Pediatric Gait, Arms, Legs,

and Spine (pGALS)

Assessment
PGI GASATAYA, CHARISSE ANN G.
 INTRODUCTION

• Children and young people present commonly with musculoskeletal

(MSK) problems.

• Majority of causes of MSK presentations in childhood are benign,

self-limiting and often trauma-related.

• However, MSK symptoms can be presenting features of Juvenile

Idiopathic Arthritis (JIA), and potentially life-threatening conditions
such as malignancy, infection, vasculitis and non-accidental injury
 INTRODUCTION

• Inflammatory arthritis is an associated feature of many chronic

pediatric conditions such as inflammatory bowel disease, cystic
fibrosis, and psoriasis.

• It is important that all clinicians to whom children and young people

with MSK problems may present, have the necessary skills to
effectively triage patients and appropriate instigate referrals to
specialists
 DEFINITION

• a simple evidence-based approach to an MSK screening assessment

in school-aged children, and is based on the adult GALS (Gait, Arms,
Legs, Spine) screen

• excellent sensitivity to detect abnormality, incorporates simple

maneuvers, and is quick to do, taking an average of 2 minutes to
perform
You can delete this slide when you’re done editing the presentation.
 NORMAL VARIANTS DURING
MUSCULOSKELETAL DEVELOPMENT
• Normal variants refer to normal development of the musculoskeletal
system

• It is important to know about them as they are a common cause for

concern for parents and a frequent reason for consultation

• Include leg alignment issues, flat feet, knock-knees, bow-legs, out-

toeing, in-toeing or toe-walking
 NORMAL VARIANTS IN
GAIT PATTERNS
Habitual toe walking is common in young children up to 3 years. In
toeing can be due to:
• Persistent femoral anteversion: characterized by child walking with
patellae and feet pointing inwards and is common between ages of 3–
8 years
• Internal tibial torsion: characterized by child walking with patella
facing forward and toes pointing inwards and is common from onset
of walking to 3 years.
• Metatarsus adductus: characterized by a flexible ‘C shaped’ lateral
border of the foot and most resolve by 6 years.
Normal Developmental Alignment
 NORMAL VARIANTS IN
LEG ALIGNMENT
• Genu varus or bow legs: are common from birth to early toddler;
often with out-toeing, maximal at approximately 1 year of age; most
resolve by 18 months
• Genu valgus or knock knees: often associated with in-toeing,
maximal at approximately 4 years of age and most resolve by age of
7 years.
• Flat feet: most children have a flexible foot with normal arch on
tiptoeing; this usually resolves by 6 years.
• Crooked toes: most resolve with weight bearing
 INDICATIONS FOR
REFERRAL
• Persistent changes (beyond the expected age ranges)
• Progressive/asymmetrical changes
• Short stature or dysmorphic features
• Painful changes with functional limitation
• Regression or delayed motor milestones
• Abnormal joint examination elsewhere
• Suggestion of neurological disease/developmental delay
 HISTORY

• Prenatal: maternal health issues such as smoking, prenatal vitamins,

illicit use of drugs or narcotics, alcohol consumption, diabetes,
immunization status, and STIs

• Perinatal and postnatal: length of pregnancy, labor (length and type),

presentation of fetus, fetal distress at delivery, birth length and
weight, APGAR, muscle tone, feeding history, period of
hospitalization

• Older infants and young children: developmental milestones for

posture, locomotion, dexterity, social activities, and speech
 RED FLAGS

Raise concern about infection, malignancy or non-accidental injury

• Fever, malaise, systemic upset (reduced appetite, weight loss, sweats)

– malignancy, infection, inflammatory disease
• Bone or joint pain with fever
• Refractory or unremitting pain, persistent night-waking
• Incongruence between history and presentation (such as the pattern
of the physical findings and a previous history of neglect) - consider
possibility of non-accidental injury, child abuse
 PHYSICAL
EXAMINATION

Inspection
Palpation
Evaluation of motion
Evaluation of stability
pGALS assessment
 INSPECTION

• should be comfortable with adequate exposure and well-lit

surroundings. Infants or young children may be examined on their
parent’s lap
• inspect how the patient moves about in the room before and during
the examination, as well as during various maneuvers. Balance,
posture, and gait pattern should also be checked.
• inspect skin for rashes, café-au-lait spots, hairy patches, dimples,
cysts, tuft of hair, or evidence of spinal midline defects
• general body habitus (signs of cachexia, pallor, and nutritional
deficiencies)
 INSPECTION

• note any obvious spinal asymmetry, axial or appendicular

deformities, trunk decompensation, and evidence of muscle spasm
or contractures.
• perform and document a thorough neurologic examination (motor,
sensory, and reflex testing)
• discrepancies in limb lengths, as well as muscle atrophy
• range of motion of all joints, their stability, and any evidence of
hyperlaxity, peripheral pulsations, and lymphadenopathy
 CLASSIFICATION
OF DEFORMITY

