GALS examination (Gait, Arms, Legs, Spine), is often used as a quick screening tool to detect locomotor abnormalities and functional disability in a patient. This GALS examination OSCE guide demonstrates how to perform the assessment in a step by step manner, with an included video guide.

Check out the GALS mark scheme here.

 


Introduction

  • Wash hands
  • Introduce yourself
  • Confirm the patient’s details (e.g. name and date of birth)
  • Explain the examination: “Today I’m going to ask you to do a number of different movements with your head, arms and legs. This is to screen for any joint problems you may have.”
  • Gain consent: “Does that sound ok?”
  • Expose the patient’s chest, upper and lower body (ideally, the patient should be wearing shorts)
  • Ask if the patient has any pain anywhere before you begin the examination

 


Screening questions

  • Do you have any pain or stiffness in your muscles, joints or back?
  • Do you have any difficulty getting yourself dressed without any help?
  • Do you have any problem going up and down stairs?

 


Gait

Ask the patient to walk to the end of the room, turn around and come back whilst you observe:

  • Inspect the gait cycle (heel strike, toe-off) and coordination
  • When the patient reaches the end of the room, are they able to turn quickly without any issues?
  • Is there any evidence of pain? (antalgic gait)
  • Are the foot arches normal or absent? (e.g. flat feet)

Assessing gait in this way screens for pathology in the ankles, subtalar, midtarsal and small joints of the feet and toes.

  • Gait (walking cycle)
    Observe gait cycle

Inspection

Ask the patient to stand in the anatomical position whilst you inspect from the front, side and behind for any abnormalities.

Front

Posture:

  • Note any obvious asymmetry/scoliosis

 

Body habitus:

  • Obesity can be associated with joint pathology (e.g. early-onset osteoarthritis in the knees)
  • A thin malnourished adult may be at increased risk of fractures of osteomalacia

 

Skin rashes:

  • Salmon coloured plaques with silvery scale over extensor surfaces is typical of psoriasis
  • Psoriatic arthritis is associated with psoriasis

 

Shoulders:

  • Assess shoulder bulk (muscle wasting suggests chronic joint disease)
  • Asymmetry of the shoulders may be due to unilateral wasting or scoliosis of the spine

 

Elbow extension:

  • Assess the patient’s carrying angle (normal is 5-15 degrees)
  • Joint contractures can result in an inability to extend the elbow at rest

 

Leg length and alignment:

  • Note any leg length inequality
  • A valgus or varus deformity of the hip or knee may result in misalignment of the limb

 

Quadriceps:

  • Assess muscle bulk and symmetry
  • Muscle wasting suggests chronic joint disease

 

Knees:

  • Swelling and erythema of a knee joint may suggest inflammatory arthritis or joint sepsis
  • Note any deformity of the knee joints (e.g. valgus or varus)
  • Note any asymmetry which may be caused by joint effusion
  • Note any hyperextension of the knee joints (e.g. hypermobility)

 

Ankles:

  • Swelling and erythema of a knee joint may suggest inflammatory arthritis or joint sepsis
  • Note any deformity of the ankle joints (e.g. valgus or varus deformity)

 

Feet:

  • Note any midfoot/forefoot deformity (e.g flat feet)
  • Note any asymmetry between the feet (e.g. hallux valgus)

 

  • Inspection GALS
    Inspect from the front

Side

Cervical spine:

  • Inspect for hyperlordosis (e.g. spondylolisthesis)

 

Thoracic spine:

  • Inspect degree of thoracic kyphosis (normal is 20-45º)
  • Hyperkyphosis = >45º (e.g. Scheuermann’s kyphosis)

 

Lumbar spine:

  • Assess the degree of lordosis 
  • Loss of lumbar lordosis may suggest sacroiliac joint disease

 

Knee joints:

  • Note the degree of flexion
  • Look for evidence of hyperextension (e.g. suggestive of hypermobility)

 

Foot arches:

  • Inspect the patient’s foot arches
  • Low arch profile (pes planus/flat feet)
  • High arch profile (pes cavus) – e.g. Charcot-Marie-Tooth disease

 

Toe clawing:

  • May indicate plantar fascial fibromatosis

 

  • Inspection GALS
    Inspect from the side

 

Behind

Shoulder muscles:

  • Assess shoulder bulk (muscle wasting suggests chronic joint disease)
  • Asymmetry of the shoulders may be due to unilateral wasting or scoliosis of the spine

 

Spinal alignment:

  • Look for evidence of scoliosis (S-shaped spine)

 

Iliac crest alignment:

  • Pelvic tilt may suggest hip abductor weakness 

 

Gluteal muscle bulk:

  • Wasting of gluteal muscles suggests reduced mobility

 

 

Popliteal swellings:

  • Baker’s cyst (non-pulsatile)
  • Popliteal aneurysms (pulsatile)

