GALS

Question 1

What does GALS stand for?

Answer 1

Gat
Arms
Legs
Spine

Question 2

What is the aim of the GALS exam?

Answer 2

To see if any of the joints are abnormal

Question 3

What further questions would you ask when carrying out GALS?

Answer 3

What is nature of joint abnormality?
What is extent of joint involvement
Are there any other features of diagnostic importance present?

Question 4

What are the key screening questions to detect rheumatological disease?

Answer 4

Have you any pain or stiffness in your muscles, joints or back?
Can you dress yourself completely without any difficulty?
Patients with proximal myopathy find it difficult to brush hair
Can you walk up and down stairs without difficulty?

Question 5

What does the locomotor/GALS examination consist of?

Answer 5

Initial rapid joint screening exam

Detailed exam of abnormal joints

Question 6

How do you assess gait in the initial screening exam?

Answer 6

First observe patient walking, turning and walking back, look for:
Smoothness and symmetry of leg, pelvis and arm movements
Normal stride length
Ability to turn quickly

Question 7

How do you assess arms in the initial screening exam?

Answer 7

Check normal girdle muscle bulk and symmetry
Check that elbows are straight and in full extension
Ask the patient to attempt to place both hands behind the head and then push elbows back
Examine the hands palms down, with fingers straight

Question 8

How do you examine the hands in the arms exam?

Answer 8

Observe normal supination and pronation
Observe normal grip. Place tip of finger on the tip of thumb to assess normal dexterity and precision grip
Squeeze across 2nd to 5th metacarpal- discomfort suggests synovitis

Question 9

How do you assess the spine in the GALS exam?

Answer 9

Many questions:
Is paraspinal and shoulder girdle muscle bulk symmetrical?
Is spine straight?
Are the iliac crests level?
Is gluteal muscle bulk normal
Are there popliteal swellings?
Are achilles tendons normal?
Things we need to do:
Press over mid point of each supraspinatus and squeeze skinfold over trapezius- tenderness suggests fibromyalgia. Associated with hypersensitivity to pain, depression and IBD
From the side, note the normal spinal curvatures. Ask the patient to bend forward and touch toes with knees straight to assess lumbar spine and hip flexion
Ask patient to try place ear on shoulder- this tests lateral cervical flexion

Question 10

What does the examination of the legs in the GALS exam involve?

Answer 10

Any knee or foot deformities
Assess flexion of the hip and knee whilst supporting the knee
Passively internally rotate each hip in flexion. Examine each knee for presence of fluid using bulge sign and patella tap sign
Squeeze across the metatarsals to detect any synovitis
Inspect soles of feet for rashes and callosities

Question 11

What does a detailed examination of abnormal joints include?

Answer 11

Inspection- swelling, redness, deformity
Palpation- warmth, crepitus, tenderness
Movement- Active, passive and against resistance
Function- loss of function

Question 12

What is arthritis?

Answer 12

Definite inflammation of a joint/s ie swelling, tenderness and warmth of affected joints

Question 13

What is arthralgia?

Answer 13

Pain within a joint without demonstrable inflammation by physical examination

Question 14

What are the signs of active inflammation?

Answer 14

Swelling (tumor)
Warmth (calor)
Erythema (rubor)
Tenderness (dolor)
Loss of function

Question 15

What is podagra?

Answer 15

Acute gout- included in acute joint inflammation

Very painful condition in which tissue deposition of monosodium urate (MSU) crystal occur as a result of hyperuricaemia

Question 16

What might gout lead to?

Answer 16

Gouty arthritis

Tophi (aggregated deposits of MSU in tissue)

Question 17

What is enthesopathy?

Answer 17

Non-articular soft tissue swelling at enthesis (site where ligament or tendon inserts into bone)

Question 18

How do you know if there is irreversible joint damage?

Answer 18

Joint deformity (malalignement of bones)
Crepitus (audible and palpable sensation resulting from movement of one roughened surface on another)- classic feature of osteoarthritis
Loss of joint range/abnormal movement

Question 19

What terms are commonly used to describe peripheral joint abnormalities and what do they mean?

Answer 19

Dislocation- articulating surfaces are displaced and no longer intact
Subluxation- partial dislocation
Valgus- lower limb deformity whereby distal part is directed away from midline e.g. hallux valgus
Varux- Lower limb deformity whereby distal part is directed towards midline

Question 20

What is ankylosing spondylitis?

Answer 20

Chronic inflammatory disease affecting the sacroiliac joints and spine, which leads to spinal fusion and deformity

Question 21

How can mechanical defects be identified?

Answer 21

Painful restriction of motion in absence of features of inflammation e.g.. knee locking due to meniscal tear or bone fragment
Instability e.g. side to side movement of tibia on femur due to ruptured collateral knee ligaments

Question 22

How is different extent of joint involvement recorded?

Answer 22

Polyarthritis- >4 joints affected
Oligoarthritis 2-4 joints affected
Monoarthritis- 1 joint affected