Gait, arms, legs and spine (GALS) screening examination

Written by David Hawes

Introduction

Introduce yourself to the patient and confirm the patient’s name and date of birth. Obtain consent and proceed to wash your hands.

General inspection

Begin the examination by inspecting the patient. They will need to be exposed entirely above and below the waist. Patients may keep their undergarments on but should remove their shoes and socks.

Ask the patient if they are comfortable or in any pain. Look around the bed for any items/clues such as walking aids or medications.

This level of exposure can be uncomfortable for some patients. Throughout the examination, make an effort to ensure that the patient is comfortable in the environment and that their dignity is maintained.

Whilst the patient is removing their garments you can make observations as to their general ability to mobilise and also observe the wear pattern of their shoes.

Screening questions

Before advancing any further, you must ask the patient three screening questions. These will give you an idea of the patient’s issues with mobility or the impact of pathology on their life. It also enables you to identify any painful regions of their musculoskeletal system which you should be careful with during your examination.

  1. 1. “Do you have any pain or stiffness in any of your joints, in your muscles, or in your back?”
  2. 2. “Do you experience any difficulty with walking up and down stairs?”
  3. 3. “Do you experience any difficulty with dressing yourself in the morning?”

These three questions address the main features of musculoskeletal disorders: pain, stiffness, swelling and functional impairment.

  1. 1. This addresses any notable symptoms the patient has identified with their musculoskeletal system and will help you to make sense of your findings.
  2. 2. This assesses gross motor function with respect to the patient’s muscle bulk. Issues with walking up and down stairs may indicate muscle wasting in the lower limb (affecting leg movement) and thorax (affecting posture).
  3. 3. This crudely assesses fine motor function of the patient and their joints.

Closer inspection

Ask the patient to stand with their forearms supinated by their side in the anatomical position. Demonstrate the pose for the patient to copy.

Anatomical position

Position your patient in the anatomical position.

Anterior inspection

Observe the patient from the front for:

A varus deformity describes an inward angulation in which the lateral segment of a joint is deviated medially. In a valgus deformity, there is an outward angulation in which the lateral segment of a joint is deviated laterally

The sacroiliac joint acts as a shock absorber during walking and it is stabilised by many ligaments. In pregnancy these ligaments can become lax.

Lateral inspection

Observe the patient from the side for:

Patients can have lax (stretchy or long) ligaments which allow for excessive joint mobility eventually leading to a hyperextended appearance. The resulting instability can increase the risk of joint dislocation.


Posterior inspection

Observe the patient from behind for:

Gait

Ask the patient to walk for 5m, turn around, and then walk back. Assess the gait for:

First five phases of the gait cycle - left leg.

First five phases of the gait cycle - left lower limb.


1. Heel strike: The initial contact of the heel with the ground.
2. Foot flat: Weight is transferred onto the foot.
3. Mid stance: Body alignment and balancing of weight on the foot.
4. Heel off: Heel lifts off the ground with the toes still touching the ground.
5. Toe off: The toes lift off the ground and the foot is no longer in contact.
6. Swing: The leg swings forward in preparation of the heel strike of the next step.



Upper limb (arms)

Arm

Ask the patient to stand in front of you and carry out the following two movements to assess their arms. Patients suffering with rotator cuff injuries may struggle or experience pain with these tasks:

  1. 1. Ask the patient to place their hands behind their head and flare out their elbows. This crudely assesses external rotation and abduction of the shoulder as well as flexion of the elbow.
  2. 2. Ask the patient to place their hands behind the small of their back. This crudely assesses >internal rotation and adduction of the shoulder as well as flexion of the elbow.
Demonstrating the movements and asking the patient to copy you is generally a smooth and slick way of helping the patien to understand what to do. In addition, patients with hearing difficulties will have a much easier experience.

Hand

Inspection

Ask the patient to extend their arms out and face their palms downwards.

Look at the back of the hands for:

Ask the patient to turn over their hands and observe the palmar aspect for:

Palpation

sing your index finger and thumb, squeeze the metacarpophalangeal (MCP) joints of each of the patient’s hands whilst observing their face to assess for pain. This will usually occur in patients with inflammatory arthritis or traumatic injury to the hand.

Power

Assess the power of the muscles in each hand. Multiple movements can be tested here, however only the following four are necessary:

Lower limb (legs)

Instruct the patient to lie on the bed set flat at 180o

Knee

With one hand on the patient’s knee and the other at the base of the patient’s foot, passively flex each knee and assess for range of movement and crepitus. Knee crepitus is a common finding in patients with osteoarthritis of the knee.

