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Learning objective
1. The student is able to perform screening musculoskeletal examination GALS
(gait, arms, legs and spine).
2. The student is able to record the findings from GALS examination.
3. The student is able to perform shoulder examination
4. The student is able to perform knee examination
5. The student is able to perform hip examination
6. The student is able to perform leg examination
GALS assessment
In combination with supervised accredited practice the successful student should be to
able to perform a GALS assessment of the musculoskeletal system
Inspection
Neck movements
Spine
Arms
Shoulder movements
Grip strength
Precision pinch
Metacarpalphalangeal
squeeze test
Knee movements
Hip movement
Leg
Patellar tap test
Inspection of feet
Metacarpalphalangeal
squeeze test
Record
Skill
Shoulder examination
Learning
outcome
The shoulder joint is the most mobile joint in the body, allowing the hand to be placed into a position
where it can operate efficiently. To achieve its range of mobility, the shoulder is dependent for stability
on surrounding soft tissue structures, in particular a group of muscles called the rotator cuff. The two
main bones of the shoulder are the humerus and the scapula. The joint cavity is cushioned by articular
cartilage covering the head of the humerus and face of the glenoid. The scapula extends up and
around the shoulder joint at the rear to form a roof called the acromion, and around the shoulder joint at
the front to form the coracoid process. The end of the scapula, called the glenoid, meets the head of
the humerus to form a glenohumeral cavity that acts as a flexible ball-and-socket joint. The joint is
Background stabilized by a ring of fibrous cartilage surrounding the glenoid called the labrum. Ligaments connect
the bones of the shoulder, and tendons join the bones to surrounding muscles. The biceps tendon
attaches the biceps muscle to the shoulder and helps to stabilize the joint. A group of short muscles
originate on the scapula and pass around the shoulder where their tendons fuse together to form the
rotator cuff. Movements of the shoulder joint are dependent on five functional areas: glenohumeral
joint; the acromioclavicular joint; the subacromial joint between the acromioclavicular arch above and
the head of the humerus below; the sternoclavicular joint and the scapulothoracic region. Shoulder pain
can arise from a number of sites including: the rotator cuff tendons, biceps tendon, subacromial bursa,
glenohumeral joint, acromioclavicular joint & the sternoclavicular joint.
Procedure INTRODUCTION, PATIENT IDENTIFICATION & CONSENT
HAND WASHING
EXPOSURE
When examining a patients shoulder, their upper garments should be removed. This will also provide
an opportunity to observe the patients shoulder function.
INSPECTION
Observe both shoulder areas from the anterior, lateral and posterior aspects. Observe for any scars,
swelling, erythema, muscle wasting or abnormal contours.
PALPATION
Prior to palpating the patients shoulders, ask if they are experiencing any pain. It is often useful to have
the patient point to the site where they are experiencing discomfort. Equally you should instruct the
patient to inform you if they experience any pain during the examination.
During palpation observe for any signs of tenderness, swelling, temperature or crepitus.You should
palpate both shoulder joints in a systematic approach. A suggested approach would be:
1) Sternoclavicular joint
2) Clavicle
3) Acromioclavicular joint
4) Humeral head
5) Coracoid process
6) Deltoid muscle
7) Spine of scapula
8) Supraspinatus muscle
9) Infraspinatus muscle
10) Trazpezus muscle
(then repeat on the other side)
MOVEMENT
Note! Remember in assessing the patients range of shoulder movements you should always compare one side
with the other.
When assessing movement in a patients shoulder joint you should assess:
Active movements (i.e. movements performed by the patient on their own)
Passive movements (i.e. movements performed by the examiner)
Resisted movements (i.e. movements against resistance)
A general rule of thumb is that reduced active movements, that improve on passive movement, suggest
muscular / tendon problems. Reduced range of both active and passive movements suggest intra-articular
disease.
The range of movements that we assess for in the shoulder joint include:
Flexion
Extension
Abduction
Adduction
Internal rotation
External rotation
Tip! To have the patient perform the various range of shoulder movements try not to use medical jargon (e.g.
Abduct your shoulder please!). Stand in front of the patient, face to face, and ask them to copy the movements
that you make (assuming that your shoulders have a normal range of movement!) - this can make patient
Alternatively you may ask the patient to place their hands behind their
head, with their elbows far back as possible.
