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Examination

Principles

GALS

  Appearance Movement
Gait    
Arms    
Legs    
Spine    
...or the shorthand grid...
  A M
G    
A    
L    
S    
A tick represents normal and a cross represents abnormality detected..

 Gait Observe the patient walking, turning and walking back, looking for smoothness and symmetry of leg, pelvis and arm movements, normal stride length and the ability to turn quickly.
Arms

Inspection from the front allows assessment of normal girdle muscle bulk and symmetry. After placing both hands down by the side with elbows straight in full extension (Figure 1), the patient should attempt to place both hands behind their head and then push the elbows back, which tests glenohumeral, acromioclavicular, and sternoclavicular joints (Figure 2).

 

Figure 2

Hands should be examined palm down with fingers straight to detect any swelling or deformity. It is important to observe normal supination/pronation (Figures 3 & 4). 

Figure 3

Figure 4

and grip. Place the tip of each finger onto the tip of the thumb in turn to assess normal dexterity and fin precision pinch (Figure 5). Discomfort in response to squeezing across the 2nd to the 5th metacarpal suggests synovitis (Figure 6).

After placing both hands down by the side with elbows straight in full extension (Figure 1)
Figure 1

Figures 5 and 6
Legs Inspect the patient standing and observe knee, hindfoot, midfoot or forefoot deformity. Later examination on the couch should include flexion each hip and knee while supporting the knee to test normal hip and knee flexion and help detect crepitus.

Each hip should be passively internally rotated in flexion (Figure 7) and the knee carefully examined the presence of fluid by pressing on each patella and palpated for the balloon sign and bulge sign (figures 8 & 9). Squeeze across the metatarsals to detect synovitis (Figure 10). Inspect the soles of the feet for callosities or rashes such as keratoderma blenorrhagica in Reiter' s syndrome.

 

       

Figures 8 and 9

Figure 7

Figure 10
Spine This is best inspected by the patient standing. 
  • From behind; Is the spine straight, are there level iliac crests, normal paraspinal and girdle muscle bulk symmetry? 'Try to place you ear on your shoulder each side' - this tests lateral cervical flexion (Figure 11). Press over the mid point of each supraspinatus: tenderness suggests fibromyalgia. 
  • From the side, note spinal curvatures. Ask the patient to bend forward and touch their toes with their knees straight, which will give an impression of lumbar spine and hip flexion.

 

More on GALS

Figure 11

Detection of early synovitis in the absence of major joint deformity