PGALS

Pediatric Gait Arms Legs and Spine: a simple examination of the musculoskeletal system

Definition: pGALS (paediatric Gait, Arms, Legs and Spine) – a simple quick musculoskeletal
assessment to distinguish abnormal from normal joints in children and young people, pGALS is
an important part of basic clinical skills to be acquired by all doctors who may be involved in
the care of children.

Differences between pGALS and adult GALS exam

The pGALS examination sequence is much the same as the adult GALS assessment with some
additional maneuvers and amendments.
1. Further assessment of the foot and ankle: the child is asked to walk on their heels and
then on their tiptoes.
2. Assessment of the temporomandibular joints: the child is asked to insert three of their
fingers into their mouth.
3. Assessment of the elbow: the child is asked to “reach up and touch the sky”.
4. Assessment of the cervical spine: the child is asked to look up at the ceiling.
Advantages of pGALS:
Easy, rapid, acceptable, and quick!
1. More appropriate in children, with additional maneuvers included because when adult
GALS was originally tested in children with JIA, it missed significant abnormalities at the
foot and ankle, wrists and temporomandibular joints.
2. pGALS has been demonstrated to have excellent sensitivity to detect abnormality,
3. Incorporates simple maneuvers often used in clinical practice, and is quick to do, taking an
average of two minutes to complete
When to perform pGALS
• Unwell child with pyrexia
• Child with limp
• Delay or regression of motor milestones
• Child with chronic disease and known association with MSK presentations (such as
inflammatory bowel disease)
• The ‘clumsy’ child in the absence of neurological disease

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RED FLAGS (to raise concern about infection, or malignancy or non-accidental injury)
• Fever, systemic upset (malaise, weight loss, night sweats)
• Lymphadenopathy, hepatosplenomegaly
• Bone pain
• Persistent night waking
• Incongruence between history and presentation/pattern of physical findings

Steps of PGALS

• Wash your hands

• Introduce yourself to the parents and child including your name and role.
• Confirm the child’s name and date of birth.
• Briefly explain what the examination will involve using child-friendly language.
• Gain consent from the parents and child to proceed with the examination.
• Adequately expose the child (ideally the child should wear only shorts and
undergarments).
• Position the child standing.
• Throughout the pGALS assessment, you should adopt a “copy me” approach, where you
first demonstrate what you want the child to do and then ask them to copy you. This is
easier for the child to follow than a sequence of verbal instructions.
• Look for non-verbal clues of discomfort (e.g. grimacing) throughout the assessment.

Screening questions

Part of the pGALS assessment involves asking three screening questions to identify
potential joint pathology, fine motor impairment and gross motor deficits.

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 Questions

First question
“Do you have any pain or stiffness in your muscles, joints or back?”
This question screens for common symptoms present in most forms of joint
pathology (e.g. osteoarthritis, rheumatoid arthritis, ankylosing spondylitis).

Second question
“Do you have any difficulty getting yourself dressed without any help?”
This question screens for evidence of fine motor impairment and significant
restriction joint range of movement.

Third question
“Do you have any problem going up and down the stairs?”
This question screens for evidence of impaired gross motor function (e.g. muscle
wasting, lower motor neuron lesions) and general mobility issues (e.g. restricted
range of movement in the joints of the lower limb)

➢ Gait
1. Standard gait assessment
Ask the child to walk to the end of the examination room and then turn and walk back
2. Heel and tiptoe walking
Ask the child to walk across the examination room again but this time using their heels and then
again using their tiptoes.

➢ Arms
▪ Compound movements
1. Hands behind head
Ask the child to put their hands behind their head and point their elbows out to the side:
• This compound movement assesses shoulder abduction and external rotation in addition to
elbow flexion.
• Restricted range of movement is suggestive of shoulder or elbow pathology (e.g.,
osteoarthritis).
• Excessive range of movement indicates hypermobility.
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2. Hands held out in front with palms facing down
Ask the child to hold their hands out in front of them, with their palms facing down and fingers
outstretched:

• This compound movement assesses forward flexion of the shoulders, elbow extension, wrist
extension and extension of the small joints of the fingers.

3. Hands held out in front with palms facing up

Ask the child to turn their hands over (demonstrating supination):

• This compound movement assesses wrist and elbow supination.

• Restriction of supination is suggestive of wrist or elbow pathology (e.g., osteoarthritis).
Inspect the thenar and hypothenar eminences for evidence of muscle wasting.

