11/13/24, 7\:09 PM Guide | pGALS examination

pGALS examination

Table of contents

pGALS vs adult GALS exam

The pGALS examination sequence is much the same as the adult GALS assessment with some additional manoeuvres and
amendments.
Further assessment of the foot and ankle\: the child is asked to walk on their heels and then on their tiptoes.
Assessment of the temporomandibular joints\: the child is asked to insert three of their
Assessment of the elbow\: the child is asked to "reach up and touch the sky
"
.
Assessment of the cervical spine\: the child is asked to look up at the ceiling.

Introduction

Wash your hands and don PPE if appropriate.
Introduce yourself to the parents and child including your name and role.
Con
Brie
Gain consent from the parents and child to proceed with the examination.
Adequately expose the child (ideally the child should wear only shorts and undergarments).
Position the child standing.
Throughout the pGALS assessment, you should adopt a "copy me" approach, where you
child to do and then ask them to copy you. This is easier for the child to follow than a sequence of verbal instructions.
Look for non-verbal clues of discomfort (e.g. grimacing) throughout the assessment.

Screening questions

Part of the pGALS 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).
Second question
" D o y o u h a v e a n y d i
This question screens for evidence of
Third question
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" 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 child, looking for clinical signs suggestive of underlying pathology\:
Body habitus\: obese children at a higher risk of developing slipped capital femoral epiphysis and thin malnourished children
are at risk of osteomalacia.
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
Look for objects or equipment on or around the child that may provide useful insights into their medical history and current
clinical status\:
Aids and adaptations\: examples include support slings, splints, walking aids and wheelchairs.
Prescriptions\: prescribing charts or personal prescriptions can provide useful information about the child's recent
medications (e.g. analgesia).

Closer inspection

Ask the child 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 child 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 child's previous surgical history and/or indicate
previous joint trauma.
Leg length discrepancy\: may be congenital or secondary to joint pathology (e.g. Legg-Calve-Perthes, slipped capital
femoral epiphysis and developmental dysplasia of the hip).
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.
Quadriceps hypertrophy is associated with Osgood-Schlatter disease.
Elbow extension\: inspect the child'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 child 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 child 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

Standard gait assessment
Ask the child 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\: children 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 child's footwear\: unequal sole wearing is suggestive of an abnormal gait.
Heel and tiptoe walking
Ask the child to walk across the examination room again but this time using their heels and then again using their tiptoes.
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Note the presence (or absence) of the longitudinal arches of the feet when the child is on their tiptoes. The presence of
(pes planus) is normal in young children, but the medial longitudinal arches of the foot should be visible when the child stands
on their tiptoes.
Assessing gait in this way screens for pathology in the ankles joints, subtalar joints, midtarsal joints and the smaller joints of
the feet and toes.
Observe gait cycle
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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Phases of the gait cycle (1-5) [2]

Arms

Compound movements

Hands behind head
Ask the child 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 child 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 child 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 child to make a
This movement assesses
The child may be unable to make a
other deformities of the small joints of the hands.
Precision grip
Ask the child to touch each
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This sequence of movements assesses co-ordination of the small joints of the
It also assesses overall manual dexterity (which should be interpreted in the context of the child's age).
Reduced manual dexterity may suggest in
Hands together palm to palm
Ask the child to put their hands together palm to palm\:
This movement assesses extension of the small joints of the
Restriction or asymmetry of movement is suggestive of joint pathology.
An excessive range of movement suggests hypermobility.
Hands together back to back
Ask the child to put their hands together back to back\:
This movement assesses
Restriction or asymmetry of movement suggests joint pathology.
An excessive range of movement suggests hypermobility.
Reaching upwards
Ask the child to reach upwards as far as they are able (as if trying to touch the sky), whilst keeping their arms straight\:
This movement assesses elbow extension, wrist extension and shoulder abduction.
Restriction or asymmetry of movement suggests joint pathology.
An excessive range of movement suggests hypermobility.
Looking upwards
Ask the child to look up at the ceiling\:
This movement assesses cervical extension.
Restriction of movement suggests joint pathology.

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
Ask the child to put their hands behind their neck [1]
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Legs

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

Active movement

Ask the child to bring each heel in turn towards their bottom\:
This movement assesses active knee
Ask the child to straighten out each leg on the bed\:
This movement assesses active knee extension.

Passive movement

Passive movement refers to a movement of the child, controlled by the examiner. This involves the child 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 child's leg,
discomfort.
Passive knee extension
If the child 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
Passive internal rotation of the hip
Normal range of movement\: 40°
Instructions\: Flex the child'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
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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 child'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
Perform patellar tap
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Ask the child 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 child to bend forwards and touch their toes.
3. Observe your
4. Observe your
together).
If the child is able to place their hands
Assess cervical lateral

Temporomandibular joint

To assess the temporomandibular joint (TMJ) ask the child to open their mouth wide and put three of their own
their mouth (you can 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.
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Assess TMJ function

To complete the examination...

Explain to the child that the examination is now
Thank the child and parents 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 J o h n , a n 1 1- y e a r-o l d b o y. 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 . T M J f u n c t i o n w a s a l s o n o r m a l .
"
Source\: geekymedics.com
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