The GALS Screen

Question 1

What is the GALS examination?

Answer 1

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?

Question 2

What do you look for in a person’s gait?

Answer 2

Observe the patient walk, turn and walk back:

• Smoothness and symmetry of legs
• Normal stride length
• Ability to turn quickly

Question 3

What do you look for in a person’s arms?

Answer 3

• 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

Question 4

What do you look for in a person’s legs?

Answer 4

• 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

Question 5

What do you look for in a person’s spine?

Answer 5

• 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?

Question 6

Define the term arthritis

Answer 6

definite inflammation of joint(s)

Question 7

Define the term arthralgia

Answer 7

a pain within a joint(s) WITHOUT demonstratable inflammation by physical examination

Question 8

Define the term dislocation

Answer 8

articulating surfaces are displaced and no longer in contact

Question 9

Define the term subluxation

Answer 9

partial dislocation

Question 10

Define the term varus deformity

Answer 10

lower limb deformity whereby distal part is directed towards the midline

Question 11

Define the term valgus deformity

Answer 11

lower limb deformity whereby distal part is directed distally from the midline

Question 12

What is gout?

Answer 12

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

Question 13

What does the site of swelling indicate?

Answer 13

Articular soft tissue -> Inflammatory joint disease

Per-articular soft tissue -> Inflammatory joint disease

Non-articular synovial -> Inflammation of structure

Bony areas -> Osteoarthritis

Question 14

What is enthesopathy?

Answer 14

literally means pathology at the enthesis – where the ligament/tendon inserts into the bone

e.g Achilles tendonitis, plantar fasciitis

Question 15

What are the signs of irreversible joint damage?

Answer 15

• joint deformity
• crepitus - sound upon articulating joint e.g in osteoarthritis
• loss of joint range or abnormal movement

Question 16

What is ankylosing spondylitis?

Answer 16

an example of a chronic inflammatory condition leading to joint deformity

AK affects/leads-to – sacroiliac joints, spine, enthesischronic enthesopathy, non-axial joints (i.e. shoulders), association with HLA-B27, RF is –ve

Question 17

What can mechanical defect signs be due to?

Answer 17

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

Question 18

Describe the pattern of arthritis

Answer 18

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

Question 19

What are other diagnostic features of RA,SLE and gout?

Answer 19

RA - subcutaneous nodules
gout - tophi (SC deposits of MSU crystals)
SLE - malar rash

Question 20

Where is synovial fluid synthesised?

Answer 20

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

Question 21

What is synovial effusion?

Answer 21

abnormal increase in synovial fluid volume

Question 22

Describe the normal and abnormal composition of synovial fluid

Answer 22

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

Question 23

What are the different types of synovial effusion?

Answer 23

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

Question 24

When would you perform a synovial fluid examination?

Answer 24

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

Question 25

What are some connective tissue disorders?

Answer 25

• SLE
• Inflammatory muscle diseases – polymyositis, dermatomyositis
• Systemic sclerosis
• Sjogren’s syndrome
• Overlap syndrome – a mixture of the above

Question 26

What are key features of connective tissue disorders?

Answer 26

• 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

Question 27

What is Sjogren’s syndrome?

Answer 27

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

Question 28

What is inflammatory muscle disease?

Answer 28

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

Question 29

What is systemic sclerosis?

Answer 29

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

Question 30

What is overlap syndrome?

Answer 30

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’)