Depends on plane of deformity:

• Axial
• Scoliosis
• Kyphosis
• Hyperlordosis
• Kyphoscoliosis
• Appendicular
• Varus (away from midline)
• Valgus (apex toward midline)
• Recurvatum (backward curvature)
• Flexion (sagittal plane)
 PALPATION

Assessment and evaluation of:

• Local temperature and tenderness
• Swelling or mass
• Spasticity or contracture
- spasticity is an abnormal increase in tone associated with
hyperreflexia while contracture is a loss of mobility of a joint from
congenital o acquired causes
• Bone or joint deformity
• Anatomic axis of limb and of limb lengths
 RANGE OF MOTION
(ROM)
Active and passive movement should be assessed, recorded, and
compared with opposite side
PGALS ASSESSMENT

SPINE
 pGALS: When to perform
• Child with muscle, joint, or bone pain

• Unwell child with pyrexia

• Child with limp

• Delay or regression of motor milestones

• 'Clumsy' child in the absence of neurological disease

• Child with chronic disease and known association with MSK

presentations
 pGALS: When to perform

When inflammatory joint disease is suspected

• The lack of reported pain does not exclude arthritis

• There is need to probe for symptoms such as: gelling (e.g. stiffness
after long car rides), altered function (e.g. play, handwriting skills,
writing, regression of milestones), deterioration in behavior
(irritability, poor sleeping)
• There is need to examine all joints as often joint involvement may be
‘asymptomatic’
pGALS: How does it differ from adult
GALS?

Same sequence but with additional maneuvers:

• Foot and ankle: walk on heels and then on tiptoes

• Wrists: palms together and then hands back to back
• Temporomandibular joints: open mouth and insert three of the
child’s fingers
• Elbow: reach up and touch the sky
• Cervical spine: look at the ceiling
 pGALS: Before starting the assessment

• Introduce yourself to the parents and child

• Confirm the child’s name and date of birth
• Briefly explain  the procedure using child-friendly language
• Gain consent from the parents and child
• Position the child standing
• Wash your hands
• Adopt a “copy me” approach, where you first demonstrate what you
want the 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)
 pGALS: Screening Questions
1. Do you have any pain or stiffness in your joints, muscles or your
back? This question screens for common symptoms present in most
forms of joint pathology (e.g. osteoarthritis, rheumatoid arthritis,
ankylosing spondylitis)

2. Do you have any difficulty getting yourself dressed without any

help? This question screens for evidence of fine motor impairment
and significant restriction joint range of movement.

3. Do you have any difficulty going up and down stairs? 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).
pGALS: GAIT
 pGALS: GAIT

• A series of rhythmical, alternating movements of the limbs and

trunk which results in the forward progression of the center of
gravity (COG)
• One cycle begins when the foot makes contact with the floor and
ends with the subsequent floor contact of the same foot.
• Children begin walking between 5-16 months of age
• Early ambulation is characterized by short stride length, a fast
cadence, and slow velocity with a wide-based stance
 pGALS: GAIT

8-15 months – child usually has a wide-based gait with hyperflexion of hips
and knees, and initial contact with the heel.

2 years – the wide gait diminishes, reciprocal arm swing begins, and there is
increased stride length and velocity.

3 years – adult fluid gait patterns usually start developing

7 years – mature adult pattern

 Gait Cycle
STANCE PHASE
- period during which the foot is in contact with the ground (60% of the cycle);
responsible for weight acceptance (Initial contact,  Loading response); also
responsible for single limb support - only one limb is in contact with the ground
(Midstance, Terminal stance)
SWING PHASE
- foot in the air (40% of the cycle); responsible for limb advancement
 Gait Abnormalities

Deviations occur in variety of orthopedic conditions:

• Muscle weakness (spina bifida, muscular dystrophy)
• Spasticity (cerebral palsy)
• Contractures (arthrogryposis)

The 3 most common categories are torsional variations (in-toeing

and out-toeing), toe-walking (equinus gait), and limping
 Torsional variations

• In-toeing and out-toeing indicates only the direction in which the foot is
pointing during ambulation
• Torsional variations can be located from the proximal to the distal region in
the involved extremity.
• Some causes are obvious (eg. Clubfeet) but can be subtle
• Most resolve with normal growth and development
 Toe-walking

• characterized by an absence of normal heel-to-floor contact (heel

strike) by both feet during gait
• can be a normal finding in children up to 3 years of age
• Persistent toe-walking thereafter or acquired toe-walking at a later
age is considered abnormal
• It can have multiple etiologies, ranging from idiosyncratic habit to
profound neuromuscular disease
 Limping

