Assessment of the rheumatological patient
Rheumatological
examination
Jane E Dacre
Jennifer G Worrall
Abstract
The locomotor system is extensive and locomotor problems are com-
mon. The most efficient and effective way to examine the locomotor
system is to perform a screening examination, the GALS (gait, arms, legs,
spine) screen, followed by a more detailed examination of any abnormal
findings. This detailed, regional examination of individual joints follows
the principles of ‘look, feel, move, function’.
Keywords GALS; rheumatological examination; locomotor; musculoskeletal
The locomotor system can be difficult to examine because it
involves many different anatomical structures. A full examina-
tion is time-consuming and seldom necessary. Most rheumatolo-
gists perform a short screening examination followed by a more
detailed assessment of the affected structures, with additional
examination of other systems if indicated. A screening exami-
nation of the locomotor system should be included as part of
the routine checking of all patients. This contribution outlines
the GALS (gait, arms, legs, spine) screen, which is a quick, reli-
able screen of the locomotor system, and describes more detailed
examination of the lumbar spine, hip, knee, shoulder, elbow,
hand and wrist, which are the most common sites for symptoms
of locomotor disease. An abnormal finding on the GALS screen
should lead to a more detailed examination of the affected joint.
A consensus view of the regional examination of the musculosk-
eletal system (REMS) has now been agreed.
Anatomy and physiology of the locomotor system
The locomotor system comprises bones, joints and muscles with
associated ligaments, tendons and bursae. The principal types
of joint are fibrous and synovial. Synovial joints permit a wide
range of movement. Fibrous joints have a simpler structure than
synovial joints and are less susceptible to disease and injury; the
Jane E Dacre FRCP is Professor of Medical Education and Director of
the Academic Centre for Medical Education at the Royal Free and
University College Medical School, London, UK, and Consultant
Physician and Rheumatologist at the Whittington Hospital, London.
Conflicts of interest: none declared.
Jennifer G Worrall FRCP is Consultant Rheumatologist at the Whittington
Hospital, London, UK. She qualified from the Royal Free Hospital,
London, and trained in general medicine and rheumatology. Conflicts
of interest: none declared.
MEDICINE 34:9
bones are connected by dense fibrous tissue and only a small
range of movement is permitted.
In a synovial joint (Figure 1), the bone ends are covered by
hyaline cartilage and the whole structure is enclosed in a cap-
sule. The capsule is lined with synovium – a specialized tissue
responsible for lubricating the joint and nourishing the articu-
lar cartilage, which has no blood supply of its own. Synovium
produces synovial fluid by a combination of ultra-filtration of
plasma and active secretion of large molecules (e.g. hyaluronan).
Normal synovial fluid is highly viscous because of entanglement
of these molecules, whereas inflammatory synovial fluid has a
low viscosity because the enzymes and free radicals associated
with inflammation break them down.
The two main causes of arthritis are degeneration and inflam-
mation. In degenerative disease (osteoarthritis), the articular
cartilage becomes dehydrated, thin and fibrillated. Abnormal
mechanical stress is transmitted to the underlying bone, which
remodels, becoming sclerotic and forming osteophytes at the
joint margins. Inflammatory disease (e.g. rheumatoid arthritis,
RA) is characterized by primary inflammation of the synovium
(synovitis), which damages the articular cartilage and bone,
leading to bony erosion. Synovium also lines the tendon sheaths
and bursae, which may be involved in the disease process.
Tendons, ligaments and fascial structures are attached to
the periosteum by a specialized structure called the enthesis.
Ankylosing spondylitis and related inflammatory arthritis are
­associated with inflammation of the enthesis. Plantar fasciitis is
an enthesitis.
Structure of a synovial joint
Muscle
Bone
Bursa
Synovium
Cavity
(joint space)
containing
synovial fluid
Hyaline cartilage
Tendon
Joint capsule
Enthesis
Structures in bold may give rise to pain or tenderness
Figure 1
340 © 2006 Published by Elsevier Ltd.
 Assessment of the rheumatological patient

GALS screen
Preliminary assessment using the GALS screen identifies most
locomotor system problems. These problems can then be charac-
terized in more detail using a regional examination. A method for
recording the results of the GALS screen is shown in Table 1.
With the patient undressed to his or her underwear, look
from the front, back and sides for any asymmetry or deformity
such as unequal leg length, flexion deformity at hip or knee, or
abnormality of spinal curvature (e.g. kyphosis, scoliosis, loss of
lumbar lordosis).

