The GALS Screen Flashcards
What is the GALS screen for?
Designed to rapidly express whether somebody has joint problems
Aims of the locomotor examination to find out? (4)
Are any of the joints abnormal?
What is the nature of the joint abnormality?
What is the extent (distribution) of the joint involvement?
Are any other features of diagnostic importance present?
Key screening questions for the GALS exam? (3)
Have you any pain or stiffness in your muscles, joints or back?
Can you dress yourself completely without any difficulty?
Can you walk up and down stairs without any difficulty?
What do you do to assess gait?
observe patient walking, turning and walking back
What do you look for when assessing gait? (3)
smoothness and symmetry of leg, pelvis and arm movements
normal stride length
ability to turn quickly
What do you look for when assessing spine? (11)
is paraspinal and shoulder girdle muscle bulk symmetrical? is the spine straight? are the iliac crests level? is the gluteal muscle bulk normal? are there popliteal swellings? are the Achilles tendons normal? Assess for fibromyalgia note the normal spinal curvatures assess lumbar spine and hip flexion tests lateral cervical flexion
How do you assess for fibromyalgia?
press over mid-point of each supraspinatus and squeeze skinfold over trapezius
How do you note the normal spinal curvatures
from the side
How do you assess lumbar spine and hip flexion
ask patient to bend forward and touch their toes, with knees straight
How do you assess lateral cervical flexion
try to place ear on the shoulder each side
What do you look for when assessing arms? (8)
normal girdle muscle bulk
and symmetry
elbows are straight and in
full extension
attempt to place both hands behind the head,
then push elbows back
examine hands palms down, with fingers straight
observe normal supination and pronation
observe normal grip
place tip of each finger on to the tip of the thumb
to assess normal dexterity and precision grip
squeeze across 2nd to 5th metacarpal (metacarpal ‘squeeze’ test) - discomfort suggests synovitis
What do you look for when assessing legs? (6)
observe any knee or foot
deformity
assess flexion of 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 the feet for rashes and/or callosities
How do you define nature of joint abnormality? (3)
Is there active inflammation?
Is there irreversible joint damage?
Is there a mechanical defect?
What does the detailed examination of abnormal joints consist of? (4)
inspection
palpation
movement
function
What do you inspect an abnormal joint for? (3)
swelling, redness, deformity
What do you palpate an abnormal joint for? (3)
warmth, crepitus, tenderness
what movements do you check in an abnormal joint? (3)
warmth, crepitus, tenderness
what is arthritis?
definite inflammation of a
joint(s) i.e. swelling, tenderness and warmth of
affected joints
What is arthralgia?
refers to pain within a joint(s) without demonstrable inflammation by physical examination
Arthralgia vs arthritis?
arthritis is definite inflammation, arthralgia has no demonstrable inflammation by physical examination
5 signs of inflammation?
swelling (tumor) warmth (calor) erythema (rubor) tenderness (dolor) loss of function (functio laesa)
What is loss of function known as?
functio laesa
What is tenderness known as?
dolor
What is swelling known as?
tumor
What is warmth known as?
calor
What is erythema known as?
rubor
What is rubor
Warmth
What is calor
Erythema
What is dolor
Tenderness
What is functio laesa
Loss of function
What is tumor
Swelling
What is gout?
disease in which tissue deposition of monosodium urate (MSU) crystals occurs as a result of hyperuricaemia and leads to one or more of the following:
Gouty arthritis
Tophi (aggregated deposits of MSU in tissue)
What does gout lead to?
Gouty arthritis
Tophi (aggregated deposits of MSU in tissue)
What is deposited in gout
Monosodium urate (MSU)
Which joint does gouty arthritis commonly affect
Gouty arthritis commonly affects the MTP joint of the big toe (first MTP joint)
Site of swelling:
articular soft tissue
Tissue involved?
Indicative of?
joint synovium or effusion
inflammatory joint disease
Site of swelling:
periarticular soft tissue
Tissue involved?
Indicative of?
subcutaneous tissue
inflammatory joint disease
Site of swelling:
non-articular synovial
Tissue involved?
Indicative of?
bursa/tendon sheath
inflammation of structure
Site of swelling:
bony areas
Tissue involved?
Indicative of?
articular ends of bone
osteoarthritis
What is joint deformity defined as
malalignment of two articulating bones
What crepitus? what is it a feature of
audible and palpable sensation resulting from movement of one roughened surface on another
classic feature of osteoarthritis e.g. patellofemoral crepitus on flexing the knee
What does irreversible joint damage result in?
loss of joint range or abnormal movement
Define dislocation:
articulating surfaces are displaced and no longer incontact
Define subluxation:
partial dislocation
Define valgus:
lower limb deformity whereby distal part is directed away from the midline e.g. hallux valgus
Define varus:
lower limb deformity whereby distal part is directed towards the midline e.g. varus knee with medial compartment OA
What is the site where tendons and ligaments insert into bone called
Entheses
Entheses are…?
the site where tendons and ligaments insert into bone
Rheumatoid factor is [positive/negative] in ankylosing spondylitis?
neg
What does ankylosing spondylitis affect? (4)
Sacroiliac joints (sacroiliitis) and spine leads to spinal fusion (ankylosis) and deformity Enthesopathy Non-axial joints – hips and shoulders (common), others less frequently involved
4 examples of Spondyloarthropathies?