4. Making a fist
Ask the child to make a fist whilst observing hand function:

• This movement assesses flexion of the small joints of the fingers as well as overall hand
function.
• The child may be unable to make a fist if they have joint swelling (e.g., inflammatory arthritis
or joint infection) or if they have other deformities of the small joints of the hands.
5. Precision grip
Ask the child to touch each finger in turn to their thumb (known as ‘precision grip’):

• This sequence of movements assesses co-ordination of the small joints of the fingers and
thumbs.
• It also assesses overall manual dexterity (which should be interpreted in the context of the
child’s age).
• Reduced manual dexterity may suggest inflammation or joint contractures of the small joints
of the hand.
6. Hands together palm to palm
Ask the child to put their hands together palm to palm:

• This movement assesses extension of the small joints of the fingers and wrists, in addition to
flexion of the elbows.
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• Restriction or asymmetry of movement is suggestive of joint pathology.
• An excessive range of movement suggests hypermobility.
7. Hands together back-to-back
Ask the child to put their hands together back-to-back:

• This movement assesses flexion of the wrist joints and elbow joints.
• Restriction or asymmetry of movement suggests joint pathology.
• An excessive range of movement suggests hypermobility.
8. Reaching upwards
Ask the child to reach upwards as far as they are able (as if trying to touch the sky), whilst keeping
their arms straight:
• This movement assesses elbow extension, wrist extension and shoulder abduction.
• Restriction or asymmetry of movement suggests joint pathology.
• An excessive range of movement suggests hypermobility.
9. Looking upwards

Ask the child to look up at the ceiling:

• This movement assesses cervical extension.

• Restriction of movement suggests joint pathology.

10.Metacarpophalangeal joint squeeze

Gently squeeze across the metacarpophalangeal (MCP) joints and observe for verbal and non-
verbal signs of discomfort. Tenderness is suggestive of active inflammatory arthropathy.

➢ Legs
Position the child lying down on the examination couch for further assessment of the lower limbs.
Active movement
Ask the child to bring each heel in turn towards their bottom:
• This movement assesses active knee flexion.

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Ask the child to straighten out each leg on the bed:
• This movement assesses active knee extension.
Passive movement
Passive movement refers to a movement of the child, controlled by the examiner. This involves
the child relaxing and allowing you to move the joint freely to assess the full range of joint
movement. It’s important to feel for crepitus as you move the joint (which can be associated with
osteoarthritis) and observe any discomfort or restriction in the joint’s range of movement.

Passive knee flexion

Normal range of movement: 0-140°
Instructions: Whilst supporting the child’s leg, flex the knee as far as you are able, making sure
to observe for signs of discomfort.
Passive knee extension
If the child can lay their legs flat on the bed, they are already demonstrating a normal range of
movement for knee extension. To assess for hyperextension:
1. On the leg being assessed, hold above the ankle joint and gently lift the leg upwards.
2. Inspect the knee joint for evidence of hyperextension, with less than 10° being considered
normal. Excessive knee hyperextension may suggest pathology affecting the integrity of the knee
joint’s ligaments or hypermobility.
Passive internal rotation of the hip
Normal range of movement: 40°
Instructions: Flex the child’s hip and knee joint to 90° and then rotate their foot laterally.
Patellar tap
The patellar tap test can be used to screen for the presence of a moderate-to-large knee joint
effusion.
1. With the child’s knee fully extended, empty the suprapatellar pouch by sliding your left hand
down the thigh to the upper border of the patella.
2. Keep your left hand in position and use your right hand to press downwards on the patella with
your fingertips.

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3. If there is fluid present you will feel a distinct tap as the patella bumps against the femur.
➢ Spine
Ask the child to stand upright for this part of the assessment. Inspection of the spine does not
need to be repeated if already performed.

Cervical lateral flexion

Assess lateral flexion of the cervical spine by asking the child to tilt their head to each side,
moving their ear towards their shoulder: “Try and touch your shoulder to your ear on each side.”

Lumbar flexion

Assess the range of lumbar flexion using your fingers to palpate for a normal range of movement
of the lumbar vertebrae (loss of lumbar flexion can be masked by good hip flexion, making
inspection without palpation less reliable):
1. Place two of your fingers on the lumbar vertebrae approximately 5-10cm apart.
2. Ask the child to bend forwards and touch their toes.
3. Observe your fingers as the child’s lumbar spine flexes (they should move apart).
4. Observe your fingers as the child extends their spine to return to a standing position (your
fingers should move back together).
➢ Temporomandibular joint
To assess the temporomandibular joint (TMJ) ask the child to open their mouth wide and put
three of their own fingers into their mouth (you can demonstrate using your own fingers and
mouth).
This maneuver assesses the temporomandibular joint’s range of movement and screens
for deviation of jaw movement.
Restricted jaw opening may be due to temporomandibular joint disease.

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Figure: Steps of pGALS

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Look for:

1. Asymmetrical changes
2. Muscle wasting (such as of the quadriceps or calf muscles) indicates chronicity of joint
disease (knee or ankle respectively).
3. Increased muscle bulk associates with types of muscular dystrophy, and proximal
myopathies
4. Ranges of joint movement
5. Lack of joint mobility
6. Joint inflammation like swelling, redness, hotness, and tenderness

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