 

Hind-foot abnormalities:

  • Thickening of the Achille’s tendon may suggest tendonitis

 

  • Inspection GALS
    Inspect from behind

 


Arms

Ask the patient to put their hands behind their head:

  • This assesses shoulder abduction and external rotation in addition to elbow flexion
  • Restricted range of movement suggests shoulder or elbow pathology
  • An excessive range of movement suggests hypermobility

 

Ask the patient to hold their hands out in front of them, with their palms facing down and fingers outstretched:

  • This assesses forward flexion of the shoulders, elbow extension, wrist extension and extension of the small joints of the fingers
  • Inspect the backs of the hands for asymmetry, joint swelling and deformity
  • Inspect the nails for signs associated with psoriasis (e.g. nail pitting)

 

Ask the patient to turn their hands over (supination):

  • This assesses wrist and elbow supination
  • Inspect the muscle bulk of the palms (thenar/hypothenar eminences) for evidence of wasting
  • Restriction of supination suggest wrist or elbow pathology

 

Ask the patient to make a fist whilst observing hand function:

  • This assesses flexion of the small joints of the fingers and hand function
  • The patient may be unable to make a fist if they have joint swelling (e.g. inflammatory arthritis or infection) or if they have other deformities of the small joints of the hands

 

Ask the patient to squeeze your fingers and assess grip strength (comparing between the hands)

  • Grip strength may be reduced due to pain (e.g. swelling of the small joints of the hand) or due to nerve pathology (e.g. carpal tunnel syndrome)

 

Ask the patient to touch each finger in turn to their thumb (precision grip):

  • This assesses co-ordination of the small joints of the fingers and thumbs
  • It also assesses overall manual dexterity
  • Reduced manual dexterity may suggest inflammation or joint contractures of the small joints of the hand

 

Gently squeeze across the metacarpophalangeal (MCP) joints:

  • Observe for non-verbal signs of discomfort
  • Inspect for symmetry of the MCP joints
  • Tenderness indicates active inflammatory arthropathy

 

  • Assess shoulder abduction & external rotation (plus elbow flexion)

 


Legs

Position the patient lying down on the examination couch.

Assess passive knee flexion and extension:

  • Assess one limb at a time
  • Flex and then extend the knee whilst feeling for crepitus over the patella
  • Note the range of movement and any asymmetry between knee joints

 

Assess passive internal rotation of the hip joint (hip and knee joint should be flexed to 90º for assessment):

  • Internal rotation of the hip joint is often the first movement to be reduced in hip pathology, making it a useful screening test
  • Note the range of movement and any asymmetry between hip joints

Patellar tap (can detect large effusions)

1. Empty the suprapatellar pouch by sliding your left hand down the thigh to the patella.

2. Keep your left hand in position and use your right hand to press downwards on the patella with your fingertips.

3. If there is fluid is present you will feel a distinct tap as the patella bumps against the femur.

It should be noted that small effusions may not be detected using patellar tap alone.

 

Squeeze across metatarsophalangeal (MTP) joints:

  • Observe for non-verbal signs of discomfort
  • Tenderness indicates active inflammatory arthropathy

 

  • Assess passive knee flexion & extension

Spine

Inspect the patient’s spine:

  • Looking from behind for evidence of scoliosis (asymmetrical shoulders and pelvic girdle)
  • Look from the side for abnormalities of lordosis (loss of lordosis due to sacroiliac disease) or kyphosis

 

Assess lateral flexion of the cervical spine:

  • Ask the patient to tilt their head to each side, moving their ear towards their shoulder
  • “Try and touch your shoulder to your ear”

 

Assess the temporomandibular joint (TMJ):

  • An adult GALS screen can include assessment of the TMJ (although previously this was only tested in children)
  • Ask the patient to open their mouth wide and put three of their fingers into their mouth (demonstrate using your own fingers and mouth)
  • 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

 

 

 

Lumbar flexion:

1. Place 2 fingers on the lumbar vertebrae 

2. Ask the patient to bend forward and touch their toes

3. Observe your fingers as the patient’s lumbar spine flexes (they should move apart)

4. Observe your fingers and the patient extends their spine to return to a standing position (your fingers should move back together)

If the patient is able to place their hands flat on the floor it suggests joint hypermobility.

 

  • Assess cervical lateral flexion

 


To complete the examination

  • Thank the patient
  • Wash your hands
  • Summarise your findings

 

Suggest further assessments and investigations

  • Perform a focused examination of joints with suspected pathology
  • Request further imaging of joints with suspected pathology (e.g. X-ray/CT/MRI)

 


References

1. Arthritis Research UK. Guide to GALS assessment. [Available here]

 


Further reading

Arthritis research UK provides some excellent free guides to musculoskeletal examination and history taking [LINK]

 


 

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