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pGALS examination (Paediatric Gait, Arms, Legs and Spine) is often used as a quick screening tool to detect locomotor abnormalities and functional disability in a child. This pGALS examination OSCE guide demonstrates how to perform the assessment in a step by step manner. Check out this excellent free pGALS app, which provides a comprehensive step-by-step guide to the examination, with examples of pathology.

Check out our pGALS OSCE mark scheme here.

 


Differences between pGALS and 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
    • Asking the child to walk on their heels and then on their tiptoes.
  • Assessment of the temporomandibular joints:
    • Asking the child to open their mouth and then inserting three of the child’s own fingers into their mouth.
  • Assessment of the elbow:
    • Asking the child to “reach up and touch the sky”
  • Assessment of the cervical spine:
    • Asking the child to look at the ceiling


Introduction

  • Wash hands
  • Introduce yourself to both the parents and the child
  • Confirm the child’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.”
  • Gain consent (from parents and child): “Does that sound ok?”
  • Expose the child’s chest, upper and lower body (ideally, the child should be wearing shorts)
  • Ask if the child has any pain anywhere before you begin the examination
  • Throughout the pGALS assessment, you should adopt a “Copy me” approach, where you first demonstrate what you want the child to do (this can be easier for the child to follow than simply a sequence of verbal instructions)
  • Look for non-verbal clues of discomfort (e.g. grimacing)

 


Screening questions

  • Do you (or does your child) have any pain or stiffness in your (their) muscles, joints or back?
  • Do you (or does your child) have any difficulty getting yourself (him/herself) dressed without any help?
  • Do you (or does your child) have any problem going up and down stairs?

 


Inspection

Ask the child to stand with their hands by their sides 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. slipped capital femoral epiphysis)
  • A thin malnourished child may be at risk 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 child’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
  • Legg-Calve-Perthes can cause unilateral limb shortening in school-age children
  • Slipped Capital Femoral Epiphysis can cause shortening of a limb in 10-16-year-olds
  • Developmental Dysplasia of the hip can cause leg shortening in toddlers
  • 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
  • Overdeveloped quadriceps are associated with Osgood–Schlatter 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 child’s foot arches
  • Low arch profile (pes planus/flat feet)
  • High arch profile (pes cavus) – e.g. Charcot-Marie-Tooth disease

 

  • 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)
  • Both of these are unlikely to be found in children

 

Hind-foot abnormalities:

  • Thickening of the Achilles tendon may suggest tendonitis

 

  • Inspection GALS
    Inspect from behind

 


Gait

Ask the child to walk to the end of the room, turn around and come back. Then ask them to do this again on their heels and then on their tiptoes whilst you observe:

  • Inspect the gait cycle (heel strike, toe-off) and coordination to assess if this is appropriate for the child’s age
  • When the child reaches the end of the room, are they able to turn quickly without any issues?
  • Is there any evidence of pain? (antalgic gait)
  • Inspect foot posture, paying attention to the presence (or absence) of the longitudinal arches of the feet when the child is on their tiptoes (flat feet are normal in young children, but the medial longitudinal arches should appear when the child stands on their tiptoes)

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

 

  • Gait (walking cycle)
    Inspect gait 1

 


Arms

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

  • This assesses flexion of the small joints of the fingers and hand function
  • The child 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 child 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 (which should be assessed in the context of the child’s age)
  • 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

 

Ask the child to put their hands together palm to palm:

  • This assesses extension of the small joints of the fingers and wrists, in addition to flexion of the elbows
  • Restriction or asymmetry of movement suggests joint pathology
  • An excessive range of movement suggests hypermobility

 

Ask the child to put their hands together back to back:

  • This assesses flexion of the wrist joints and elbow joints
  • Restriction or asymmetry of movement suggests joint pathology
  • An excessive range of movement suggests hypermobility

 

Ask the child to “Reach up and touch the sky”:

  • This assesses elbow extension, wrist extension and shoulder abduction
  • Ask the child to reach up as far as they can manage, keeping their arms straight
  • Restriction or asymmetry of movement suggests joint pathology
  • An excessive range of movement suggests hypermobility

 

Ask the child to look at the ceiling:

  • This assesses cervical extension

 

Ask the child to put their hands behind their neck:

  • 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

 

  • Inspect hands
    Ask the child to hold their hands out in front of them, with their palms facing down and fingers outstretched

 


Legs

Position the child lying down on the examination couch.

Assess active knee flexion and extension whilst feeling for crepitus:

  • Ask the child to “Try and bring your heel towards your bottom.” and then “Straighten out your leg on the bed.”
  • Test one leg at a time
  • Assess and compare the degree of flexion and extension of the knee joints
  • Restricted flexion or extension suggests knee pathology (e.g. active inflammatory arthritis or joint contractures)
  • A swollen, red knee joint is suggestive of inflammatory arthritis, haemarthrosis or joint sepsis

 

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 (assessing for knee joint effusion)

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.

 

  • Active Knee Flexion
    Assess active knee flexion and extension whilst feeling for crepitus

 


Spine

Inspect the child’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 child 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):

  • Ask the child 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

 

 

Assess lumbar flexion:

1. Place 2 fingers on the lumbar vertebrae 

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

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

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

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

 

  • Inspection GALS
    Inspect the spine

 


To complete the examination

  • Thank the child and parents
  • 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. Professor Helen Foster (Professor of Paediatric Rheumatology). Paediatric Musculoskeletal Matters (PMM) Online. Guide to pGALS assessment [Available here]. Images used with permission.

 


Recommended reading

  • Check out this excellent free pGALS app, produced by Paediatric Musculoskeletal Matters (PMM). It provides a comprehensive step-by-step guide to the examination, with included images of relevant pathology. [Available here]
  • You can also see the full written guide by Paediatric Musculoskeletal Matters (PMM) online here.
  • Want to learn more about the pGALS assessment? Check out the free eModule produced by Professor Helen Foster in collaboration with Newcastle University [Available here]
  • Arthritis research UK provides some excellent free guides to musculoskeletal examination and history taking [Available here]

 


REVIEWED BY

Professor Helen Foster

Professor of Paediatric Rheumatology

Newcastle University, UK

Twitter: @NcleUniHFoster and @pmmonlineorg


TMJ JOINT ASSESSMENT ILLUSTRATION BY

Aisha Ali

Medical student and illustrator

 


 

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