GALS Screen

This examines the overall integrity of the locomotor/musculoskeletal system. It is a screening examination and covers lots in a little time. If abnormalities are detected, further examination of this will be necessary. The tests and movements in the GALS screen are those which are first affected by musculoskeletal disease. Other joints/movements are included because they are of important functional value

G = Gait A = Arms L = Legs S = Spine

Always introduce yourself, gain consent for the examination, explain briefly what it is, confirm who they are and answer and questions or concerns they may have.

Questions (allows rapid and wide-covering detection of any abnormalities) 1. Any pain or stiffness in your muscles joints or in your back? (joint stiffness may indicate arthritis! Early morning arthritis is typical of inflammatory arthritis) 2. Are you able to dress yourself completely without any difficulty? 3. Are you able to walk up and down stairs without any difficulty? Gait 1. Ask patient to stand, walk towards to a point, turn around and return to where they started. 2. Watch their gait! Is it smooth and symmetrical? Are they comfortable? Can they turn quickly without difficulty? 3. Look for Arm Swing, Stride Length and Pelvic Tilt Spine 1. Ask them stand upright and observe them from behind. Inspect, starting at the top and moving downwards. a. Are the muscles of the shoulder symmetrical? b. Causes of muscle atrophy (doesnt happen with myopathy)
2. 3. 4. 5. 6. 7. 8. 9. 10. 11.
diabetes (diabetic neuropathy) burns poliomyelitis amyotrophic lateral sclerosis (ALS or Lou Gehrig's disease) Guillain-Barre syndrome muscular dystrophy myotonia congenita myotonic dystrophy some atrophy that occurs normally with aging cerebrovascular accident (stroke)

12. 13. 14. 15. 16.

spinal cord injury peripheral nerve injury (peripheral neuropathy) prolonged immobilization rheumatoid arthritis prolonged corticosteroid therapy

a. b. c. d. e. f.

Are the paraspinal muscles symmetrical? rhomboids Is the spine straight or is there scoliosis? Are the iliac crests equal and level? Are the gluteal muscles symmetrical? Observe the back of the knee for popliteal swellings

17. Baker's cyst 18. causes 19. tear in the meniscal cartilage of the knee 20. Knee arthritis (in older adults) 21. Rheumatoid arthritis 22. 23. 24. 25. 26. 27. 28. 29. 30. 31. 32. 33. Transilluminate it. Popliteal artery aneurysm Cellulitis Popliteal abscess Neoplasm Varicose veins Fracture Torn tendon Deep vein thrombosis Lymphadenopathy Lipoma

34.

a. Are the achilles tendons visible and normal? Move to the shoulders. Pinch the fold of skin over the trapezius in both shoulders. Then firmly press over the midpoint of the supraspinatus. (There may be a little tenderness in normal patients however in fibromyalgia there is increased pain due to a hyperalgaesic response = allodynia)
Cause of myopathy steroids, alcohol, AZT, hypothyroidism, Duchenne's muscular dystrophy, polymyositis, AIDS and mitochondrial diseas

35. Observe the patient from the spine and look for normal spinal curvature. (cervical and lumbar lordosis, with thoracic kyphosis(should be mild)) 36. Now ask the patient to bend over and touch their toes while keeping their knees straight. This is to assess lumbar spine flexion. While they are bent over place two fingers about 5cm apart (one on the lumbosacral junction and one above) over the lumbar spine and then ask patient to slowly stand back up straight. Both fingers should come almost completely back together. (in some circumstances the fingers will stay apart such as

in ankylosing spondylitis which results in complete fusion of the lumbar spine) 37. Then ask the patient to touch their ear to the ipsilateral shoulder and then do it on the alternate side. This is used to assess lateral cervical spine flexion. (inhibited most commonly in neck pain syndrome)
Flexion/extension C1-C7 T1-T6 T7-T12 L1-sacrum Lateral flexion Rotation

