The GALS Screen Flashcards
What is the GALS examination?
Gait, Arms, Legs, Spine – observe the patient walk, turn and walk back
Key questions:
- Have you any pain in your muscles, joints or back?
- Can you dress yourself completely without any difficulty?
- Can you walk up and down the stairs without any difficulty?
What do you look for in a person’s gait?
Observe the patient walk, turn and walk back:
- Smoothness and symmetry of legs
- Normal stride length
- Ability to turn quickly
What do you look for in a person’s arms?
- look for normal girdle muscle bulk and symmetry
- look if there’s full extension at the elbows
- are the shoulder joints normal
- examine hands palms down with fingers straight
What do you look for in a person’s legs?
- look for foot deformity
- assess flexion of hip and knee
- look for knee swelling
- test for synovitis at metatarso-phalangeal joints
- inspect soles of feet
What do you look for in a person’s spine?
- is paraspinal and shoulder girdle muscle bulk symmetrical?
- is spine straight?
- are iliac crests level?
- is gluteal muscle bulk normal?
- are the popliteal swellings?
- are the achilles tendons normal?
- are there signs of fibromylagia?
- are spinal curvatures normal?
- is lumbar spine and hip flexion normal?
- is cervical spine normal?
Define the term arthritis
definite inflammation of joint(s)
Define the term arthralgia
a pain within a joint(s) WITHOUT demonstratable inflammation by physical examination
Define the term dislocation
articulating surfaces are displaced and no longer in contact
Define the term subluxation
partial dislocation
Define the term varus deformity
lower limb deformity whereby distal part is directed towards the midline
Define the term valgus deformity
lower limb deformity whereby distal part is directed distally from the midline
What is gout?
A disease where deposition of monosodium urate (MSU) crystals in the tissue because of hyperuricemia leads to one or more of the following:
- Gouty arthritis
> Commonly affects the 1st MTP joint – podagra
> Abrupt onset, painful, all cardinal inflammation signs, resolves spontaneously over 3-10 days
- Tophi – aggregated deposits of MSU in tissue
What does the site of swelling indicate?
Articular soft tissue -> Inflammatory joint disease
Per-articular soft tissue -> Inflammatory joint disease
Non-articular synovial -> Inflammation of structure
Bony areas -> Osteoarthritis
What is enthesopathy?
literally means pathology at the enthesis – where the ligament/tendon inserts into the bone
e.g Achilles tendonitis, plantar fasciitis
What are the signs of irreversible joint damage?
- joint deformity
- crepitus - sound upon articulating joint e.g in osteoarthritis
- loss of joint range or abnormal movement
What is ankylosing spondylitis?
an example of a chronic inflammatory condition leading to joint deformity
AK affects/leads-to – sacroiliac joints, spine, enthesischronic enthesopathy, non-axial joints (i.e. shoulders), association with HLA-B27, RF is –ve
What can mechanical defect signs be due to?
May be due to inflammation, degenerative arthritis or trauma, identified by:
- Painful restriction of motion in absence of features of inflammation – e.g. knee “locking”
- Instability – e.g. side-to-side movement of tibia on femur
Describe the pattern of arthritis
Determine the number of joints involved:
- Polyarthritis >4
- Oligoarthritis 2-4
- Monoarthritis 1
Note symmetrical involvement
Note size of involved joints
Note any axial involvement
e. g
- RA – Bilateral, symmetrical, large and small joints
- ReA – Lower limb, asymmetrical, Oligoarthritis, axial involvement
- Gout – exclusive 1st MTP joint involvement
What are other diagnostic features of RA,SLE and gout?
RA - subcutaneous nodules
gout - tophi (SC deposits of MSU crystals)
SLE - malar rash
Where is synovial fluid synthesised?
Synthesised by the synovial lining cells, type A and type B (1-3 cells deep)
- Type A – macrophage-like cells
- Type B – fibroblast-like cells – secrete hyaluronic acid -> increased viscosity of synovial fluid
What is synovial effusion?
abnormal increase in synovial fluid volume
Describe the normal and abnormal composition of synovial fluid
Normal composition – abnormal mechanical stimulation (i.e. osteoarthritis) increases hyaluronic acid production -> more oncotic pressure -> increased synovial volume
Abnormal composition – synovitis due to inflammation -> inflammatory exudate = abnormal composition
What are the different types of synovial effusion?