Alternatively you may ask the patient to place their thumbs up their back
and try to touch their back as high as possible
PASSIVE MOVEMENTS:
Prior to passive movements it is important to have your patient relax as
best as possible.
Depending on your clinical findings you may want to perform resisted movements. This will be covered
in the CSEC & in your clinical attachments
When making an assessment of a patients shoulder there are many other special tests / manoeuvres that
can be performed. They will not be discussed here.
You may also consider examining the patients peripheral neurological system in the upper limbs and
circulation status.
Skill
Knee examination
Learning outcome
To be able to i) identify surface anatomy of the knee & ii) examine a patients knee
Back ground
Knee pain can be a source of significant disability & health care utilization. Around
4.5 million people in the UK have severe knee pain. Because of our ageing
population & increasing levels of obesity, the number of patients with disabling
knee pain is set to increase. In order to make an accurate diagnosis of a patients
knee pain a thorough physical examination needs to take place including
i) a careful inspection of the knee
ii) palpation of the knee
iii) assessment for joint effusion
PROCEDURE
Introduction
Hand
hygiene
Hand washing
Exposure
Make sure that both knees are fully exposed. The patient
should be in either a gown or shorts. Rolled up trouser
legs generally does not provide adequate exposure.
Inspection
Palpation
Feel systematically around the knee joint for tenderness
including the patella, quadriceps tendon, prepatellar &
collateral ligaments. Bend the knee to 90 degrees & feel
around the medial & lateral joint lines for tenderness.
Remember to feel at the back of the knee for a popliteal
(Bakers cyst) With the back of your hand do you feel an
increased temperature compared to the other knee?
Assess for
an effusion
Patella tap
Bulge test:
Using your thumb and index finger - milk down any fluid
from above the knee. Keep this hand in this position.
Now with the other hand stroke the medial side of the knee
to empty the medial compartment of fluid then stroke the
lateral side. Observe the medial side of the knee for any
bulging? This may indicate an effusion.
Applying pressure to the lateral aspect of
the knee and observing for any bulging on
the medial side of the knee
Active movement
Ask the patient to fully bend (flex) then straighten (extend)
their knee. Always compare the range of movement with
the other knee. Is there any reduced range of movement?
Active flexion of the knee
Passive movement
Place one hand on the patients knee and then with the
other hand flex (bend) the knee as far as possible & then
extend the knee. With the hand that is placed over the
knee do you feel a 'grinding' sensation? Such a grinding
sensation (crepitus) is usually indicative of degenerative
knee disease (osteoarthritis) which reflects a loss of the
normal smooth movement between the articulating
structures (i.e. femur, tibia, and patella).
Special tests
Collateral
ligament
assessment
Cradle the patients lower leg between your arm and body.
The knee should be flexed to 30 degrees. Now with your
other hand apply valgus stress to the knee joint. Excessive
movement indicates ligament damage.
Lateral Collateral Ligament
Cradle the patients lower leg between your arm and body.
The knee should be flexed to 30 degrees. Now with your
other hand apply varus stress to the knee joint. Excessive
movement indicates ligament damage.
Cruciate
ligament
assessment
Menisci
Skill
Spine examination
Learning
outcome
Background
1= Vertebral body
2= Vertebral foramen
3= Spinous process
4= Pedicle
5= Superior articular process
6= Transverse process
7= Lamina
1= Cervical lordosis
2=Thoracic kyphosis
3= Lumbar lordosis
4= Sacral kyphosis
1="Vertebra prominens"
Spinous process of C7
2= 2nd Lumbar vertebra
3= L4-5 inter vertebral space
4= Iliac crests
5= Dimples of Venus / Sacroiliac joints
Introduction Introduce your self to the patient, identify the patient's details and gain
informed consent.
Patient
instructions
Ask if they are in any pain, and to inform you if they experience any
discomfort during the examination. Exposure of spine- remove upper
garment; ideally should be wearing shorts or an examination gown.
Hand
washing
Inspection
Inspection
Gait
Ask the patient to walk several yards, turn around and then walk back.
