GALs Examination

Question 1

What screening questions would you ask at the start of a GALs examination and why?

Answer 1

First question

“Do you have any pain or stiffness in your muscles, joints or back?”

This question screens for common symptoms present in most forms of joint pathology (e.g. osteoarthritis, rheumatoid arthritis, ankylosing spondylitis).

Second question

“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.

Third question

“Do you have any problem going up and down the 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).

Question 2

What is Trendelenburg’s gait?

Answer 2

Trendelenburg’s gait: an abnormal gait caused by unilateral weakness of the hip abductor muscles secondary to a superior gluteal nerve lesion or L5 radiculopathy.

Question 3

What is waddling gait?

Answer 3

Waddling gait: an abnormal gait caused by bilateral weakness of the hip abductor muscles, typically associated with myopathies (e.g. muscular dystrophy).

Question 4

Why would you examine a patients footwear?

Answer 4

Assess the patient’s footwear: unequal sole wearing is suggestive of an abnormal gait.

Question 5

Describe the gait cycle

Answer 5

The gait cycle has six phases:

Heel-strike: initial contact of the heel with the floor.

Foot flat: weight is transferred onto this leg.

Mid-stance: the weight is aligned and balanced on this leg.

Heel-off: the heel lifts off the floor as the foot rises but the toes remain in contact with the floor.

Toe-off: as the foot continues to rise the toes lift off the floor.

Swing: the foot swings forward and comes back into contact with the floor with a heel strike (and the gait cycle repeats).

Question 6

What is the following sign and what does it suggest?

Answer 6

Wasting of muscles: suggestive of disuse atrophy secondary to joint pathology or a lower motor neuron injury.

Question 7

What is the following sign and what does it suggest?

Answer 7

Psoriasis: typically presents with scaly salmon coloured plaques on extensor surfaces (associated with psoriatic arthritis).

Question 8

What is the following sign and what does it suggest?

Answer 8

Posture: note any asymmetry which may indicate joint pathology or scoliosis.

Question 9

What may cause unilateral joint swelling?

Answer 9

Joint swelling: note any evidence of asymmetry in the size of joints that may suggest unilateral swelling (e.g. effusion, inflammatory arthropathy, septic arthritis).

Question 10

What may cause asymmetry in muscle bulk?

Answer 10

Muscle bulk: note any asymmetry in upper and lower limb muscle bulk (e.g. deltoids, pectorals, biceps brachii, quadriceps femoris). Asymmetry may be caused by disuse atrophy (secondary to joint pathology) or lower motor neuron injury.

Question 11

Explain the difference between cubitus valgus and cubitus varus

Answer 11

Elbow extension: inspect the patient’s carrying angle which should be between 5-15°. An increased carrying angle is known as cubitus valgus. Cubitus valgus is typically associated with previous elbow joint trauma or congenital deformity (e.g. Turner’s syndrome). A decreased carrying angle is known as cubitus varus or ‘gunstock deformity’. Cubitus varus typically develops after supracondylar fracture of the humerus.

Question 12

What is the following deformitiy and its underlying cause?

Answer 12

Valgus joint deformity: the bone segment distal to the joint is angled laterally. In valgus deformity of the knee, the tibia is turned outward in relation to the femur, resulting in the knees ‘knocking’ together.

Question 13

What is the following deformitiy and its underlying cause?

Answer 13

Varus joint deformity: the bone segment distal to the joint is angled medially. In varus deformity of the knee, the tibia is turned inward in relation to the femur, resulting in a bowlegged appearance.

Question 14

What can cause pelvic tilt?

Answer 14

Pelvic tilt: lateral pelvic tilt can be caused by scoliosis, leg length discrepancy or hip abductor weakness.

Question 15

What is the following clinical sign and what does it indicate?

Answer 15

Cervical lordosis: hyperlordosis is associated with chronic degenerative joint disease (e.g. osteoarthritis).

Question 16

What is the following clinical sign and what does it indicate?

Answer 16

Thoracic kyphosis: the normal amount of thoracic kyphosis is typically between 20-45º. Hyperkyphosis is associated with Scheuermann’s disease (congenital wedging of the vertebrae).

Question 17

What is the following clinical sign and what does it indicate?

