The GALS Screen

Question 1

what is the purpose of the locomotion examination?

Answer 1

identify abnormal joints

Question 2

what does GALS stand for?

Answer 2

Gait
Arms
Legs
Spine

Question 3

what is observed in gait?

Answer 3

observe the patient walk, turn and walk back

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

Question 4

what are the key questions asked in the GALS examination?

Answer 4

o Have you any pain in your muscles, joints or back?

o Can you dress yourself completely without any difficulty?

o Can you walk up and down the stairs without any difficulty?

Question 5

what are the signs inflammation?

Answer 5

o	Rubor (Red)
o	Calor (Hot)
o	Tumor (Swelling)
o	Dolor (Pain)
o	Funcio laesa (Loss of function)

or SWELT:
Swelling
Warmth
Erythema
Loss of function 
Tenderness

Question 6

what can be examined in the arms?

Answer 6

pronation and supination 
grip
MCP squeeze
tip of fingers to thumb 
shoulder movement

Question 7

what is the significance of the MCP and MTP squeeze?

Answer 7

indicative of synovitis when there is discomfort

Question 8

what is examined in the legs?

Answer 8

• flexion of hip and knees
• examine knee for fluid (patellar tap sign where patella bounces)
• MTP squeeze
• sole of feet inspected for rashes/callosities

Question 9

what is the difference between arthritis and arthralgia?

Answer 9

Arthritis – refers to a definite inflammation of a joint(s).

Arthralgia – refers to a pain within a joint(s) WITHOUT demonstrable inflammation by physical examination

Question 10

what is dislocation and subluxation?

Answer 10

Dislocation – articulating surfaces are displaced and no longer in contact.

Subluxation – partial dislocation.

Question 11

what is the difference between varus deformity and valgus deformity?

Answer 11

Varus deformity – lower limb deformity whereby distal part is directed towards the midline
– e.g. varus knee with medial compartment osteoarthritis.

Valgus deformity - lower limb deformity whereby distal part is directed distally from the midline
– e.g. hallux valgus.

Question 12

what are some indicators of inflammation occurring?

Answer 12

• gout (example of arthritis)
• joint swelling
• enthesopathy (enthesis)

Question 13

what is the enthesis?

Answer 13

where the ligament/tendon connective inserts into the bone

e.g. in the spine or knee

Question 14

what does deposition of monosodium urate (MSU) crystals in the tissue lead to?

Answer 14

o Gouty arthritis (commonly affects the 1st MTP joint) aka podagra.

o Tophi
– aggregated deposits of MSU in tissue

Question 15

what is the cause of deposition of monosodium urate (MSU) crystals in the tissue?

Answer 15

hyperuricaemia

Question 16

what are the different sites of inflammation?

Answer 16

• Articular soft tissue (Inflammatory joint disease)
• Peri-articular soft tissue (Inflammatory joint disease)
• Non-articular synovial (Inflammation of structure)
• Bony areas (Osteoarthritis)

Question 17

what are some example of enthesopathies?

Answer 17

Achilles tendonitis

plantar fasciitis

Question 18

what are some signs of irreversible joint damage?

Answer 18

o Joint deformity.

o Crepitus
– sound upon articulating joint i.e. in osteoarthritis.

o Loss of joint range or abnormal movement.

Question 19

what are the signs of mechanical defects due to inflammation, degenerative arthritis or trauma?

Answer 19

o Painful restriction of motion in absence of features of inflammation
– e.g. knee “locking”.

o Instability
– e.g. side-to-side movement of tibia on femur.

Question 20

what are the terms to indicate the number of joints involved the arthritis?

Answer 20

o Polyarthritis= >4.
o Oligoarthritis= 2-4.
o Monoarthritis= 1.

Question 21

what is observed when describing the pattern of arthritis?

Answer 21

• Note symmetrical involvement.
• Note size of involved joints.
• Note any axial involvement.

Question 22

how is the pattern of arthritis described in RA?

Answer 22

Bilateral
symmetrical
large and small joints

Question 23

how is the pattern of arthritis described in ReaA?

Answer 23

Lower limb
asymmetrical
Oligoarthritis
axial involvement.

Question 24

what joint is commonly affected in gout?

Answer 24

1st MTP joint involvement.

Question 25

name an additional diagnostic feature of RA

Answer 25

subcutaneous nodules

Question 26

name an additional diagnostic feature of gout

Answer 26

tophi (monosodium urate deposition due to hyperuricaemia)

Question 27

name an additional diagnostic feature of SLE

Answer 27

malar rash sparing nasolabilal folds

Question 28

where is synovial fluid produced?

Answer 28

synovial lining cells(1-3 cells deep).
o Type A – macrophage-like cells.

o Type B – fibroblast-like cells – secrete hyaluronic acid and increased viscosity of synovial fluid.

Question 29

what is synovial effusion?

Answer 29

abnormal increase in synovial fluid volume

can be:
•	Normal.
•	Non-inflammatory (Osteoarthritis)	
•	Inflammatory (Gout)		
•	Infectious (Bacterial infections)

Question 30

what happens to the composition of synovial in OA? how does this change the volume of synovial fluid?

Answer 30

increases hyaluronic acid production

more oncotic pressure increased synovial volume.

Question 31

how does synovial fluid normally look? how does it change in inflammation?

Answer 31

normally clear or pale yellow

becomes more turbid in disease

Question 32

how is synovial fluid sampled?

Answer 32

arthrocentesis

look for pathogens (ABs assay) and crystals (polarising light microscopy)

Question 33

what are the contraindications and complications of arthrocentesis?

Answer 33

o Contraindications
– bleeding disorders (genetics or drugs like warfarin), overlying skin infection.

o Complications
– introducing infection, Haemarthrosis, damage to structures.

Question 34

what diseases can be determined with synovial fluid examination?

Answer 34

• septic arthritis (postive gram stain and culture)

- olecranon bursitis (crystals present)

Question 35

name some connective tissue disorders

Answer 35

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

Question 36

what is the Raynaud’s phenomenon?

Answer 36

is often associated with arthritis and arthralgia in connective tissue disorders (not exclusively)

• Intermittent vasospasm of digits on exposure to the cold.
• Colour changes (blue to red)
  – vasospasm blanches digit, cyanosis as static venous blood deoxygenates, reactive hyperaemia.

Question 37

what is Sjogren’s Syndrome?

Answer 37

Autoimmune exocrinopathy

– lymphocytic infiltration of exocrine glands e.g parotid, hence the parotid gland enlargement

Question 38

what does Sjogren’s Syndrome result in? what are signs in relation to connective tissue disorders in general?

Answer 38

o	Dry eyes 
– xerophthalmia.
o	Dry mouth 
– xerostomia.
o	Parotid gland enlargement 

importantly non-erosive arthritis and Raynaud’s phenomenon.
“Secondary Sjogren’s syndrome” if occurs with another connective tissue disorder like SLE

Question 39

what is inflammatory muscle disease?

Answer 39

Proximal myopathy (AI-mediated inflammation) with either dermatomyositis (rash) or polymyositis (no rash).

Question 40

what is systemic sclerosis?

Answer 40

thickened skin with raynauds syndrome (skin changes are diffuse or limited)

Question 41

what is Overlap Syndrome?

Answer 41

has features of more than one connective tissue disorder e.g. SLE plus inflammatory muscle disease