• Can either be painful (antalgic) or painless with differential diagnosis

ranging from benign to serious causes
• Painful gait: stance is shortened as the child decreases the time spent on
the painful extremity
• Painless gait: stance is equal between the involved and uninvolved
sides, but child leans or shifts the center of gravity over the involved
extremity for balance; indicates proximal muscle weakness or hip
instability
Differential Diagnosis of Limping in Children

Child Early walker Adolescent

(3-10 years old) (1-3 years old) (11 years old to maturity)

Painful limp Painful limp Painful limp

Septic arthritis & osteomyelitis Septic arthritis & osteomyelitis Septic arthritis & osteomyelitis
Trauma Occult trauma (“toddler’s fracture”) Trauma
JIA Rheumatologic disorder
Malignancy
Malignancy Malignancy
Abuse
Slipped capital femoral epiphysis (acute, unstable)
Painless limp Painless limp Painless limp
Developmental hip dysplasia Developmental hip dysplasia Slipped capital femoral epiphysis (chronic, stable)
Polio Polio Developmental hip dysplasia
Cerebral palsy Cerebral palsy Neuromuscular disorder
Muscular dystrophy
 Antalgic gait

• One of the most common forms of altered gait in children 

• A limp adapted so as to avoid pain on weight-bearing structures,
characterized by a very short stance phase relative to the swing
phase
• Predominantly caused by traumatic, infectious, inflammatory,
vascular, or neoplastic processes affecting the lower back or lower
extremity
 Non-Antalgic: Trendelenburg gait

• Indicates unilateral weakness of the hip abductors (gluteus

medius and gluteus minimus) or hip instability
• generally caused by congenital, developmental, or neuromuscular
disorders
• pelvis tilts downwards instead of upwards on the non-weight
bearing extremity.
• to lessen this effect, the person compensates by lateral tilt of the
trunk away from the affected hip, thus center of gravity is mostly
on the stance limb causing a reduction of the pelvic drop.
 Trendelenburg test

• a quick physical examination to assess for any hip dysfunction

• a positive test is one in which the pelvis drops on the contralateral side
during a single leg stand on the affected side.
• during gait, compensation occurs by side flexing the trunk towards the
involved side during stance phase on the affected extremity
 Foot and Toe Abnormalities:
Pes Planus (Flatfoot)

• Common diagnosis with ~23% of the public affected

• Often seen in neonates and infants due to physiologic ligament laxity.
• Improvement may be seen when longitudinal arch develops in 5-10 years of
age.
• Common source of concern for parents, these children are rarely
symptomatic
 Pes Planus

• Normal longitudinal arch in a non weight bearing position or standing on the

toes, but the arch disappears when standing flat.
• Hindfoot collapses into valgus, and the midfoot sag becomes evident.
• Generalized hypermobility and ligamentous laxity are often observed.
• When assessing range of motion at the ankle, the foot should always be
inverted while testing dorsiflexion.
 Foot and Toe Abnormalities:
Pes Cavus

• deformity involving plantar flexion of the forefoot or midfoot on

the hindfoot and may involve the entire forepart of the foot or just
the medial column
• A deformity of the hindfoot will often develop to compensate for
the primary forefoot abnormality.
• Resulting elevation of the medial longitudinal arch
• Unilateral: occult intraspinal anomaly
• Bilateral: underlying nerve or muscle disease
 Foot and Toe Abnormalities:
Talipes Equinovarus (Clubfoot)

• malalignment of the calcaneotalarnavicular complex

• CAVE mnemonics:
Cavus – plantar flexion
Adductus – adduction of forefoot and midfoot to hindfoot
Varus of hindfoot
Equinus – foot is held in downward position
 Talipes Equinovarus (Clubfoot)

Two types:
- Positional or postural clubfoot - normal foot that has been held in a
deformed position in utero and is found to be flexible on examination
in the newborn nursery.
- Congenital clubfoot - can either be idiopathic or syndromic.

All patients will exhibit calf atrophy.