Observe their gait carefully. Is there easy following movement? Is there
symmetrical movement? Is there a normal gait cycle from heel strike to
toe off? Do you observe an Antalgic gait? (where pain or deformity
causes the patient to hurry off one leg and to spend most of the gait
cycle on the other. May suggest abnormality in one region e.g. lumbar
spine or hip)
From behind
and in front
From the
side
Palpation
Palpation:
Movement
Observe for any restricted movements, smoothness of movement and
for any pain experienced during movements. In addition to your verbal
patient instructions, you may want to demonstrate these movements to
the patient.
Cervical spine
Cervical
spine
Thoracolumbar
Lumbar flexion
Try to touch your toes without bending
knees
Lumbar extension
Lean back
Thoracolumbar rotation
Sit down and turn round, looking over
your shoulder
(Sitting down helps fix the patients
pelvis)
Other tests
Other tests
Given the close proximity of the spine and the spinal cord and nerve
roots it is very important to consider performing a peripheral
neurological examination, together with some special nerve root
stretch tests. In the CSEC and your attachments you will learn further
information about conditions such as Sciatica and cauda equina (Click
here for further information)
Lasegues
test:
Sacroiliac
joints:
Abdominal
examination:
Skill
Hip examination
Learning
outcome
Background
Procedure
INSPECTION
Procedure
i) Standing:
Observe the patient from all sides with the patient standing
stationary. Inspect for the level of the iliac crests. Now have
the patient walk to the other side of the room, turn around
and walk back. Observe the patients gait and pelvic
movements. In a Trendelenburg gait the pelvis on the
opposite drops and the body leans away from the affected
side, when weight bearing is on the affected hip.
ii) Lying supine:
Have the patient lie supine on a couch. Are any scars
present? Muscle wasting present? Is there any obvious
discrepancy in leg length?
PALPATION
Palpate around the hip area. Specifically is there any
tenderness around the inguinal area and the greater
trochanter area? Is there any tenderness? Heat? Swelling?
Measurement
True length of the legs using a tape measurer measure
the distance between the anterior iliac spine to the tip of the
medial mallous, with the anterior spines lying at the same
transverse level. Compare one side to the other.
MOVEMENT:
FLEXION
Have the patient flex their knees & move their
hip joint into the flexed position as fair as
possible.
(Normal range ~ 120 degree)
(If you keep the knee extended the range of
movement in the hip joint is limited by tension in
the hamstring muscles)
ABDUCTION
Make sure you stabilze the pelvis by placing a
hand on the opposite anterior iliac crest and
holding the ankle with the other hand. The hip is
abducted until the pelvis tilts.
(Normal range of movement ~ 45 degrees)
ADDUCTION
Cross one leg over the other until pelvis begins
to tilt.
(Normal range of movement ~ 30 degrees)
INTERNAL ROTATION
Flex the hip and knee to 90 degrees. Now move
the leg laterally.
(Normal range of movement ~ 45 degrees)
EXTERNAL ROTATION
Again with the hip and knee flexed move the
patients leg medially. (Normal range of
movement ~ 60 degrees)
EXTENSION
Have the patient lie prone on the couch.
Immobilise the pelvis with one hand while
extending the hip with the other hand.
SPECIAL TESTS:
i) THOMAS' TEST
Thomas test Is used to detected a fixed flexion
deformity in the hip. Place your hand behind the
small of the patients back, between it and the
couch. There is normally a small gap here due
to normal lumbar lordosis. Abolish the lumbar
lordosis by asking the patient to flex the hip and
feel the lumbar spine flatten out onto your hand.
When you are happy that the lumbar spine is
flat, see if the patients other knee is flat on the
couch. If not, measure the angle of (fixed) hip
flexion. Then repeat the test asking the patient
to clasp their other knee up against their chest
and observe for fixed flexion deformity in the
previously flexed hip.
Standing on both
legs
Abnormal - the
Normal - the pelvis rises on the
pelvis drops on the
side of the lifted leg
side of the lifted leg.
Further reading
1. The Arthritis Research Campaign,2005.
2. Rheumatology Examination and Injection Techniques,2nd ed. M Doherty, BL
Hazleman, CW Hutton et al. WB Saunders.
3. Current Rheumatology Diagnosis & Treatment. J Imboden, DB Hellmann, JH
Stone. McGraw Hill,2005