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38. 39. Finally ask them to open their mouth and swing their jaw from side to side. This tests the tempromandibular joints. (Can be affected in inflammatory arthritides e.g. RA) Arms 1. Ask the patient to stand facing you with arms slightly abducted and palms of the hands facing forwards. a. Are the shoulder girdle muscles symmetrical? b. Can the patient fully extend their elbows? 2. Then ask the patient to put their hands on the back of their heads (as though being arrested). Then get them to push their elbows backwards as far as possible. This places the arms in abduction and external rotation and stresses the posterior and superior components of the rotator cuff. It also tests movement in the sternoclavicular and AC joints. # 3. Then ask the patient to bring their arms to their sides and hold out their forearms with them supinated (as though holding a pile of towels) a. Can the patient fully supinate their hands? b. Is there any evidence in the hands of joint redness or swelling?(is there reduced straightening of the fingers? Is it Dupuytrens contracture) 4. Now ask the patient to pronate their hands. Can they full pronate their hands? 5. Test their grip strength by asking them to squeeze your two fingers. Both sides! 6. Test precision movement and dexterity in both hands by asking patient to touch each finger to their thumb in sequence and in both directions. 7. Then gently squeeze over their metacarpophalangeal joints and ask them if it is tender. (inflammation and tenderness is characteristic of inflammatory arthritis) 8. Then ask the patient to bring their arms up and and put their hands together as if praying, achieving a 90 degree extension of the wrist. And then repeat but with flexion. Legs (first standing and then on the exam couch)

1. Firstly observe closely from the front. a. Are the quadriceps muscle bulk symmetrical? b. Are the knees aligned and are they swollen or deformed (varus or valgus)? c. Check both feet for presence of the medial arch with 2 fingers (lost in pes planus(flat feet))

Causes Family history - experts say fallen arches can run in families.

Weak arch - the arch of the foot may be there when no weight is placed on it, for example, when the person is sitting. But as soon as they stand up the foot flattens (falls) onto the ground.

Injury

Arthritis

Tibialis posterior (ruptured tendon)

Pregnancy

Nervous system or muscle diseases - such as cerebral palsy, muscular dystrophy, or spina bifida.

Tarsal Coalition - the bones of the foot fuse together in an unusual way, resulting in stiff and flat feet. Most commonly diagnosed during childhood.

Diabetes

Age and wear and tear - years of using your feet to walk, run, and jump eventually may take its toll. One of the eventual consequences could be fallen arches. The posterior tibial tendon may become weakened after long-term wear a tear. The postario tibial tendon is the main support structure of the arch of our feet. The tendon can become inflamed (tendinitis) after overuse sometimes it can even become torn. Once the tendon is damaged, the arch shape of the foot may flatten.

2. 3. 4. 5. 6.

d. e. Look for any forefoot deformity in the toes (e.g. hallux valgus) Ask the patient to lie on the couch in a comfortable position and relax. Place one hand on the knee and test knee flexion asking them to bend their knee. Feel/Hear for crepitus as you do this. Then holding leg in the same way assess hip flexion by holding it at 90 degrees. Then from this position assess internal and external rotation. Repeat in the opposite side. Do the patellar tap to look for an effusion in the knee joint. Compress the knee joint grippin the thigh proximally and squeezing downwards. Then use other finger to press down on the patella and if there is fluid it will give a ballooning sensation.

7. Eliciting a patellar tap: extend the knee and empty the suprapatellar pouch by applying pressure from the palm of your hand above the knee. This will push fluid underneath the patella, lifting it. Maintain this pressure. Next, press down on the patella with the fingers of the other hand and the patella will be felt to move down and touch ('tap') the underlying bone. 8. The massage (bulge) test: again, with the knee in extension, use the palm of your hand to massage any fluid in the anteromedial compartment of the knee into the suprapatellar pouch. Next, stroke the lateral side of the joint and the lateral side of the suprapatellar pouch. This will push any fluid present back into the anteromedial compartment. Look for a fluid impulse.2

9. 10. Then perform the metatarsophalangeal squeeze test. This is analogous with the MCP squeeze test. 11. Finally inspect the soles looking for callosities which may indicate uneven loadbearing.

Abnormalities in the GALS screen

Unilateral and asymmetrical chronic deformity in arm and hand with decreased movement and evidence of swelling and deformity of MCP joint associated with tenderness on the MCP squeeze test. This, along with an obvious skin deformity on the contralateral hand suggested a case of psoriatic arthritis. Inspect elsewhere for rash. (not typical presentation!) If patient has trouble putting hands behind head and pushing shoulders back they have bilateral glenohumeral joint dysfunction. Cannot fully supinate hand and there is ulnar deviation of fingers. Severe limitation of wrist extension and flexion. Reduced grip strength and impaired dexterity. Bilateral hand deformity and reduced movement along with joint tenderness is most commonly RA. Swelling of the whole finger is dactylitis. Swelling outside of the joint capsule may be over tendons such as a synovitis.

If there is apine deformity always assess chest expanision to ensure their breathing is not impaired. Thoracic Kyphosis use the head to wall measurement to assess progression of this curvature. Inflammatory spinal disease increased lordosis in the neck. Very increased thoracic kyphosis and a flat lumbar spine with no lordosis. Lumbar flexion will show little movement and flexion at the hip. Also, lateral flexion and rotation of the cervical spine will be very impaired.