pGALS Flashcards
Give the overall structure of pGALS
1) Questions:
- do you have any pain or stifness in muscles, joints or back?
- any difficulty getting self dressed without help?
- any difficulty going up or down stairs?
2) General inspection:
- general
- anterior
- lateral
- posterior
3) Gait:
- standard
- heel walking
- tiptoe walking
4) Arms:
- compound movements
- MCP joint squeeze
5) Legs:
- active movement
- passive movement
- MTP joint squeeze
- patella tap
6) Spine:
- cervical lateral flexion
- lumbar flexion
7) Temporomandibular joint
What are the 3 questions initially asked at beginning of pGALS?
1) Any pain or stiffness in your back, joints or muscles?
2) Any difficulty going up and down the stairs?
3) Any difficulty getting yourself dressed without help?
What is the following question screening for: any pain or stiffness in your back, joints or muscles?
Screens for common symptoms present in most forms of joint pathology e.g. osteoarthritis, RA, ankylosing spondylitis.
What does the following question screen for: do you have any difficulty getting yourself dressed without any help?
Screens for evidence of FINE motor impairment and significant restriction of joint range of movement.
What does the following question screen for: “Do you have any problem going up and down the stairs?”
Screens for evidence of impaired GROSS motor function (e.g. muscle wasting, LMN lesion) and general mobility issues (e.g. restricted range of movement in the joints of the lower limb).
What are you looking for in general inspection?
1) Clinical signs:
- body habitus
- scars
- wasting of muscles
- psoriasis
2) Objects:
- wheelchair
- splints
- support slings
- prescriptions
What is wasting of muscles indicative of?
Disuse atrophy 2ary to joint pathology or a LMN injury.
What are you looking for in closer ANTERIOR inspection?
- Posture e.g. scoliosis
- Scars
- Leg length discrepancy
- Elbow carrying angle
- Knee valgus or varus joint deformity
- Erythema or swelling of joints
- Muscle bulk
- Pelvic tilt
- Fixed flexion deformity of the toes
- Big toe (hallux valgus or varus)
What can leg length discrepancy indicate?
1) May be congenital
2) May be 2ary to joint pathology:
- Perthes disease
- SUFE
- DDH
What can joint swelling or erythema indicate? (2)
1) Inflammatory arthropathy
2) Septic arthritis
What is the normal elbow carrying angle in a child?
5-15 degrees
what is an increased elbow carrying angle known as (i.e. hand is further from body)?
Cubitus valgus
what is a decreased elbow carrying angle known as (i.e. hand is closer to body)?
Cubitus varus (or ‘gunstock deformity’)
What is cubitus valgus typically associated with?
1) Previous elbow joint trauma
2) Congenital deformity (e.g. Turner’s syndrome)
What elbow deformity can be seen in Turner’s?
Cubitus valgus (i.e. increased carrying angle)
What is cubitus varus typically 2ary to?
Supracondylar fracture of humerus
What genetic syndrome is often associated with cubitus valgus?
Turner’s syndrome
What is valgus deformity of the knee?
When foot is further from the body i.e. causing knocked knees
Tibia is turned outward in relation to femur
What is varus deformity of the knee?
The tibia is turned inward in relation to the femur - causing bowlegged appearance.
What can a pelvic tilt be caused by?
- scoliosis
- leg length discrepancy
- hip abductor weakness
What are you looking for in closer LATERAL inspection?
1) Cervical lordosis
2) Thoracic kyphosis
3) Lumbar lordosis
4) Knee joint hyperextension or fixed flexion
5) Foot arch
What is the normal amount of thoracic kyphosis?
Typically between 20-45 degrees
what is hyperkyphosis associated with?
Scheuermann’s disease (congenital wedging of the vertebrae
What is lumbar lordosis associated with?
Sacroiliac joint disease (e.g. ankylosing spondylitis).
What are 2 causes of knee joint hyperextension?
1) ligamentous damage
2) hypermobility syndrome
What is cervical lordosis associated with?
Chronic degenerative joint disease (e.g. osteoarthritis).
What are you looking for in closer POSTERIOR inspection?
1) Muscle bulk
2) Spinal alignment e.g. scoliosis
3) Iliac crest alignment
4) Popliteal swellings
5) Achille’s tendon thickening
6) Valgus joint deformity
7) Varus joint deformity
What is Achille’s tendon thickening associated with?
Achille’s tendonitis
What are 2 possible causes of popliteal swellings?
1) Baker’s cyst
2) Popliteal aneurysm (typically pulsatile)
What are the 3 aspects of the gait assessment?
1) Standard gait assessment
2) Heel walking
3) Tiptoe walking
How do you perform a standard gait assessment?
Ask the child to walk to the end of the examination room and then turn and walk back whilst you observe their gait.
What are you looking for in a standard gait assessment? (8)
1) Gait cycle e.g. abnormalities in toe-off or heel strike
2) Range of movement
3) Limping
4) Leg length
5) Turning
6) Trendelenburg’s gait
7) Waddling gait
8) Assess child’s footwear
What may limping indicate?
1) Joint pain i.e. antalgic gait
2) Weakness
What is Trendelenburg’s gait?
An abnormal gait caused by unilateral weakness of the hip ABductor muscles 2ary to a superior gluteal nerve lesion or L5 radiculopathy.
The weakness of these muscles causes drooping of the pelvis to the contralateral side while walking.
What muscles are weak in Trendelenburg’s gait?
