Easy Musculoskeletal Assessment for GPs: The GALS Method

1. Easy assessment of musculoskeletal system for GPs Aspects of examining the musculoskeletal system

2. Revisiting the basics • GALS • Video • Some bits and pieces / a personal view

3. History • “Have you any pain or stiffness in your muscles, joints or back?” • “Do you have any trouble getting up or down stairs?” • “Do you have any difficulty getting dressed?”

5. Revisiting the basics • Inspection Look • Palpation Feel • Movement Move • Stability • Function • Compare with opposite side

6. Inspection • Skin colour / rashes • Swelling • Deformity • Scars • Muscle wasting • Surrounding structures - bursae, tendons

7. Palpation • Nature of swelling • bony • synovial • effusion • Warmth • Tenderness

8. Movement • Active and passive • Range of movement • Crepitus • Note pain • Instability

9. Stability • Subluxation or dislocation • MCP • Radioulnar • subtalar • MTP

10. Function • Lower limbs - gait • Hands • pincer grip • power grip

12. Doherty, Dacre, Dieppe and Snaith (1992) The GALS locomotor screen, Annals of Rheumatic diseases 51: 1165-9 GAIT ARMS LEGS SPINE G A L S

13. G A L S • “…provide a valuable screening test for use in general practice” • “the procedure can be viewed as a general functional (disability), as well as a basic musculoskeletal assessment” • “..be useful in selective situations as a rapid test of functional performance and to screen out regional locomotor abnormalities that merit closer scrutiny”

14. GALS recording

16. Hands Wrists - CTS + de Q Shoulders Backs Hips Feet - biomechanics Hypermobility Fibromyalgia Bits and pieces

17. Hand - RA

18. Early synovitis • PIP - skin discolouration and tenderness • Clench fist - MCPs should be white with no infilling • MCP squeeze to elicit tenderness • Inferior radio ulnar stress test • Bulge sign at knee • MTP squeeze test

19. Hand OA

20. Raynauds 1

21. Raynauds 2

22. Scleroderma early

23. Scleroderma

24. Sclerodactaly (acrosclerosis)

25. Carpal Tunnel Syndrome • Phalen’s • Tinel’s

26. De Quervains tenosynovitis • APL and EPB tendons • tender over radial styloid • sometimes nodule (thickened sheath) • Finkelsteins test • Rest it • Inject it

27. Shoulders • Shoulder or not • Glenohumeral or not - external rotation • Tenderness • bicipital groove • subacromial • Painful arc of abduction

28. Shoulder - abduction

29. Shoulder function related to abduction

30. Backs • Lumbar flexion • Modified Schobers - or use your fingers • Fingers to floor = misleading • Lumbar extension • Lumbar lateral flexion • “Sacroiliac restriction”

31. Backs - neurology

32. Hips • Internal rotation - can examine sitting • Trochanteric bursitis • Trendelenburg - to distinguish lumbosacral from hip pain

33. Trendelenburg test

34. Foot - biomechanics • Swing phase • Stance phase • Contact (27%) • Midstance (40%) • Propulsive (33%)

35. Biomechanics - stance phase • Contact • outer border heel strikes then • PRONATION at subtalar joint shifts centre gravity medially • causes tibia to internally rotate • purpose is shock absorption/adaption uneven ground

36. Biomechanics - stance phase (2) • Midstance • forefoot loaded • subtalar joint supinates • causes tibia to externally rotate • foot is converted to rigid lever ready for propulsion • ends with heel lift

37. Biomechanics - stance phase (3) • Propulsion • app 25% bodyweight on metatarsals and toes (esp 1st) • ends with toes off

38. Abnormal pronation and supination

39. Subtalar pronation unchecked longitudinal arch stretches and flattens excess rotation of tibia Hallux valgus Plantar fasciitis Achilles tendonitis Post tibial tendonitis stress# navicular anterior knee pain low back pain Over pronation

40. Hypermobility • Dorsiflexion of 5th MCP to 90 degrees • Apposition of thumb to volar aspect of forearm • Hyperextension of elbow by 10 degrees • Hyperextension of knee by 10 degrees • Hands flat on floor with knees extended

41. Fibromyalgia

42. The End