The screening examination
A brief screening examination, which takes 1–2 minutes, has been devised for use in routine clinical assessment. This has been shown to be highly sensitive in detecting significant abnormalities of the musculoskeletal system. It involves inspecting carefully for joint swelling and abnormal posture, as well as assessing the joints for normal movement.
This screening examination is known by the acronym ‘GALS’, which stands for Gait, Arms, Legs and Spine. The sequence in which these four elements are assessed can be varied – in practice, it is usually more convenient to complete the elements for which the patient is weightbearing before asking the patient to climb onto the couch (this is the approach adopted in the accompanying DVD).
pGALS (paediatric GALS) is a modification of ‘GALS’ for use in school-aged children. You can find a full description of pGALS in our Hands On report (PDF, 298 KB, published June 2008) or access the pGALS videos online.
Ask the patient to walk a few steps, turn and walk back. Observe the patient’s gait for symmetry, smoothness and the ability to turn quickly.
- With the patient standing in the anatomical position, observe from behind, from the side, and from in front for:
- bulk and symmetry of the shoulder, gluteal, quadriceps and calf muscles
- limb alignment
- alignment of the spine
- equal level of the iliac crests
- ability to fully extend the elbows and knees
- popliteal swelling
- abnormalities in the feet such as an excessively high or low arch profile, clawing/retraction of the toes and/or presence of hallux valgus.
- Ask the patient to put their hands behind their head. Assess shoulder abduction and external rotation, and elbow flexion (these are often the first movements to be affected by shoulder problems).
- With the patient’s hands held out, palms down, fingers outstretched, observe the backs of the hands for joint swelling and deformity.
- Ask the patient to turn their hands over. Look at the palms for muscle bulk and for any visual signs of abnormality.
- Ask the patient to make a fist. Visually assess power grip, hand and wrist function, and range of movement in the fingers.
- Ask the patient to squeeze your fingers. Assess grip strength.
- Ask the patient to bring each finger in turn to meet the thumb. Assess fine precision pinch (this is important functionally).
- Gently squeeze across the metacarpophalangeal (MCP) joints to check for tenderness suggesting inflammatory joint disease. (Be sure to watch the patient’s face for non-verbal signs of discomfort).
- With the patient lying on the couch, assess full flexion and extension of both knees, feeling for crepitus.
- With the hip and knee flexed to 90º, holding the knee and ankle to guide the movement, assess internal rotation of each hip in flexion (this is often the first movement affected by hip problems).
- Perform a patellar tap to check for a knee effusion. Slide your hand down the thigh, pushing down over the suprapatellar pouch so that any effusion is forced behind the patella. When you reach the upper pole of the patella, keep your hand there and maintain pressure. Use two or three fingers of the other hand to push the patella down gently. Does it bounce and ‘tap’? This indicates the presence of an effusion.
- From the end of the couch, inspect the feet for swelling, deformity, and callosities on the soles.
- Squeeze across the metatarsophalangeal (MTP) joints to check for tenderness suggesting inflammatory joint disease. (Be sure to watch the patient’s face for signs of discomfort).
- With the patient standing, inspect the spine from behind for evidence of scoliosis, and from the side for abnormal lordosis or kyphosis.
- Ask the patient to tilt their head to each side, bringing the ear towards the shoulder. Assess lateral flexion of the neck (this is sensitive in the detection of early neck problems).
- Ask the patient to bend to touch their toes. This movement is important functionally (for dressing) but can be achieved relying on good hip flexion, so it is important to palpate for normal movement of the vertebrae. Assess lumbar spine flexion by placing two or three fingers on the lumbar vertebrae. Your fingers should move apart on flexion and back together on extension.
Recording the findings from the screening examination (GALS)
It is important to record both positive and negative findings in the notes. The presence or absence of changes – in appearance or movement – in the gait, arms, legs or spine should be noted in a grid. The first table shows a normal result. If there are abnormalities, these should be recorded with a cross, and a note should be made describing the abnormalities – for a patient with wrist and knee swelling and associated loss of movement the recording might be as shown in the second table.
If you have been alerted to a musculoskeletal problem – by the screening questions, your examination or the spontaneous complaints of the patient – you will need to take a detailed history (as described above). You should also conduct a regional examination of relevant joints – this is described in the sections which follow.
'GALS' screening examination: checklist
- Observe gait
- Observe patient in anatomical position
- Observe movement – hands behind head
- Observe backs of hands and wrists
- Observe palms
- Assess power grip and strength
- Assess fine precision pinch
- Squeeze MCPJs
- Assess full flexion and extension
- Assess internal rotation of hips
- Perform patellar tap
- Inspect feet
- Squeeze MTPJs
- Inspect spine
- Assess lateral flexion of neck
- Assess lumbar spine movement
CMC(J) carpometacarpal (joint); CT computerized tomography; DEXA dual-energy x-ray absorptiometry; DIP(J) distal interphalangeal (joint); ESR erythrocyte sedimentation rate; GALS gait, arms, legs and spine; MCP(J) metacarpophalangeal (joint); MRI magnetic resonance imaging; MTP(J) metatarsophalangeal (joint); NSAID non-steroidal anti-inflammatory drug; OA osteoarthritis; PIP(J) proximal interphalangeal (joint); RA rheumatoid arthritis; REMS regional examination of the musculoskeletal system.