Patellar tap test

Perform the patellar tap test on each leg to test for an effusion. Keep the knees extended and glide your hand down the patient’s thigh to squash the suprapatellar pouch. This pushes an effusion, if present, out of the pouch and behind the patella. Utilising two fingers of the other hand press downwards gently on the patella itself. The test will be positive if the patella bounces and taps.

Feet

Inspection

In a similar manner to the hands, inspect the patient’s feet for any swellings, deformities or callosities that may be present.

Palpation

Squeeze the MTP joints of each of the patient’s feet whilst observing their face to assess for pain. Patients with inflammatory arthritis, gout, or traumatic injury to the foot may experience pain on MTP palpation.

Spine

Ask them to stand upright one more, but this time place your index fingers on the lumbar spine roughly 10 cm apart. Instruct the patient to lean forwards as if to touch their toes. As they flex their back, crudely assess for lumbar extension. Expect extension of approximately 5cm. An extension of <5cm is indicative of a decreased range of movement and should be confirmed accurately using Schöber’s test.

Stand facing the patient and ask the patient to follow your movements. Patient’s suffering from conditions such as ankylosing spondylitis, osteoarthritis, discitis or other spinal pathologies will have limited range of movement when asked to carry out these tasks.

Completion

Present your findings or record them in the patient notes.

QGOSAL Some students utilise this alternative method as a tool to guide them through the GALS OSCE to ensure they cover each main heading from the examination.

Questions Gait Observations Spine Arms Legs.

This method minimised patient movement, allowing for a smoother examination.

Additional examinations

If there were any notable findings from your GALS screen, or the patient complained of any symptoms, proceed to perform the relevant regional examination of the musculoskeletal system (REMS). Ideally after this point, to complete your examination you should closely examine the joint above and the joint below the REMS joint. In an examination, you will probably be stopped by the examiner at this point.

Following the complete examination (including REMS if necessary), thank the patient for allowing you to examine them and offer to help them get dressed and ensure they are comfortable.

Interactive markscheme


When assessing each other, click on each list item as you go along. Doing so will turn the list item green. Make careful note of any steps missed at the end. We recommend completing any examination or procedure in under 10 minutes, but you can adjust the timer to suit your needs.
:

  1. Introduction: “Hello, I’m SimpleOSCE and I am a medical student. I've been asked to do a screening examination of your body to check the function of your muscles and joints, would that be ok? Can I confirm your name and DOB? Thank you.”
  2. Gain consent and ensure adequate exposure.
  3. Wash your hands.
  4. Ask if the patient is in any pain.
  5. Perform a general inspection of the patient and around the bed.
  6. Screening questions

  7. Ask the patient: "Do you have any pain or stiffness in any of your joints, in your muscles, or in your back?".
  8. Ask the patient: "Do you experience any difficulty with walking up and down stairs?".
  9. Ask the patient: "Do you experience any difficulty with dressing yourself in the morning?"".
  10. Closer inspection

  11. Observe the patient from the front for muscle bulk and symmertry, joint alignment and foot deformity.
  12. Observe the patient from the side for spinal alignment, knee and elbow joint extensibility and foot deformity.
  13. Observe the patient from the back for muscle bulk and symmetry, joint alignment and knee/ankle swelling and deformity.
  14. Gait

  15. Assess the patient's gait.
  16. Upper limbs ("Arms")

  17. Ask the patient to place their arms behind their head and flare out their elbows.
  18. Ask the patient to place their hands behind the small of their back.
  19. Inspect the dorsal and palmar surfaces of the hands.
  20. Palpate the metacarpophalangeal joints.
  21. Assess finger abduction and grip strength.
  22. Lower limbs ("Legs")

  23. Flatten the bed to 180o.
  24. Assess the knee joint for range of movement and crepitus.
  25. Perform the patellar tap test.
  26. Inspect the feet for callosities and deformities.
  27. Palpate the metatarsophalangeal joints.
  28. Spine

  29. Ask the patient to stand and lean backwards.
  30. Assess for lumber extension.
  31. Completion

  32. Thank the patient and present your findings to the examiner.
  33. If indicated, state that you wish to perform a regional examination of a specific joint in addition to the joint above and below.
  34. Record your findings in the patient notes.
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