GALS Screening Examination OSCE — Gait, Arms, Legs, Spine with Three Screening Questions

Why GALS Is Tested

The GALS (Gait, Arms, Legs, Spine) screen is a validated, rapid musculoskeletal examination that takes approximately 2-3 minutes to perform. It was developed to allow efficient identification of musculoskeletal abnormalities in a clinical setting, particularly in primary care and general medicine. It is widely taught in UK medical schools and frequently appears as an OSCE station, often paired with a clinical vignette (e.g., a patient presenting with joint pain, fatigue, or rheumatoid arthritis).

The Three Screening Questions

Always begin the GALS screen with these three standard questions:

1. 1*"Do you have any pain or stiffness in your muscles, joints, or back?"*
2. 2*"Can you dress yourself completely without any difficulty?"*
3. 3*"Can you walk up and down stairs without any difficulty?"*

A "no" answer to all three questions and a normal physical examination constitutes a normal GALS screen. Document it as such.

Screening Examination — Overview

The GALS screen examines four domains:

G — Gait

Ask the patient to walk away from you, turn, and walk back. Observe:

• Smoothness: antalgic gait (shortened stance = pain), Trendelenburg gait (abductor lurch)
• Symmetry: leg length discrepancy, foot drop (high-stepping gait)
• Turning: ability to turn quickly and safely
• Arm swing: reduced unilaterally = shoulder pathology; reduced bilaterally = Parkinson's disease

What to say: *"Could you walk to the end of the room, turn around, and walk back for me please?"*

A — Arms

Hands and Wrists

Ask the patient to:

1. 1Extend the hands palm-down — inspect for rheumatoid deformities (ulnar deviation, swan neck, boutonnière), psoriatic changes, Heberden's and Bouchard's nodes (OA), wasting of intrinsic muscles
2. 2Turn hands over (supination) — check range of wrist movement and look for palmar erythema, Dupuytren's contracture
3. 3Make a fist — assess grip strength
4. 4Perform a precision pinch (touch each finger to thumb in sequence) — dexterity and fine motor
5. 5Squeeze across the MCP joints — note pain (positive squeeze test) — sensitive for early RA

Elbows

Ask the patient to extend the elbows fully — loss of full extension = effusion or OA. Look for rheumatoid nodules, psoriatic plaques on extensor surfaces, gouty tophi.

Shoulders

Ask the patient to:

1. 1Place both hands behind their head (external rotation + abduction) — *"Put your hands behind your head like this"*
2. 2Note any restriction or pain

L — Legs

Hip

Ask the patient to:

1. 1Flex the hip to 90° while supine (hold the knee and lift)
2. 2Then internally rotate the hip (move foot outward, knee inward)
3. 3Pain or restriction = hip pathology (OA, avascular necrosis, inflammatory arthritis)

Knee

1. 1Passive flexion — hold the knee and heel, fully flex
2. 2While flexing, feel for crepitus with the other hand over the patella
3. 3Extend fully — check for fixed flexion deformity
4. 4Inspect for swelling, effusion, valgus/varus deformity
5. 5Patellar tap: test for effusion if swelling is present

Ankle and Foot

1. 1Dorsiflex the ankle — normal range ~20° from neutral; restricted in OA or posterior tibial tendon dysfunction
2. 2Squeeze the metatarsal heads (MTP joints) — positive if painful, indicates MTP synovitis (RA, gout)
3. 3Inspect the soles: callosities (altered gait mechanics), rash (keratoderma blennorrhagica in reactive arthritis), vesicles (psoriasis)

S — Spine

Cervical Spine

Ask the patient to:

1. 1Rotate the head left and right — normal 70-80° each way; restriction suggests cervical OA or inflammatory spondylarthropathy
2. 2Tilt the ear to each shoulder — lateral flexion

Lumbar Spine

1. 1Forward flexion: ask the patient to bend forward and try to touch their toes — observe lumbar curve (flattening = ankylosing spondylitis or OA). Measure fingertip-to-floor distance. Alternatively use Schober's test: mark 10 cm above and 5 cm below the lumbosacral junction — should increase by ≥5 cm on full forward flexion
2. 2Lateral flexion: slide hands down the side of each thigh toward the knee
3. 3Check for paravertebral muscle spasm or tenderness

Documenting the GALS Screen

Document as: G A L S followed by normal (N) or abnormal (A) for each domain.

Example: G(N) A(A) L(A) S(N) — abnormal arms and legs, normal gait and spine.

