By Dr. Marcus Judge

OSCE

In any OSCE examination, it is important to understand the pathology and the reasoning behind each sign and symptom you find. This applies even if the patient is 'normal'. This article explains how to perform a GALS screening examination and the key findings you should look for, showing you what each sign means and what conditions it may indicate.

GALS stands for Gait, Arms, Legs and Spine. It is a rapid screening tool designed to detect significant musculoskeletal abnormalities and the functional disability they cause. Rather than examining a single joint in detail, GALS sweeps across the whole locomotor system (the muscles, bones and joints used for movement) in a few minutes, flagging up areas that warrant a more focused regional examination. It is built around a simple principle: assess each region for appearance (look), movement (move) and any associated pain or tenderness.

Contents

  1. Introduction
  2. General Inspection
  3. Gait
  4. Spine
  5. Arms
  6. Legs
  7. Recording Your Findings
  8. Completing the Examination
  9. Quiz

Introduction

Wash your hands and don personal protective equipment if appropriate.

Introduce yourself to the patient and ensure to mention your grade e.g. 3rd year medical student/junior doctor/consultant.

Confirm the patient's details taking 3 points of identification usually; full name, date of birth and NHS/hospital number.

Briefly explain the examination and obtain consent. A useful way to explain GALS is to say you would like to watch them walk and then check the joints in their arms, legs and back to make sure everything is moving as it should.

Position the patient standing in their underwear where possible, as adequate exposure is essential for inspecting the spine, joints and muscle bulk. Give the patient privacy to undress and dress, and keep them covered as much as possible to maintain their dignity. Explain that they can ask at any time for the examination to stop. If any part of the examination is intimate, offer a chaperone (an impartial observer, usually a health professional). You will need space for the patient to walk a few metres away from you and back.

Before touching the patient, ask the three GALS screening questions, which quickly flag up the presence of musculoskeletal disease and its functional impact:

  • "Do you have any pain or stiffness in your muscles, joints or back?" This screens for symptoms common to almost all joint pathology, such as osteoarthritis (wear-and-tear arthritis), rheumatoid arthritis (an autoimmune inflammatory arthritis) and inflammatory spondyloarthritis (inflammatory arthritis that affects the spine and sometimes other joints). The pattern matters: early-morning stiffness lasting more than 30 minutes points towards an inflammatory cause, whereas pain that worsens with use and eases with rest is more typical of degenerative disease.
  • "Can you dress yourself completely without any difficulty?" This screens for restricted joint range of movement and fine motor impairment in the upper limbs, both of which interfere with tasks such as doing up buttons.
  • "Can you walk up and down the stairs without difficulty?" This screens for gross motor function and lower-limb joint disease, since climbing stairs demands good hip, knee and ankle movement together with adequate proximal muscle power.

Always ask whether the patient is currently in any pain before you begin, so you avoid causing distress and can interpret guarding (the patient tensing up to protect a painful area) correctly.

General Inspection

Begin with a general inspection of the patient and the surrounding area. Look at the patient as a whole for clues to an underlying rheumatological (joint and connective tissue) or neurological condition. Note any obvious asymmetry, muscle wasting, joint swelling or deformity, and observe whether the patient appears comfortable or is holding a limb protectively.

Scan the bedside and the patient's belongings for objects that hint at their functional status, such as walking aids (sticks, frames or crutches), wheelchairs, splints or orthotics (shoe inserts or supports), and any analgesia or disease-modifying medication packaging. These items give an immediate impression of how much the patient's mobility and independence are affected, which is exactly what GALS is designed to detect.

Gait

Ask the patient to walk a few metres away from you, turn, and walk back, then observe a few cycles. Watching gait is one of the most informative parts of the screen. Normal walking requires the hips, knees, ankles and spine to move smoothly and in coordination, so almost any significant lower-limb or spinal problem will alter it.

Assess the gait for symmetry and smoothness, a normal stride length, normal heel strike (the heel hitting the ground) and toe off (the toes leaving it), good arm swing, and the ability to turn quickly and steadily. Patients with joint disease often turn slowly and in several small steps because of pain, stiffness or instability.

Several abnormal gait patterns are worth recognising:

  • An antalgic gait develops in response to pain. The patient spends as little time as possible bearing weight on the painful leg, shortening the stance phase (the part of the step when the foot is on the ground) on that side and producing a limp.
  • A Trendelenburg gait is caused by weakness of the hip abductors (gluteus medius and minimus, the smaller buttock muscles that hold the pelvis level), which can be due to damage (a lesion) of the superior gluteal nerve, hip joint disease or an L5 radiculopathy (a pinched or irritated nerve root at the fifth lumbar vertebra). The pelvis drops towards the unsupported (swinging) side during stance because the abductors cannot stabilise it.
  • A waddling gait arises from bilateral proximal muscle weakness, classically in the myopathies (muscle diseases) and muscular dystrophies (inherited muscle-wasting diseases), giving a broad-based, rolling pattern.
  • Reduced or absent arm swing on one side is an early clue to Parkinson's disease (a movement disorder), and is typically accompanied by short shuffling steps and difficulty initiating movement.