Answer 17

Lumbar lordosis: loss of normal lumbar lordosis suggests sacroiliac joint disease (e.g. ankylosing spondylitis).

Question 18

What is the following clinical sign and what does it indicate?

Answer 18

Knee joint hyperextension: causes include ligamentous damage and hypermobility syndrome.

Question 19

What is the following clinical sign and what does it indicate?

Answer 19

Foot arch: inspect for evidence of flat feet (pes planus) or an abnormally raised foot arch (pes cavus).

Question 20

What can cause misalignment of the iliac crest indicate?

Answer 20

Iliac crest alignment: misalignment may indicate a leg length discrepancy or hip abductor weakness.

Question 21

What can cause popliteal swellings?

Answer 21

Popliteal swellings: possible causes include a Baker’s cyst or popliteal aneurysm (typically pulsatile)

Question 22

What can cause achilles tendon thickening?

Answer 22

Achilles’ tendon thickening: associated with Achilles’ tendonitis.

Question 23

What can cause weakness in grip strength?

Answer 23

Grip strength may be reduced due to pain (e.g. swelling of the small joints of the hand) or due to lower motor neuron lesions (e.g. median nerve damage secondary to carpal tunnel syndrome).

Question 24

Tenderness experienced when squeezing across the metacarpophalangeal (MCP) joints is suggestive of what?

Answer 24

Active inflammatory arthropathy.

Question 25

How do you assess for joint effusion?

Answer 25

Patellar tap

Joint effusion can be caused by ligament rupture (e.g. anterior cruciate ligament), septic arthritis, inflammatory arthritis and osteoarthritis.

Question 26

What further investigations/examinations will you do after completing a GALs examination?

Answer 26

A focused examination of joints with suspected pathology.

Further imaging if indicated (e.g. X-ray and MRI).

Question 28

What can asymmetry of the shoulder girdle?

Answer 28

Asymmetry of the shoulder girdle: may be caused by scoliosis, arthritis, fractures or dislocation.

Question 29

What can abnormal hair growth on the back suggest?

Answer 29

Abnormal hair growth: may indicate underlying bony abnormalities such as spina bifida.

Question 30

Describe Schobers test

Answer 30

Schober’s test

Schober’s test can be used to identify restricted flexion of the lumbar spine, which may occur in conditions such as ankylosing spondylitis.

Assessment

1. Identify the location of the posterior superior iliac spine (PSIS) on each side.
2. Mark the skin in the midline 5cm below the PSIS.
3. Mark the skin in the midline 10cm above the PSIS.
4. Ask the patient to touch their toes to assess lumbar flexion.
5. Measure the distance between the two lines.

Interpretation

If a patient has normal lumbar flexion the distance between the two marks should increase from the initial 15cm to more than 20cm.

Reduced range of motion is associated with conditions such as ankylosing spondylitis.

Question 31

Describe the sciatic stretch test

Answer 31

Sciatic stretch test (a.k.a. straight leg raise)

The sciatic stretch test is used to identify sciatic nerve irritation.

Assessment

1. Position the patient supine on the clinical examination couch.
2. Holding the patient’s ankle, raise their leg by passively flexing the hip whilst keeping the patient’s knee fully extended.
3. The normal range of movement for passive hip flexion is approximately 80-90º.
4. Once the patient’s hip is flexed, dorsiflex the patient’s foot.

Interpretation

The sciatic stretch test is considered positive if the patient experiences pain in the posterior thigh or buttock region.

A positive test is suggestive of sciatic nerve irritation (e.g. secondary to lumbar disc prolapse).

Question 32

Describe the femoral nerve test

Answer 32

Femoral nerve stretch test

The femoral nerve stretch test is used to identify femoral nerve irritation.

Assessment

1. Position the patient prone on the clinical examination couch.
2. Flex the patient’s knee to 90º and then extend the hip joint.
3. Finally, plantarflex the patient’s foot.

Interpretation

The femoral nerve test is considered positive if the patient experiences pain in the thigh and/or inguinal region.

Question 33

What further assessments would you do upon completing a spine exam?

Answer 33

Further assessments and investigations

Neurovascular examination of the upper and lower limbs.

Examination of the hip and shoulder joints.

Further imaging if indicated (e.g. X-ray/MRI).