The GALS screen: the rapid rheumatological exam

The gait, arms, legs and spine (GALS) locomotor screening examination encourages doctors to make an initial examination of the joints.1 It combines techniques used by experienced consultants in the initial assessment of a patient who may have musculoskeletal problems. This technique is taught in all British medical schools and features commonly in OSCE examinations,2 and takes 5 minutes to perform (Box). As with several other physical examination techniques, its sensitivity and specificity for detecting joint disease has not been formally evaluated; it does not detect all conditions with soft tissue or significant systemic involvement.

Any findings are followed up by a regional joint examination focusing on where the abnormality was detected, using the “look, feel, move” system.

The GALS examination

Screening questions:

• “Do you have any pain in your muscles, joints or back?”
• “Can you dress and undress yourself without any difficulty?”
• “Can you walk up and down stairs without any difficulty?”

Examination: the patient is undressed down to the underwear, but this is not essential.

Gait

The patient is asked to stand and walk across the room, turn and walk back. The observer watches the symmetry and flow of the gait, looking for obvious signs of pain and observing the posture.

Arms

The observer asks the patient to show their hands, with the elbows tucked into the waist, then to turn the hands over. This demonstrates pronation and supination of the forearms. Next, the observer gently squeezes across the metacarpophalangeal joints, looking for evidence of pain and feeling for synovitis, which is an indicator of a symmetrical arthritis, such as rheumatoid arthritis. The observer asks the patient to touch each finger to the tip of the thumb in turn, which demonstrates opposition of the thumb — an indicator of hand function.

Next, the patient is asked to straighten the arms (looking for full extension of the elbows), and to place the hands behind the head (demonstrating abduction and external rotation of the shoulders and flexion of the elbows).

Legs

The patient is asked to sit back on an examination couch or chair. The observer lifts each leg in turn and internally rotates the hip, while placing a hand on the bended knee to feel for crepitus. Limitation of internal rotation of the hip is an early sign of hip disease.

Each leg is straightened in turn, and a quick assessment is made for a knee effusion using the bulge test.

The patient is then asked to flex, extend, pronate and supinate each foot in turn, looking at ankle and forefoot movement, and the observer squeezes the toes across the metatarsals checking for pain.

Spine

As part of the initial gait assessment, or separately, the observer looks at the spine. Assessing the overall posture, as an “S” shape, with a normal thoracic kyphosis and lumbar lordosis. The observer asks the patient to put their ear on each shoulder in turn allowing assessment of lateral flexion of the neck.

Then the patient is asked to bend over and attempt to touch the floor with their hands. The observer places two of their fingertips across two of the patient's spinous processes and watches to see how far they move apart as the patient bends. This is a modification of the Schober test — a clinical test looking for evidence of spinal stiffening and reduction of flexion seen in ankylosing spondylitis. Positive findings are recorded in a simple table, with a description of the problem.

Evaluation of the GALS screen has shown that it improves confidence and competence in the examination of the joints for medical students and in primary and secondary care,3 and it has been adjusted for use in children (pGALS).4

Most clinicians adapt the screen for their own use.