Some cases will have internal tibial torsion, foot length shortening, and
leg-length discrepancy (shortening of the ipsilateral extremity).
pGALS: ARMS
pGALS: ARMS
pGALS: ARMS
pGALS: ARMS
pGALS: ARMS
pGALS: ARMS
pGALS: ARMS
pGALS: ARMS
pGALS: LEGS
pGALS: LEGS
pGALS: LEGS
 Arthritis

• inflammation of a joint accompanied by swelling, redness,

tenderness, warmth, and pain with movement
• may present with pain, limited range of motion, limp, and refusal to
use or move the affected joint
• must be differentiated from ARTHRALGIA

Arthralgia is the presence of joint pain without objective signs of

inflammation (warmth, erythema, tenderness, and swelling) on
physical examination.
 Arthritis

RHEUMATIC CAUSES NON-RHEUMATIC CAUSES

Juvenile Idiopathic Arthritis Reactive arthritis
Systemic Lupus Erythematosus Trauma
Vasculitis Infection
Scleroderma Kawasaki disease
Acute Rheumatic Fever Lyme disease
Mixed connective tissue disease Malignancy
 Juvenile Idiopathic Arthritis

• Most common chronic rheumatologic disease in children and is one of

the most common chronic diseases of childhood
• Three types: Oligoarthritis (40-50%), Polyarthritis (25-30%),
Systemic JIA (5-15%)
• Essentially a diagnosis of exclusion (must exclude other causes)
• Hips, temporomandibular joint, and small joints in the spine do not
demonstrate swelling when affected by synovitis but demonstrate the
combination of loss of motion and pain
• Children often stop using joints normally (eg, develop contractures of
joints, decreased wrist range, limp) rather than complain of pain
Juvenile Idiopathic Arthritis
 Juvenile Idiopathic Arthritis

 There is a longer left leg, valgus The photographs below show extensive
deformity and thigh wasting in the left joint swelling and deformity in the hands
knee. There is also a valgus deformity at and wrists in polyarticular JIA. 
the left ankle
 Systemic Lupus Erythematosus

• Chronic autoimmune disease characterized by

multisystem inflammation and the presence of
circulating autoantibodies directed against self-
antigens
• Peak onset: early teen years and rarely occurs in
children younger than 5 years.
• Presents with fever, malar rash, photosensitivity, and
arthritis.
• The arthritis is most often symmetric and
polyarticular, and frequently involves the small
joints of the hands and feet.
Systemic Lupus Erythematosus
 Scleroderma
Overproduction of abnormal collagen causes normal tissues to be replaced
with thick, dense scar tissue that can affect underlying bones and muscles if
left untreated
1. Systemic sclerosis: can be life threatening, involves internal organs and
cause widespread skin disease; severe Raynaud’s phenomenon,
thickening of skin over the hands and face, flexion contractures of the
small joints
2. Localized scleroderma: limited to the skin and subcutaneous tissues,
more common in childhood, and rarely progresses to involve internal
organs; growth of the limb may be affected, joint tightness resulting to
limited range of motion
 Scleroderma

Tapering of the fingers (sclerodactyly) due to chronic ischemia

and loss of subcutaneous tissues in systemic sclerosis

The child has a smaller right foot due

to chronic disease.
 Henoch-Schönlein Purpura

• most common vasculitis of childhood

• usually a self-limited IgA-mediated vasculitis
• affects vessels in the skin, joints, gastrointestinal tract, and kidneys
• Clinical manifestations: palpable purpura over extensor surfaces
(typically the legs and buttocks)
• Associated findings: arthralgias and arthritis (50-80%); edema of
the feet, hands, face, scrotum, and scalp; melena
• Arthritis commonly involves large joints such as knees and ankles
but can involve wrist, elbows, and small joints
 Henoch-Schönlein Purpura

The photograph below shows the Swollen joints in the foot in a

typical palpable purpura of HSP patient with HSP
 Kawasaki disease

• medium-vessel vasculitis of childhood

with a predilection for the coronary arteries
• 2nd most common vasculitis of childhood
• majority (75-85%) of affected children are less than 5 years old
• Arthritis or arthralgia complicates up to one‐third of KD patients

2 types of arthritis:
Early-onset: affects small and large joints
Late-onset: affects weight-bearing joints
 Kawasaki disease

The photograph below The photograph below shows Other clinical manifestations
shows characteristic skin typical features of bilateral including arthritis
peeling after 10-14 days. conjunctivitis and red lips
pGALS: SPINE
pGALS: SPINE
pGALS: SPINE
pGALS: SPINE
 Scoliosis

• Curved deformity of the spine; a combination of

lateral deviation and rotation of vertebral bodies
• does not always produce back pain; if with pain,
look for the cause of symptoms (infection, tumor,
fractures)
• Types: Congenital and Idiopathic

Idiopathic has 3 groups:

 infantile – birth to 3 years old Adolescent scoliosis: note the right-sided
thoracic prominence; rib prominence
 juvenile – 4-10 years old more apparent when bending forward
 adolescent (90%) – over 10 years old or after puberty
 Kyphosis

• A spinal disorder in which an excessive outward curve

of the spine results in an abnormal rounding of the upper
back
• Normal kyphosis is between 20 to 45 degrees; abnormal
if more than the normal range
• May be congenital, neuromuscular, or idiopathic in
origin
• Severe kyphosis is disfiguring, often causes back pain,
and may lead to spinal cord compromise
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