Reactive arthritis and Reiter’s syndrome
Ankylosing spondylitis
Arthritis associated with psoriasis (psoriatic arthritis)
Arthritis associated with gastrointestinal inflammation (enteropathic synovitis
What causes mechanical joint defects? (3)
consequence of inflammation, degenerative arthritis or trauma
Identifying mechanical joint defects? (2)
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
Types of irreversible joint damage?
Joint deformity
Crepitus
Loss of joint range or abnormal movement
Common finger deformities in RA? (2)
Swan-neck and Boutonnière deformities
Swan-neck and Boutonnière deformities
How to determine the extent of joint involvement? (4)
determine number of joints involved:
note if involvement is symmetrical
note the size of the involved joints
is there axial involvement?
bilateral and symmetrical involvement of large and small joints is typical of X
RA
lower limb asymmetrical oligoarthritis and axial involvement would be typical of X
reactive arthritis
exclusive inflammation of the distal interphalangeal joints of th/e fingers is highly suggestive of X
psoriatic arthritis
Joints commonly spared in RA? (3)
DIP
thoracic spine
lumbar spine
Joints commonly spared in osteoarthritis? (6)
MCP, wrist, elbow, shoulder, ankle, tarsal joints
Joints commonly involved? in osteoarthritis (9)
1st CMC, DIP, PIP, cervical spine, thoracolumbar spine, hip, knee, 1st MTP, toe IP
Joints commonly involved in RA? (11)
PIP, MCP, wrist, elbow, shoulder, cervical spine, hip, knee, ankle, tarsal, MTP
Joints commonly involved in polyarticular gout? (3)
1st MTP, ankle, knee
Joints commonly spared in polyarticular gout?
axial
Other features of diagnostic importance to look out for? What disease do they suggest?
rheumatoid nodules - RA
tophi - Gout
What is synovial effusion
Abnormal increase in synovial fluid volume
What cells in the synovium lining secrete what which contributes to the viscosity of the fluid
Type B fibroblast like cells secrete the hyaluronic acid which results in the increased viscosity of synovial fluid
What does normal synovial fluid look like?
Clear or pale yellow and viscous
What does non-inflammatory synovial fluid look like?
Slightly turbid
What does inflammatory synovial fluid look like?
Turbid
What does infected synovial fluid look like?
Very turbid
What does slightly turbid synovial fluid suggest? (2)
Osteoarthritis
Mechanical defects
What does turbid synovial fluid suggest? (2)
Gout
Rheumatoid arthritis
What does very turbid synovial fluid suggest? (2)
Bacterial Infections
When and how do you examine synovial fluid?
mandatory when joint infection is suspected
needle aspiration under aseptic conditions (termed arthrocentesis)
What is Raynauds phenomenon
Intermittent vasospasm of digits on exposure to cold
What HLA serotype is SLE associated with?
HLA-DR3
Clinical manifestations of SLE? (9)
Malar rash – erythema that spares the nasolabial fold
Photosensitive rash
Mouth ulcers
Hair loss
Raynaud’s phenomenon
Arthralgia and sometimes arthritis
Serositis (pericarditis, pleuritis, less commonly peritonitis)
Renal disease – glomerulonephritis (‘lupus nephritis’)
Cerebral disease – ‘cerebral lupus’ e.g. psychosis
What is Sjogrens syndrome? Who is it more common in? What are the symptoms? (3) What antibodies are associated with it? (2)
Autoimmune exocrinopathy
Typically diagnosed in middle-aged female
Typically diagnosed in middle-aged female
Antinuclear antibody - Anti-Ro and Anti-La antibodies
Rheumatoid factor
What is inflammatory muscle disease?
Proximal muscle weakness due to autoimmune-mediated inflammation either with (dermatomyositis) or without (polymyositis) a rash
Skin changes in inflammatory muscle disease?
Lilac-coloured (heliotrope) rash on eyelids, malar region and naso-labial folds
Red or purple flat or raised lesions on knuckles (Gottron’s papules)
Subcutaneous calcinosis
Mechanic’s hands (fissuring and cracking of skin over finger pads)
Antibodies associated with inflammatory muscle disease?
Antinuclear antibody – Anti-tRNA synthetase antibodies
CPK in inflammatory muscle disease?
Elevated
What is systemic sclerosis?
Thickened skin with Raynaud’s phenomenon
caused by:
Dermal fibrosis, cutaneous calcinosis and telangiectasia
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
What are connective tissue diseases? (5)
SYSTEMIC SCLEROSIS INFLAMMATORY MUSCLE DISEASE SJÖGREN’S SYNDROME SYSTEMIC LUPUS ERYTHEMATOSUS RAYNAUD’S PHENOMENON