Also note any obvious leg-length discrepancy or reduced range of movement, both of which commonly accompany chronic joint disease.

Spine

With the patient standing, inspect the spine and posture from behind, from the side and from the front, then assess a small number of key movements.

From behind, the spine should appear straight with no lateral curvature. A sideways curvature is termed scoliosis and may be postural (a temporary, correctable curve) or structural (a fixed curve, often with a twist of the spine). Check that the paraspinal muscles are symmetrical, that the shoulders and gluteal muscle bulk are equal, and that the iliac crests (the top edges of the pelvis) are level, since pelvic tilt can indicate a leg-length discrepancy or hip pathology. Asymmetrical muscle bulk may reflect wasting from disuse or a neurological lesion.

Scoliosis of the spine viewed from behind SimpleMed

Image - Scoliosis seen on inspection of the spine from behind. The lateral curvature of the spine and the resulting asymmetry are key findings in the spinal component of GALS

Creative commons source by Lucien Monfils [CC BY-SA 3.0 (https://creativecommons.org/licenses/by-sa/3.0)]

From the side, confirm the normal sagittal curves: a gentle cervical lordosis, a thoracic kyphosis and a lumbar lordosis. A lordosis is an inward curve and a kyphosis is an outward curve, seen from the side. An exaggerated thoracic curve (a hyperkyphosis) may result from osteoporotic vertebral wedge fractures (collapse of the front of a spinal bone in weakened bone) in older patients. A fixed question-mark posture with loss of lumbar lordosis can develop in ankylosing spondylitis (radiographic axial spondyloarthritis, an inflammatory arthritis that stiffens the spine) as the spine stiffens over time.

Normal sagittal curves of the vertebral column SimpleMed

Image - The normal sagittal curves of the vertebral column: cervical lordosis, thoracic kyphosis and lumbar lordosis. Inspecting the spine from the side allows you to spot an exaggerated kyphosis or a lost lumbar lordosis

SimpleMed original image, credit 'SimpleMed original'

To assess lumbar flexion, ask the patient to bend forward and try to touch their toes while you rest two fingers on adjacent lumbar spinous processes (the bony bumps you feel down the midline of the back). Your fingers should separate as the spine flexes. If they stay together, the lumbar spine is moving as a stiff block, which means lumbar flexion is restricted. This has several causes, including mechanical back pain, which is far more common than inflammatory back disease. In a younger patient with back pain lasting more than 3 months, it also raises the possibility of inflammatory back disease such as ankylosing spondylitis (radiographic axial spondyloarthritis). This is a quick bedside version of Schober's test. In the formal test, you mark a point over the L5 spinous process and a second point 10 cm above it. With full flexion, the distance between the two marks should increase to at least 15 cm. A smaller increase indicates restricted lumbar flexion.

From the front, assess cervical lateral flexion by asking the patient to tilt each ear towards the corresponding shoulder. Restriction here is common in cervical spondylosis (wear-and-tear arthritis of the neck) and inflammatory neck disease. You can also confirm there is no obvious facial or limb asymmetry from this view.

To assess the temporomandibular joints (the jaw joints), ask the patient to open their mouth fully and then move the jaw from side to side. Watching the jaw open in the midline checks for restricted range of movement and any deviation to one side. Listening and feeling for clicking or crepitus (a grating feeling or sound) can reveal joint involvement, which occurs in conditions such as rheumatoid arthritis.

Arms

The arm sequence screens the shoulders, elbows, wrists and hands for restricted movement, deformity and impaired grip and dexterity.

Ask the patient to place both hands behind the head with the elbows pointing out to the sides. This single movement screens shoulder abduction and external rotation together with elbow flexion, and is frequently limited early in shoulder pathology such as a rotator cuff problem (damage to the shoulder tendons) or adhesive capsulitis (a stiff, painful "frozen" shoulder).

Ask the patient to hold their arms out straight in front with the palms facing down and fingers outstretched. Inspect the dorsum of the hands for joint swelling, deformity and muscle wasting. Look in particular for Heberden's nodes (bony swellings at the distal interphalangeal joints, the finger joints nearest the nails) and Bouchard's nodes (bony swellings at the proximal interphalangeal joints, the middle finger joints). Both are signs of osteoarthritis, caused by osteophyte (bony spur) formation at the joint margins.

Heberden's nodes of the distal interphalangeal joints SimpleMed

Image - Heberden's nodes affecting the distal interphalangeal joints. These bony swellings are a classic sign of osteoarthritis of the hand

Creative commons source by Drahreg01 [CC BY-SA 3.0 (https://creativecommons.org/licenses/by-sa/3.0)]

Now look for the pattern of joint involvement that distinguishes the major types of arthritis. Rheumatoid arthritis typically causes a symmetrical deforming polyarthritis (arthritis in many joints) affecting the metacarpophalangeal (MCP) joints, the knuckles, and the proximal interphalangeal joints. Classic late deformities include ulnar deviation of the fingers (drifting towards the little-finger side), swan-neck deformities (the middle finger joint bent back and the end joint bent forwards), boutonnière deformities (the middle finger joint bent forwards and the end joint bent back) and Z-shaped thumbs (a thumb bent at two joints in opposite directions). Psoriatic arthritis (arthritis linked to the skin condition psoriasis) often involves the distal interphalangeal joints and may be associated with nail pitting (small dents in the nails) and dactylitis (a swollen, sausage-shaped finger or toe).

