Screening examination for musculoskeletal disorders (GALS)

Screening examination for musculoskeletal disorders (GALS) - screening examination is known by the acronym 'GALS', which stands for Gait, Arms, Legs and Spine

• 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

Gait

• observe gait
  • 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
      
      
• observe patient in anatomical position
  • ask the patient to stand 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

Arms

• observe movement - hands behind head
  • assess shoulder abduction and external rotation, and elbow flexion (these are often the first movements to be affected by shoulder problems)
    
    
• observe backs of hands and wrists
  • patient's hands held out, palms down, fingers outstretched
  • inspect the backs of the hands for joint swelling and deformity
    
    
• observe palms
  • inspect the palms for muscle bulk and for any visual signs of abnormality
    
    
• assess power grip and grip strength
  • assess power grip, hand and wrist function, and range of movement in the fingers
    
    
• assess fine precision pinch
  • ask the patient to squeeze your fingers. Assess grip strength
    
    
• squeeze MCPJs
  • gently squeeze across the metacarpophalangeal (MCP) joints to check for tenderness suggesting inflammatory joint disease - watch the patient's face for non-verbal signs of discomfort

Legs

• assess full flexion and extension
  • patient lying on the couch, assess full flexion and extension of both knees, feeling for crepitus
    
    
• assess internal rotation of hips
  • position patient so that hip and knee flexed to 90 degrees
    • 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 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 - is there a consequent bounce and 'tap'? - if so then indicates the presence of an effusion
      
      
• inspect feet
  • from the end of the couch
    • for swelling, deformity, and callosities on the soles
      
      
• squeeze MTPJs
  • to check for tenderness suggesting inflammatory joint disease - watch the patient's face for signs of discomfort

Spine

• inspect spine
  • whilst the patient is standing
    • inspect the spine from behind for evidence of scoliosis, and from the side for abnormal lordosis or kyphosis
      
      
• assess lateral flexion of neck
  • assess lateral flexion of the neck (this is sensitive in the detection of early neck problems).
  • ask the patient to tilt their head to each side, bringing the ear towards the shoulder
    
    
• assess lumbar spine movement
  • 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

Reference:

• Arthritis Research Campaign - Clinical assessment of the musculoskeletal system - a guide for medical students and healthcare professionals