic tilt\: lateral pelvic tilt can be caused by scoliosis, leg length discrepancy or hip abductor weakness.
Fixed
Big toe\: note any evidence of lateral (hallux valgus) or medial (hallux varus) angulation.
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Inspect from the front
Lateral inspection
Inspect the patient from the side noting any abnormalities\:
Cervical lordosis\: hyperlordosis is associated with chronic degenerative joint disease (e.g. osteoarthritis).
Thoracic kyphosis\: the normal amount of thoracic kyphosis is typically between 20-45º
. Hyperkyphosis is associated with
Scheuermann's disease (congenital wedging of the vertebrae).
Lumbar lordosis\: loss of normal lumbar lordosis suggests sacroiliac joint disease (e.g. ankylosing spondylitis).
Knee joint hyperextension\: causes include ligamentous damage and hypermobility syndrome.
Foot arch\: inspect for evidence of
Inspect from the side
Posterior inspection
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Inspect the patient from the behind noting any abnormalities\:
Muscle bulk\: note any asymmetry in upper and lower limb muscle bulk (e.g. deltoid, trapezius, triceps brachii, gluteal
muscles, hamstrings, calves). Asymmetry may be caused by disuse atrophy (secondary to joint pathology) or lower motor
neuron injury.
Spinal alignment\: inspect for lateral curvature of the spine suggestive of scoliosis.
Iliac crest alignment\: misalignment may indicate a leg length discrepancy or hip abductor weakness.
Popliteal swellings\: possible causes include a Baker's cyst or popliteal aneurysm (typically pulsatile).
Achille's tendon thickening\: associated with Achille's tendonitis.
Valgus joint deformity\: the bone segment distal to the joint is angled laterally. In valgus deformity of the ankle, the foot is
turned outward in relation to the tibia.
Varus joint deformity\: the bone segment distal to the joint is angled medially. In varus deformity of the ankle, the foot is
turned inward in relation to the tibia.
Inspect from behind

Gait

Ask the patient to walk to the end of the examination room and then turn and walk back whilst you observe their gait paying
attention to\:
Gait cycle\: note any abnormalities of the gait cycle (e.g. abnormalities in toe-o
Range of movement\: often reduced in the context of chronic joint pathology (e.g. osteoarthritis, in
Limping\: may suggest joint pain (i.e. antalgic gait) or weakness.
Leg length\: note any discrepancy which may be the cause or the result of joint pathology.
Turning\: patients with joint disease may turn slowly due to restrictions in joint range of movement or instability.
Trendelenburg’s gait\: an abnormal gait caused by unilateral weakness of the hip abductor muscles secondary to a superior
gluteal nerve lesion or L5 radiculopathy.
Waddling gait\: an abnormal gait caused by bilateral weakness of the hip abductor muscles, typically associated with
myopathies (e.g. muscular dystrophy).
Assess the patient’s footwear\: unequal sole wearing is suggestive of an abnormal gait.
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Observe the patient's gait
Gait cycle
The gait cycle has six phases\:
1. Heel-strike\: initial contact of the heel with the
2. Foot
3. Mid-stance\: the weight is aligned and balanced on this leg.
4. Heel-o
5. Toe-o
6. Swing\: the foot swings forward and comes back into contact with the
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Stages of the gait cycle (1-5) [1]

Arms

Compound movements

Hands behind head
Ask the patient to put their hands behind their head and point their elbows out to the side\:
This compound movement assesses shoulder abduction and external rotation in addition to elbow
Restricted range of movement is suggestive of shoulder or elbow pathology (e.g. osteoarthritis).
Excessive range of movement indicates hypermobility.
Hands held out in front with palms facing down
Ask the patient to hold their hands out in front of them, with their palms facing down and
This compound movement assesses forward
small joints of the
Inspect the dorsum the hands for asymmetry, joint swelling and deformity.
Inspect the nails for signs associated with psoriasis (e.g. nail pitting).
Hands held out in front with palms facing up
Ask the patient to turn their hands over (demonstrating supination)\:
This compound movement assesses wrist and elbow supination.
Restriction of supination is suggestive of wrist or elbow pathology (e.g. osteoarthritis).
Inspect the thenar and hypothenar eminences for evidence of muscle wasting.
Making a
Ask the patient to make a
This movement assesses
The patient may be unable to make a
other deformities of the small joints of the hands.
Grip strength
Ask the patient to squeeze your
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Grip strength may be reduced due to pain (e.g. swelling of the small joints of the hand) or due to lower motor neuron lesions
(e.g. median nerve damage secondary to carpal tunnel syndrome).
Precision grip
Ask the patient to touch each
This sequence of movements assesses co-ordination of the small joints of the
Reduced manual dexterity may suggest in

