Musculoskeletal and joint examination: GALS and regional

This page is the bedside musculoskeletal (MSK) examination you will use in almost every OSCE and ward clerkship. It has two layers, and you should keep them separate. The first layer is a rapid screen of the whole locomotor system: the GALS examination (gait, arms, legs and spine), which takes about three minutes and asks three questions, looks at the whole patient, and tells you whether anything is wrong. ^[1] The second layer is a regional examination of a single joint when the screen, the history or a presenting complaint points to a problem. Regional examination is not a repeat of GALS; it is look, feel, move, special tests and function for one joint, done in that order, with comparison to the other side.

The examination establishes four things: whether the problem is articular or peri-articular, whether it is inflammatory or mechanical, what the functional loss is, and whether there is neurovascular involvement. It supports but never replaces imaging. Always look at the patient, not just the joint: posture, gait, skin, nails, muscle wasting, equipment and scars tell as much as the joint itself.

Setting matters. A warm, well-lit room, correct bed height, exposure from waist down with shorts and underwear, a chaperone when needed, a pillow for the head and neck if standing is unsafe, a tape measure, a goniometer if your institution uses one, and time for the patient to relax. Ask about pain before you touch, and leave the painful area to the end.

Inflammatory joint disease shows warmth, erythema, swelling, pain at rest or at night, morning stiffness that eases as the patient moves, and often small-joint symmetry. Mechanical problems show pain on use, brief stiffness, locking or giving way, and deformity from wear or instability. The two can coexist, and the distinction is made from the pattern of symptoms plus the signs below, not from a single finding.

Introduce yourself, confirm identity and date of birth, explain in plain words what you will do ("I need to watch you walk, then look, feel and move your joints"), and ask for permission. Offer a chaperone for any examination before proceeding, even when the patient does not ask for one, and document whether it was accepted or declined. Tell the patient they can stop the examination at any point and that they will be covered when not being examined. Ask where pain is before you start, and say you will keep it to the end.

Clean your hands and any equipment. Expose appropriately: for GALS, the patient stands in shorts and underwear; for a regional examination, expose the whole limb plus the joint above and below. Keep the patient warm and dignified. Position for safety: standing only if balance is safe, otherwise examine seated or on the couch.

Do the same sequence every time. ^[1] Variant is allowed only when a step is genuinely impossible, and then you state what you omitted and why.

Position the patient standing. Ask the three screening questions in full:

1. "Do you have any pain or stiffness in your muscles, joints or back?"
2. "Do you have any difficulty getting yourself dressed without any help?"
3. "Do you have any problem going up and down stairs?"

Then inspect and screen the four regions:

General inspection. Body habitus (obesity raises mechanical load), scars, muscle wasting, psoriatic plaques, objects and aids around the bed.

Gait. Ask the patient to walk to the end of the room, turn and walk back. Note symmetry and smoothness, stride length, heel strike and toe-off, limping, leg length, speed of turning, Trendelenburg's gait (unilateral hip abductor weakness, pelvis drops to the opposite side) and waddling gait (bilateral hip abductor weakness). Note unequal sole wear on footwear.

Arms.

• Hands behind the head, elbows out: shoulder abduction and external rotation plus elbow flexion.
• Hands held out in front, palms down: shoulder flexion, elbow extension, wrist extension, finger extension. Inspect the dorsum of the hands for asymmetry, joint swelling and deformity; inspect the nails for psoriatic pitting.
• Hands held out in front, palms up: wrist and elbow supination. Inspect the thenar and hypothenar eminences for wasting.
• Ask the patient to make a fist and to oppose thumb to each finger (precision grip). Inspect hand function.
• Grip strength, comparing sides; reduced grip suggests painful small joints or a lower motor neuron lesion such as median nerve compression.
• MCP (metacarpophalangeal) squeeze: gentle pressure across the 2nd to 5th MCPs; tenderness suggests active inflammatory arthropathy. ^[1]

Legs. Position the patient lying down. Assess:

• passive knee flexion (normal 0 to 140 degrees) and extension; look for hyperextension of less than about 10 degrees as normal and excessive hyperextension as ligamentous laxity or hypermobility. ^[1]
• passive internal rotation of the hip (normal about 40 degrees), flexing the hip and knee to 90 degrees and rotating the foot laterally. ^[1]
• MTP squeeze across the forefoot for tenderness suggesting active inflammatory arthropathy. ^[1]
• patellar tap for a moderate-to-large effusion (below).
• quadriceps bulk and asymmetry.
• crepitus on passive movement, associated with osteoarthritis.

