GALS (Gait, Arms, Legs, Spine) Examination (OSCE)

Introduction 

Greet the patient and introduce yourself 

Confirm patient details

Briefly explain the procedure in a patient friendly manner 

Get patient consent ✅

Expose the patient as required

Wash hands ✋

Screening Questions

1. Do you suffer from pain/stiffness in muscles/joints/back❓
2. Do you struggle to dress yourself independently❓
3. Do you have any difficulty using stairs❓

Gait

Observe the patient as they walk to the end of the room and back:

Gait cycle: identify abnormalities 🚶

Waddling gait: indicates weakness of the hip abductor muscles on both sides, associated with myopathies

Trendelenburg’s gait: indicates weakness of the hip abductor muscles on one side, due to L5 radiculopathy or superior gluteal nerve lesion

Leg length: differences can indicate joint pathology 📏

Limp: can indicate joint pain/weakness

Slow turning: can indicate joint restrictions

Footwear: unequal wearing of the sole can indicate an abnormal gait 🚶

Movement: reduced range of movement indicates chronic joint pathology

Normal gait cycle:

1. Heel makes contact with floor 🚶
2. Foot becomes flat and weight is transferred onto it
3. Weight balanced on flat foot’s leg
4. Heel lifted off floor
5. Toes lifted off floor
6. Foot swings forward and cycle begins again  

Inspection

Identify any clinically relevant signs:

Scars: indicate prior surgery

Psoriasis: scaly plaques on extensor surfaces, can indicate psoriatic arthritis

Obesity: significant joint pathology risk factor ❌

Muscle wastage: indicates lower motor neuron injury or disuse atrophy

Identify any clinically relevant objects or equipment:

Prescriptions: indicate recent medications 💊

Aids/adaptations: wheelchair/walking aids/slings/splints ♿

Inspect the patient from an anterior aspect in a standing position:

Scars: indicate prior surgery or trauma 

Swollen joints: identify unilateral swelling which can indicate effusion, septic arthritis or inflammatory arthropathy

Erythema of joints: indicates active inflammation which can indicate septic arthritis or inflammatory arthropathy

Posture: asymmetry can indicate scoliosis or pathology of joints

Deformity of the valgus joint: knees knocking together

Deformity of the varus joint: bowlegged appearance

Muscle bulk: upper and lower asymmetry can indicate lower motor neuron injury or disuse atrophy 

Big toe: identify medial or lateral angulation 👣

Elbow extension: identify cubitus valgus (carrying angle above within 5-15°), caused by congenital deformity or elbow joint trauma or cubitus varus “gunstock deformity” (carrying angle below 5-15°), caused by supracondylar fracture of the humerus 

Lateral pelvic tilt: caused by difference in leg lengths, scoliosis or weak hip abductor muscles

Inspect the patient from a lateral aspect in a standing position :

Arched foot: inspect for flat feet or a raised foot arch 👣

Lumbar lordosis: loss of normal inward curve of the spine’s lumbar region indicates sacroiliac joint disease

Cervical lordosis: hyperlordosis suggests chronic degenerative joint disease

Hyperextension of knee joint: caused by ligamentous damage or hypermobility syndrome

Thoracic kyphosis: normal range is 20-45°, higher indicates Scheuermann’s disease 📐

Inspect the patient from a posterior aspect in a standing position:

Deformity of valgus joint: foot turned outwards 👣

Deformity of the varus joint: foot turned inwards 👣

Spinal alignment: lateral curvature of spine indicative of scoliosis

Thickened Achilles tendon: Achilles tendonitis

Muscle bulk: asymmetry between upper and lower limbs can be caused by lower motor neuron injury or disuse atrophy

Iliac crest alignment: misalignment can indicate weakness of hip abductor muscles or or difference in leg length

Popliteal swellings: indicates possible Baker’s cyst or popliteal aneurysm

Arms

Assess compound Movements:

1. Ask patient to put hands behind head and pint elbows to sides ✋
   • Restricted movement range indicates pathology of shoulder/elbow
   • Excessive movement range can suggest hypermobility
2. Ask patient to hold their arms out in front of their body with their palms facing the floor and their finger stretched out
   • Assess dorsum for asymmetry/deformity/joint swelling
   • Assess nails for signs indicative of psoriasis
3. Ask patient to turn hands over ✋
   • Restricted movement indicates pathology of wrist/elbow
4. Ask patient to form fist with hand ✋
   • Inability to do so can be due to swollen joints/deformities
5. Ask patient to squeeze your fingers, assessing strength of grip
   • Low grip strength can be caused by pain/ lower motor neuron lesions
6. Ask patient to touch each finger with thumb of same hand ✋
   • Inability may be due to inflammation or the small joint may have joint contractures

Squeeze the Metacarpophalangeal joint:

Assess patient for discomfort when you squeeze the joints gently

Tenderness indicates active inflammatory arthropathy

Legs

Assess passive movement, controlled by you:

Passive knee flexion: support knee and flex leg as far as possible before patient experiences discomfort (normal 0-140°) 📐

Passive knee extension: a patient laying flat on the bed is showing normal knee extension, assess for hyperextension by holding above their ankle, then lifting the leg upwards identifying hyperextension >10° 📐

Passive internal hip rotation:

Flex hip and knee joint to 90°, then rotate foot laterally (normal 40°) 📐

Squeeze the metatarsophalangeal joint:

Assess patient for discomfort when you squeeze the joints gently 

Tenderness indicates active inflammatory arthropathy

Tap the patellar:

Can identify moderate/large knee joint effusion caused by ligament rupture, inflammatory/septic/osteo-arthritis

1. Extend the knee fully and slide your hand down the thigh until it reaches the patella’s upper border ✋
2. Holding your left hand in that position, assert pressure on the patella with your right hand ✋
3. A distinct tap indicates the presence of fluid as the patella bumps against the femur

Spine

Ask the patient to stand upright

Cervical lateral flexion:

Ask patient to try to touch their ears to shoulders 

Assess cervical spine lateral flexion 

Lumbar flexion:

Palpate for a range of movements to assess lumbar flexion

1. Place 2 fingers between 5 and 10cm apart of the lumbar vertebrae 📏
2. Ask patient to touch their toes by bending towards downwards 
3. Assess whether your fingers move apart 
4. Ask the patient to stand straight
5. Assess whether your fingers move back together 

Hypermobility = ability to place hands flat on the floor ✋

Temporomandibular joint

Observe as patient inserts 3 of their fingers into their mouth 

Identify deviation or restriction of jaw movement 

Completion 

Tell the patient that the examination is now complete ✅

Thank patient 

Wash hands ✋

Summarise what the examination revealed 

Summary:

1. Greet the patient and briefly explain the examination, then perform screening questions
2. Observe the patient walking from one side of the room to the other to assess if they have a normal gait cycle
3. Inspect the gait, arms, legs and spine to identify anything clinically relevant
4. With the patient in a standing position, inspect them from an anterior, lateral and posterior aspect
   
5. Assess the compound movement of the arms and squeeze the Metacarcophalangeal joint
6. Assess passive movement of the legs and passive internal hip rotation, squeeze the Metatarsopholangeal joint, and Tap the patellar
7. With the patient standing upright, assess cervical lateral flexion, and lumbar flexion
8. Assess the Temporomandibular joint
9. Complete the procedure by thanking the patient