Hip abductor muscles
What are the 2 causes of Trendelenburg gait?
1) Superior gluteal nerve lesion
2) L5 radiculopathy
What is a waddling gait?
An abnormal gait cauesd by bilateral weakness of hip abductor muscles, typically associated with myopathies (e.g. muscular dystrophy).
what is a waddling gait typically associated with?
Myopathies e.g. muscular dystrophy
What is the purpose of assessing gait with heel & tiptoe walking in pGALS?
Screens for pathology in the ankles joints, subtalar joints, midtarsal joints and the smaller joints of the feet and toes.
Also calf muscles & achilles tendon.
What are the compound movements when assessing ‘arms’? (9)
1) Hands behind head
2) Hands held out in front with palms facing down
3) Hands held out in front with palms facing up
4) Making a fist
5) Precision grip
6) Hands held together palm to palm
7) Hands together back to back
8) Reaching upwards
9) Looking upwards
How many arm compound movements are you assessing in pGALS?
9
What is the compound movements ‘hands behind the head’ assessing?
1) shoulder abduction
2) external rotation
3) elbow flexion
What does the compound movement ‘hands held out in front with palms facing down’ assess?
1) Forward flexion of shoulders
2) Elbow extension
3) Wrist extension
4) Extension of small joints of fingers
Describe the compound movement: ‘hands held out in front with palms facing down’
Ask the child to hold their hands out in front of them, with their palms facing down and fingers outstretched.
What can you assess the dorsum of the hand for when assessing the compound movement: ‘Hands held out in front with palms facing down’?
1) Asymmetry
2) Joint swelling
3) Deformity
4) Inspect nails for signs associated with psoriasis (e.g. nail pitting)
Describe the compound movement: ‘hands held out in front with palms facing up’
Ask the child to turn their hands over (demonstrating supination)
What does the compound movement ‘hands held out in front with palms facing up’ assess?
1) Wrist supination
2) Elbow supination
What is restriction of arm supination indicative of?
wrist or elbow pathology (e.g. osteoarthritis)
What can you assess the palm of the hand for when assessing the compound movement: ‘Hands held out in front with palms facing up’?
Inspect the thenar and hypothenar eminences for evidence of muscle wasting.
What does the compound movement ‘making a fist’ assess?
1) Flexion of the small joints of the fingers
2) Overall hand function
When may a child be unable to make a fist?
If they have joint swelling (e.g. inflammatory arthritis or joint infection) or if they have other deformities of the small joints of the hands.
What is involved in ‘precision grip’?
Ask the child to touch each finger in turn to their thumb.
What does ‘precision grip’ assess?
1) Coordination of the small joints of the fingers and thumbs
2) Manual dexterity (which should be interpreted in the context of the child’s age)
What does reduced manual dexterity indicate?
May suggest inflammation or joint contractures of the small joints of the hand.
What does the compound movement ‘Hands together palm to palm’ assess?
1) Extension of small joints of fingers and wrists
2) Flexion of elbows
What does the compound movement ‘Hands together back to back’ assess?
1) Flexion of wrist joints
2) Flexion of elbow joints
Describe the compound movement: ‘reaching upwards’
Ask the child to reach up as far as they are able (as if trying to touch the sky), whilst keeping their arms straight.
What does the compound movement ‘reaching upwards’ assess?
1) Elbow extension
2) Wrist extension
3) Shoulder abduction
Describe the compound movement: ‘looking upwards’
Ask the child to look up at the ceiling.
What does the compound movement ‘looking upwards’ assess?
Cervical extension
What is tenderness on MCP joint squeeze suggestive of?
Active inflammatory arthropathy
What are the 2 aspects of active movement assessment of the legs?
1) Active knee flexion - ask the child to bring each heel in turn towards their bottom
2) Active knee extension - ask the child to straighten out each leg on the bed
What are the 3 aspects of passive movement assessment of the legs?
1) Passive knee flexion
2) Passive knee extension
3) Passive internal rotation of the hip
Describe passive knee extension assessment
If the child is able to lay their legs flat on the bed, they are already demonstrating a normal range of movement for knee extension.
To assess for hyperextension:
1) On the leg being assessed, hold above the ankle joint and gently lift the leg upwards.
2) Inspect the knee joint for evidence of hyperextension, with less than 10° being considered normal.
What is the normal range of internal rotation of the hip?
40 degrees
What does the patellar tap assess for?
Moderate to large knee joint effusion.
Joint effusion can be caused by ligament rupture (e.g. anterior cruciate ligament), septic arthritis, inflammatory arthritis and osteoarthritis.
Describe the patellar tap test
1) With the child’s knee fully extended, empty the suprapatellar pouch by sliding your left hand down the thigh to the upper border of the patella.
2) Keep your left hand in position and use your right hand to press downwards on the patella with your fingertips.
3) If there is fluid present you will feel a distinct tap as the patella bumps against the femur.
What are the 2 aspects of spine assessment?
1) Cervical lateral flexion
2) Lumbar flexion
Describe the assessment of lateral flexion of the cervical spine
Ask the child to tilt their head to each side, moving their ear towards their shoulder:
“Try and touch your shoulder to your ear on each side.”
Describe the assessment of the TMJ
Ask the child to open their mouth wide and put three of their own fingers into their mouth (you can demonstrate using your own fingers and mouth).
What are 2 possible further investigations following a pGALS?
1) Focused exam of joints with suspected pathology
2) Further imaging if indicated (e.g. X-ray and MRI)