Spine (patient standing, then flexing).

• Inspect shoulders and iliac crests for height, scoliosis and posterior muscle bulk.
• Inspect anteriorly, laterally and posteriorly for lordosis and kyphosis; hyperlordotic lumbar spine, hyperkyphosis of 20 to 45 degrees is the usual range, loss of lumbar lordosis suggests sacroiliac disease. ^[1]
• Lateral cervical flexion: ear towards shoulder.
• Lumbar flexion with palpation of the lumbar vertebrae, so that hip flexion does not mask loss of lumbar movement; normal is separation of your fingers. Hands flat on the floor suggests hypermobility. ^[1]
• Temporomandibular joint: open the mouth and place three fingers between the teeth; restricted opening suggests TMJ disease. ^[1]

An adult GALS screen can also include the TMJ, which was previously screened only in children as part of pGALS. ^[1]

Once the screen indicates a region, examine that joint, and the joints above and below.

Look. Standing inspection from anterior, lateral and posterior, then supine. Note posture, gait, leg length discrepancy, pelvic tilt, scars, wasting, swelling, erythema, deformity, aids, footwear, psoriatic plaques, rheumatoid nodules, skin thinning. Compare sides. For the shoulder, inspect the carrying angle at the elbow, normally 5 to 15 degrees; an increased angle is cubitus valgus, a decreased angle cubitus varus (gunstock deformity). ^{[2] [3]}

Feel. Temperature using the back of the hand; local warmth with swelling and tenderness suggests septic, inflammatory or bursal pathology. Palpate in a set order, noting tenderness, bony irregularity, joint line pain, effusion and tendon. Palpate proximal and distal to the joint line for muscle bulk and nerves.

Move. Active first (patient moves their own joint), then passive if abnormal. Record both, state whether pain, crepitus or instability limits the range, and compare sides. If you give a number, say what it was measured against (for example, "knee flexion to 110 degrees, firm end-feel"). Use the normal ranges in the table as a rough guide, but the comparison between sides and against the patient's own normal is more useful than the number alone.

Special tests. Only those indicated by the story and findings; they are supporting evidence, not a diagnosis.

Neurovascular and function. Light touch and motor power in the relevant peripheral nerves, pulses across the joint, capability tasks (grip, stairs, standing from a chair, heel and toe walk).

The table collects the signs you are most likely to elicit and name. "How to elicit it" is the bedside action; "what it means" is the clinical inference, which is rarely one-to-one.

A presentation has five parts in this order: the headline, the region, the positives, the negatives that matter, then a one-line summary and differential. Keep it under about a minute.

1. Headline. Lead with the most important finding, or state "the examination is unremarkable". Decide by what determines management, not by what you found first.
2. Region and positives. Describe the abnormal region first, then findings in the order you examined them: look, feel, move, special tests. State numbers and measurements, not adjectives, for example "effusion present on patellar tap" and "Schober increase 3 cm".
3. Other regions. State the important findings from the screen briefly, especially normal regions that make a diagnosis less likely.
4. Negatives that matter. Only those that change the differential: no warmth or erythema, no effusion, no fixed flexion deformity, no neurodeficit, no extra-articular features. Do not list every normal finding.
5. Summary and differential. One sentence on what you think, one on what you would do next, and name the key alternative.

How to write it in the notes. Short lines, one finding per line, same order as the spoken presentation, with numbers: "GALS: 3 screening questions negative; gait normal, no Trendelenburg, no waddle. Hands: no nodes, no ulnar deviation, MCP squeeze negative. Knees: right knee varus deformity, quadriceps wasting, reduced range, positive patellar tap, negative Lachman, negative anterior drawer. Left knee normal. Hips and spine screened: Thomas negative, Schober normal." Do not copy prose, and never add a diagnosis the findings do not support.

All patient details below are invented and illustrative; they are not real patients. These lines are teaching style and do not need a source quote.

Normal GALS and single normal knee (spoken). "A 24-year-old man has no musculoskeletal symptoms. On inspection he stands and walks normally with no Trendelenburg, deformity or wasting. Hands behind the head and palms up and down are full and symmetrical, with no node, no joint swelling and a negative MCP squeeze. Knees are normal in appearance, with full extension, range to about 140 degrees and no effusion on patellar tap. Hip rotation is full bilaterally, and Schober testing runs from 15 to 22 cm. In summary, the examination is normal, with no evidence of inflammatory or degenerative arthritis."