Types of synovial effusions – turbidity increases going down:
- Normal
- Non-inflammatory - Osteoarthritis - 10-20% neutrophils
- Inflammatory - Gout - 20-70% neutrophils
- Infectious - Bacterial infections 70%+ neutrophils
When would you perform a synovial fluid examination?
mandatory when joint infection is suspected, confirms diagnosis of crystal arthritis
Performed using needle aspiration – “arthrocentesis”
- Contraindications include – bleeding disorders (genetics or drugs like warfarin), overlying skin infection
- Complications include – introducing infection, Haemarthrosis, damage to structures
Synovial fluid is gram stained -> cultured -> antibiotic sensitivity assay
Polarising light microscopy detects crystals which can be seen in gout and pseudo-gout
What are some connective tissue disorders?
- SLE
- Inflammatory muscle diseases – polymyositis, dermatomyositis
- Systemic sclerosis
- Sjogren’s syndrome
- Overlap syndrome – a mixture of the above
What are key features of connective tissue disorders?
- Arthralgia (pain within a joint with NO inflammation) and arthritis are typically NON-EROSIVE
- Serum antibodies are characteristic – aid diagnosis, correlate with disease activity, may be pathogenic
- Raynaud’s phenomenon is common:
> Intermittent vasospasm of digits on exposure to the cold
> Colour changes (blue -> red) – vasospasm blanches digit, cyanosis as static venous blood deoxygenates, reactive hyperaemia
What is Sjogren’s syndrome?
Autoimmune exocrinopathy – lymphocytic infiltration of exocrine glands
Diagnosed in middle-aged females typically (F: M = 9: 1)
Exocrine gland pathology results in:
- Dry eyes – xerophthalmia
- Dry mouth – xerostomia
- Parotid gland enlargement (seen pictured)
Commonest extra-glandular manifestations are non-erosive arthritis and Raynaud’s phenomenon
Termed “Secondary Sjogren’s syndrome” if occurs with another connective tissue disorder (e.g. SLE)
Auto-antibodies – ANAs and RF
What is inflammatory muscle disease?
Proximal myopathy (AI-mediated inflammation) with either dermatomyositis (rash) or polymyositis (no rash)
Skin changes (with dermatomyositis):
- Lilac-coloured (heliotrope) rash on eyelids, malar region and naso-labial folds
- Gottron’s papules – red/purple flat or raised lesions on knuckles
- SC calcinosis
- Mechanic’s hands – fissures and cracking of hands over finger pads
Auto-antibodies – ANAs – anti-tRNA synthetase antibodies
Elevated CPK, abnormal electromyography, abnormal muscle biopsy (CD8 T cells = polymyositis, CD4 T cells = dermatomyositis with b cells)
Associated with malignancy and pulmonary fibrosis
What is systemic sclerosis?
Thickened skin with Raynaud’s phenomenon
- Dermal fibrosis, cutaneous calcinosis and telangiectasia
Skin changes may be limited or diffuse
- Diffuse systemic sclerosis
- Fibrotic skin proximal to elbows or knees (excluding face and neck)
- Anti-topoisomerase-1 (anti-Scl-70) antibodies
- Pulmonary fibrosis, renal (thrombotic microangiopathy) involvement
- Short history of Raynaud’s phenomenon
Limited systemic sclerosis*
- Fibrotic skin hands, forearms, feet, neck and face
- Anti-centromere antibodies
- Pulmonary hypertension
- Long history of Raynaud’s phenomenon
What is overlap syndrome?
When features of more than 1 connective tissue disorder are present e.g. SLE and inflammatory muscle disease we can use the term overlap syndrome
When incomplete features of a connective tissue disease are present we can use the term undifferentiated connective tissue disease
In one instance a group of patients with features of seen in SLE, scleroderma, rheumatoid arthritis, and polymyositis were identified by the presence of an autoantibody:
- Anti-U1-RNP antibody*
….this condition was termed Mixed Connective Tissue Disease (‘MCTD’)