Describe the abnormality: *"The GALS screen was abnormal. There was restriction of internal rotation of both hips with crepitus on flexion, consistent with bilateral hip OA. The knee showed a moderate effusion on the right with crepitus. The remainder of the screen was normal."*

Common Findings and Their Significance

Completing the Examination

*"This concludes the GALS screen. The screen shows an abnormality in [region]. I would now proceed to a detailed examination of [region], obtain a full rheumatological history including morning stiffness duration, family history, and extra-articular features, and request baseline investigations including FBC, ESR, CRP, RF, anti-CCP, and plain radiographs of the affected joints."*

Common Mistakes

• Forgetting to ask the three screening questions before the physical examination
• Not squeezing the MCP joints (most commonly omitted step)
• Omitting the foot/MTP squeeze
• Failing to state the screen is a screen, not a detailed examination
• Not documenting findings in the standard G A L S format

Examiner Tips and Mark Scheme Pointers

Mark schemes typically award points for:

1. 1Three screening questions asked
2. 2Gait observation with correct commentary
3. 3Arms: hand extension, fist, pinch, MCP squeeze, shoulder abduction
4. 4Legs: hip internal rotation, knee flexion and crepitus, MTP squeeze
5. 5Spine: cervical rotation, lumbar flexion
6. 6Appropriate documentation of findings
7. 7Statement that detailed regional examination would follow

Frequently Asked Questions

"What are the three GALS screening questions and why must they be asked before the physical examination?"

The three standard GALS screening questions are: (1) "Do you have any pain or stiffness in your muscles, joints, or back?"; (2) "Can you dress yourself completely without any difficulty?"; and (3) "Can you walk up and down stairs without any difficulty?" They must be asked before examining because they direct your attention to potential abnormalities and form part of the validated screening tool. A normal GALS screen is only documented as normal if all three questions are answered with "no" AND the physical examination is unremarkable. Missing the questions is one of the most heavily penalised errors in this station.

"What is the MCP squeeze test and why is it the most commonly omitted step in the GALS screen?"

The MCP (metacarpophalangeal joint) squeeze test involves squeezing across all four MCP joints simultaneously from the medial and lateral sides. Pain on squeezing is a positive test, indicating MCP synovitis — the hallmark of early rheumatoid arthritis. It is the most commonly omitted step because candidates focus on visual inspection and forget the palpation component. A positive squeeze test in the context of ulnar deviation, swan neck deformity, and early morning stiffness strongly supports a diagnosis of rheumatoid arthritis.

"How is the GALS screen documented and what does an abnormal result mean in practice?"

Document the GALS screen using the format G A L S with N (normal) or A (abnormal) for each domain — for example, G(N) A(A) L(A) S(N) indicates abnormal arms and legs with normal gait and spine. An abnormal result does not provide a diagnosis — it identifies which region requires a detailed examination. Always state to the examiner: "This GALS screen is abnormal. I would now perform a detailed examination of [the affected region], beginning with [appropriate detailed test]." This shows you understand the hierarchical role of the screen.

"What finding in the lumbar spine assessment should make you consider ankylosing spondylitis?"

Restricted lumbar forward flexion with loss of the normal lumbar lordosis — particularly in a young male with a history of inflammatory back pain (worse at rest, better with exercise, morning stiffness lasting more than 30 minutes) — should raise strong suspicion for ankylosing spondylitis (axial spondyloarthritis). The Schober's test quantifies lumbar flexion: marks are placed 10 cm above and 5 cm below the lumbosacral junction — the distance should increase by at least 5 cm on full forward flexion. An increase of less than 5 cm is positive. Mention HLA-B27 and sacroiliac joint X-ray/MRI as investigations.

"Why is the shoulder assessment in the GALS screen so important and what is the single most sensitive manoeuvre?"

The single most sensitive screening manoeuvre for shoulder pathology is asking the patient to place both hands behind their head — this combines abduction, external rotation, and flexion simultaneously. A patient who cannot do this has significant restriction in at least one of these planes. Common causes include rotator cuff pathology, glenohumeral OA, and adhesive capsulitis (frozen shoulder). Identifying bilateral versus unilateral restriction helps narrow the differential. Candidates who omit shoulder assessment in the arms section of GALS consistently lose marks.

"What is the difference between a GALS screen and a detailed regional examination, and when must you perform each?"

The GALS screen is a validated 2-3 minute rapid assessment tool designed to detect the presence or absence of musculoskeletal abnormalities — it does not provide sufficient detail to characterise pathology. If the GALS screen is abnormal, a detailed regional examination of the affected area is required: for an abnormal arm result, this means a detailed hand, wrist, elbow, and shoulder examination; for abnormal legs, a detailed hip and knee examination. In an OSCE, you will typically be asked to perform the GALS screen and then indicate which detailed examination you would proceed to — both steps are mark-scorable.

Related guides: Knee Examination OSCE · Hip Examination OSCE · Hand Examination OSCE · Musculoskeletal History OSCE