Metacarpophalangeal joint squeeze

Gently squeeze across the metacarpophalangeal (MCP) joints and observe for verbal and non-verbal signs of discomfort.
Tenderness is suggestive of active in
Shoulder abduction and external rotation

Legs

Position the patient lying down on the examination couch for further assessment of the lower limbs.

Passive movement

Passive movement refers to a movement of the patient, controlled by the examiner. This involves the patient relaxing and
allowing you to move the joint freely to assess the full range of joint movement. It's important to feel for crepitus as you move
the joint (which can be associated with osteoarthritis) and observe any discomfort or restriction in the joint's range of
movement.
Passive knee
Normal range of movement\: 0-140°
Instructions\: Whilst supporting the patient's leg,
discomfort.
Passive knee extension
If the patient is able to lay their legs
extension. To assess for hyperextension\:
1. On the leg being assessed, hold above the ankle joint and gently lift the leg upwards.
2. Inspect the knee joint for evidence of hyperextension, with less than 10° being considered normal. Excessive knee
hyperextension may suggest pathology a
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Passive internal rotation of the hip
Normal range of movement\: 40°
Instructions\: Flex the patient’s hip and knee joint to 90°
and then rotate their foot laterally.

Metatarsophalangeal joint squeeze

Gently squeeze across the metatarsophalangeal (MTP) joints and observe for verbal and non-verbal signs of discomfort.
Tenderness is suggestive of active in
Assess passive knee

Patellar tap

Joint e
osteoarthritis.
The patellar tap test can be used to screen for the presence of a moderate-to-large knee joint e
1. With the patient's knee fully extended, empty the suprapatellar pouch by sliding your left hand down the thigh to the upper
border of the patella.
2. Keep your left hand in position and use your right hand to press downwards on the patella with your
3. If there is
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Perform patellar tap
Ask the patient to stand upright for this part of the assessment. Inspection of the spine does not need to be repeated if already

Spine

performed.

Cervical lateral

Assess lateral
shoulder\:
" T r y a n d t o u c h y o u r s h o u l d e r t o y o u r e a r o n e a c h s i d e .
"

Lumbar

Assess the range of lumbar
of lumbar
1. Place two of your
2. Ask the patient to bend forwards and touch their toes.
3. Observe your
4. Observe your
together).
If the patient is able to place their hands
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Assess cervical lateral

Temporomandibular joint

An adult GALS screen can include assessment of the temporomandibular joint (previously this was only tested in children as
part of pGALS).
To assess the temporomandibular joint (TMJ) ask the patient to open their mouth wide and put three of their
mouth (demonstrate using your own
This manoeuvre assesses the temporomandibular joint's range of movement and screens for deviation of jaw movement.
Restricted jaw opening may be due to temporomandibular joint disease.

To complete the examination...

Explain to the patient that the examination is now
Thank the patient for their time.
Dispose of PPE appropriately and wash your hands.
Summarise your
Example summary
" T o d a y I e x a m i n e d M r S m i t h , a 3 2- y e a r-o l d m a l e. O n g e n e r a l i n s p e c t i o n , t h e p a t i e n t a p p e a r e d c o m f o r t a b l e a t r e s t , w i t h
n o s t i g m a t a o f m u s c u l o s k e l e t a l d i s e a s e . T h e r e w e r e n o o b j e c t s o r m e d i c a l e q u i p m e n t a r o u n d t h e b e d o f r e l e v a n c e .
" A s s e s s m e n t o f t h e p a t i e n t' s g a i t , a r m s , l e g s a n d s p i n e w e r e u n r e m a r k a b l e .
"
" I ns u m m a r y , t h e s e
"
Source\: geekymedics.com
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