Osteoarthritis of the knee (spoken). "A 68-year-old woman reports medial knee pain worsened by walking and stairs. Inspection shows a varus deformity of the right knee with quadriceps wasting and no erythema. There is a bony enlargement at the joint line on palpation, with crepitus on movement and no warmth; a small effusion is present on the sweep test. Knee range is reduced and there is no fixed flexion deformity, with an endpoint on full extension. Lachman and anterior drawer are negative. In summary, this is osteoarthritis of the right knee with a varus deformity, mild effusion and reduced range; alternatives to consider are a torn meniscus if there is intermittent locking, and a stress fracture if bone pain predominates."

Rheumatoid hands (spoken). "A 46-year-old woman reports symmetrical small-joint pain with prolonged morning stiffness. On inspection there is ulnar deviation at both MCP joints, boutonniere deformity of the left ring finger and Z-thumb on the right, with thin skin. Palpation shows warm, tender 2nd to 5th MCP joints with synovial swelling, a positive MCP squeeze bilaterally, and rheumatoid nodules at both elbows. Flexion and extension of the fingers is limited by pain. Grip is reduced on both sides and wrist extension is restricted. In summary, active polyarticular synovitis in a rheumatoid pattern involving the MCPs and PIPs, with extra-articular nodules and deformity; alternative diagnoses include psoriatic arthritis if there are skin or nail changes, and systemic lupus erythematosus if there is a malar rash or serositis."

Acute hot joint (spoken). "A 52-year-old man has a painful, swollen right knee for one day, with fever and shaking. Inspection shows a swollen, erythematous knee held in slight flexion with an antalgic gait. Palpation is hot and exquisitely tender, and a large effusion is present on patellar tap. The hip and ankle are normal, there is no rash and the first MTP is normal. Passive range is severely reduced by pain and Lachman is difficult to assess. In summary, an acute monoarthritis of the right knee with systemic upset; the emergency differential is septic arthritis, which must be excluded before gout or an inflammatory flare, and the joint needs aspiration and culture."

• Doing the whole regional examination before screening the whole patient, so a second region is missed.
• Not warming hands, or palpating through clothing.
• Pressing the painful area first, losing cooperation.
• Recording ranges without comparing sides or without saying how they were measured.
• Performing special tests before looking and feeling, so you do not know what you are testing.
• Relying on one special test; most have poor or moderate diagnostic accuracy, and McMurray in particular is no longer recommended in the UK.
• Calling a negative squeeze test "normal small joints" without including inflammatory features from the history.
• Missing gait, footwear, muscle wasting and aids in the inspection phase.
• Confusing active and passive loss of range: passive loss suggests capsular or mechanical disease, active loss without passive loss suggests weakness or pain inhibition.
• Forgetting to screen the joint above and below the painful one.
• Using active tests in an acute hot joint instead of aspirating early.
• Presenting findings in the order found instead of leading with the one that determines management.

• Screen the whole locomotor system with GALS in about three minutes before focusing on a joint.
• GALS has three screening questions, then gait, arms, legs and spine; include the TMJ when indicated.
• Sequence every regional examination as look, feel, move, then special tests, with comparison to the other side.
• Inflammatory arthritis is warm, swollen and stiff after rest, often symmetrical in small joints; mechanical pain is use-related with brief stiffness.
• Effusions are assessed with patellar tap for moderate-to-large and the sweep test for small amounts.
• Deformity, wasting, temperature and skin are inspected before moving the joint.
• Special tests support a clinical impression; most have limited diagnostic accuracy individually.
• Lachman at about 30 degrees and the anterior drawer at about 90 degrees test the anterior cruciate ligament; posterior drawer and posterior sag test the posterior cruciate ligament; McMurray tests the menisci but is not recommended in the UK.
• Schober testing uses 5 cm below and 10 cm above the posterior superior iliac spines, with an increase from 15 cm to more than 20 cm in normal lumbar flexion. ^[8][9]
• A positive straight leg raise is pain in the posterior thigh or buttock, suggesting sciatic nerve irritation.
• True and apparent leg length are measured differently and tell you different things.
• Rheumatoid hands show ulnar deviation, boutonniere, swan neck, Z-thumb and boutonniere deformities with MCP and PIP synovitis and nodules; osteoarthritic hands show Heberden and Bouchard nodes.
• Present with the headline first, then regional and screening findings with numbers, then the negatives that matter, then a summary and differential.