Ask the patient to turn the hands over (supination), which screens wrist and forearm movement, and inspect the palms. Look at the thenar and hypothenar eminences (the muscle pads at the base of the thumb and the little finger) for muscle wasting. Isolated thenar wasting suggests median nerve compression, as in carpal tunnel syndrome (compression of the median nerve at the wrist). It is associated with rheumatoid arthritis and other causes.

Ask the patient to make a tight fist, then assess function with a few quick tests:

  • Power grip: ask the patient to squeeze two of your fingers. A weak grip suggests joint disease, tendon damage or neurological weakness.
  • Precision (pincer) grip: ask the patient to touch each fingertip to the tip of the thumb in turn. This screens fine motor control and small-joint function, which are needed for buttons and other everyday tasks.

Finally, gently squeeze across the metacarpophalangeal joints (the MCP squeeze) while watching the patient's face. Tenderness on squeezing across the MCPs is an early sign of inflammatory joint disease such as rheumatoid arthritis, often present before obvious deformity develops.

Legs

With the patient now lying supine on the couch, screen the hips, knees and ankles by combining inspection with a small number of passive movements and special tests.

Inspect the legs for any swelling, deformity, muscle wasting (particularly of the quadriceps, which wastes quickly in knee disease) and obvious leg-length discrepancy. Look for a knee effusion (excess fluid in the joint) filling out the normal hollows around the patella. Remember to glance at the back of the knee. A Baker's (popliteal) cyst (a fluid-filled swelling behind the knee) can present as a swelling in the hollow behind the knee (the popliteal fossa) in patients with chronic knee disease.

Assess passive knee and hip movement together by holding the knee and flexing the hip and knee fully, feeling for any crepitus (a grating feeling or sound), which may reflect roughened joint surfaces, as in osteoarthritis. On its own, crepitus does not make the diagnosis. With the hip and knee flexed to 90 degrees, assess passive internal rotation of the hip by swinging the foot outwards. Restricted and painful internal rotation is often the earliest sign of hip osteoarthritis.

Assess passive knee flexion and extension through their full range, again feeling for crepitus and noting any fixed flexion deformity that prevents the knee from straightening fully.

Perform a patellar tap to detect a knee effusion. Slide one hand down the thigh to empty the suprapatellar pouch (the fluid-filled space just above the kneecap), then push the patella sharply downwards with a finger of the other hand. If fluid is present, the patella is felt to bounce against the femur and tap back, indicating an effusion from inflammation, infection or injury. For smaller effusions the bulge (sweep) test is more sensitive. To do it, stroke the fluid upwards from the inner side of the knee, then stroke down the outer side and watch for a bulge of fluid reappearing on the inner side.

Finally, inspect the feet, looking at the soles for callosities (areas of thickened skin, which indicate abnormal weight-bearing) and the forefoot for deformities such as hallux valgus (the big toe angled towards the other toes). Gently squeeze across the metatarsophalangeal joints (the MTP squeeze) and watch for tenderness. Like the MCP squeeze in the hand, this is a useful early indicator of inflammatory joint disease. The MTP joints are a classic site of involvement in gout (a crystal arthritis) and rheumatoid arthritis.

Hallux valgus deformity of the great toe SimpleMed

Image - Hallux valgus, in which the great toe deviates laterally at the metatarsophalangeal joint. It is a common forefoot deformity to spot when inspecting the feet during the leg component of GALS

SimpleMed original image, credit 'SimpleMed original'

Recording Your Findings

GALS findings are conventionally recorded in a simple grid that captures, for each region, whether appearance and movement are normal. A tick is placed for normal and a cross for abnormal, with a short note describing any abnormality.

  • The rows are Gait, Arms, Legs and Spine.
  • The columns are Appearance (A) and Movement (M); gait has a single combined entry.

For example, a completely normal screen would be documented as "Gait normal; A and M normal for arms, legs and spine". This concise format makes it easy to communicate that a screen was performed and to highlight exactly which region needs a fuller regional examination.

Completing the Examination

Thank the patient and allow them to dress in privacy, then wash your hands.

Summarise your findings, stating clearly whether the screen was normal or which regions were abnormal in appearance or movement.

To complete the examination, explain that you would perform a focused regional examination of any joint or area that screened as abnormal (for example a full hip, knee, hand or spine examination). You would also take a thorough musculoskeletal history. You would perform a neurovascular assessment of the affected limb (checking its nerve supply and blood supply) and consider a functional assessment of activities of daily living.

Relevant bedside tests and investigations include a urine dip (for example to look for blood or protein in suspected connective tissue disease), blood tests such as full blood count, inflammatory markers (ESR and CRP), rheumatoid factor, anti-CCP antibodies and serum urate, and imaging such as plain radiographs of the affected joints or further imaging where indicated.

Quiz

Preview the GALS Screening OSCE Examination quiz

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