Gait
Ask the patient to walk a few steps, turn around and walk back.
Observe whether he or she swings the arms and moves the legs
symmetrically. The fluidity of the normal gait may be lost when
a patient experiences pain, because persistent muscle contraction
splints the painful part.
In an antalgic gait, the patient avoids bearing weight on
the painful leg or foot and spends most of the gait cycle on the
un­affected leg. If the gait is normal, the patient is unlikely to
have any major locomotor problems in the legs or lumbar spine.
Arms
• Ask the patient to hold out the hands, palms down. Inspect
the arms for obvious abnormalities (e.g. swelling, deformity,
nodules). Inspect the hands for skin or nail changes that may
be associated with arthritis (e.g. the scaly rash or onycholysis
of psoriasis (Figure 2), the digital vasculitis of systemic lupus
erythematosus, the colour changes of Raynaud’s disease).
• Ask the patient to turn the hands over. This assesses the ­radio-
ulnar joint, which is commonly affected in RA (Figure 3). Ensure
that the elbows are tucked in to the trunk to prevent the patient
using his or her shoulders to reproduce this movement. Inspect
the palms, looking for signs such as Dupuytren’s contracture and
thenar wasting.
• Ask the patient to make a tight fist with each hand (Figure 4)
and check that the fingers flex fully into the palms. Power of grip
can be assessed by offering the index and middle fingers of your
hands and asking the patient to grip your fingers tightly.
• Ask the patient to place the tip of the index finger onto the
tip of the thumb. This assesses opposition of the thumb and fine
movements, which are often limited in RA.
• Squeeze across the hand from the second to the fifth meta-
carpophalangeal joints, to assess tenderness.
Figure 2 Onycholysis in psoriatic arthritis.
• Ask the patient to put the hands behind the head, pressing the
elbows back (Figure 5). This movement assesses abduction and
external rotation at the shoulders and flexion at the elbows, and
is of functional importance in combing the hair.
Legs
• With the patient lying supine on the couch, inspect for flexion
deformity at the hip or knee, then passively flex the hip and knee
with a hand placed over the knee. Assess knee flexion while feel-
ing for crepitus and assessing hip flexion.
• Passively internally rotate the hip with the knee and hip
still flexed (Figure 6). Internal rotation is the first movement to
­become restricted in hip disease.
• Ask the patient to dorsiflex, extend, invert and evert the ­ankle
to assess tibiotalar movement (affected by osteoarthritis) and
subtalar movement (affected by RA).
• Squeeze across the foot at the level of the metatarsophalan-
geal joints, looking for tenderness.
• Inspect the feet for callosities from the end of the bed.
Spine
• With the patient standing, ask him or her to put the ear on the
shoulder on the same side, keeping the shoulder still (Figure 7).
This assesses lateral flexion of the cervical spine, which is the
first movement to become restricted in degenerative or inflam-
matory disease.

Record of the GALS locomotor system screening

examination in a normal patient

Appearance Movement

G – gait ✓ ✓
A – arms ✓ ✓
L – legs ✓ ✓ Figure 3
S – spine ✓ ✓ Assessment
of radio-ulnar
Table 1 function.

MEDICINE 34:9 341 © 2006 Published by Elsevier Ltd.

 Assessment of the rheumatological patient
Figure 4 Making a tight fist to assess hand power and function.
• Place two of your fingers over adjacent spinous processes in
the lumbar region and ask the patient to bend over and touch the
toes. Your fingers should move apart. This is an essential part of
the assessment of the lumbar spine because patients with a rigid
spine caused by ankylosing spondylitis may be able to touch
their toes without moving the spine if they have supple hips.
Joint examination for common symptoms
If abnormalities are found using the GALS screen, a more
detailed examination, or REMS, (‘look, feel, move, function’) of
the abnormal joints should be performed.
• Look for swelling and deformity.
• Feel to assess whether swelling is soft (soft tissue or fluid) or
hard (bony) and, if it is soft, whether it is warm or cool.
• Move the joint to assess range of movement and instability.
Do not worry if you cannot remember the range of movement of
all the joints. If the problem is unilateral, you can compare the
abnormal side with the normal side; if it is bilateral, compare it
with your own joints.
• Assess the joints for function.
Figure 5 Assessment of abduction and external rotation of the
shoulders.
MEDICINE 34:9
Figure 6 Flexion of the knee with internal rotation of the hip.
Neck and back pain
The lumbar spine should be examined with the patient standing,
then supine and then prone.
Standing: look at the curvature of the spine. Scoliosis may be
caused by muscle spasm in acute sciatica or may be postural if
the patient’s legs are of unequal length. Loss of normal lordosis
is a sign of inflammatory spinal disease (e.g. ankylosing spondy-
litis). Palpate the erector spinae muscles to assess spasm.
Ask the patient to lean to each side in turn and run his or her
hand down the side of the leg to the knee; this assesses lateral
flexion, which is often the first movement to become restricted in
spinal disease. Then ask the patient to lean backwards to assess
extension. Painful extension suggests facet joint disease (usually
degenerative). It is helpful to place your hands lightly on the
patient’s shoulders when assessing lateral flexion and extension;
this gives patients confidence that you will support them if they
feel unsteady.
Ask the patient to lean forwards to assess flexion. Start by
placing two fingers on the spine, one finger about 5  cm below
the lumbosacral junction and one finger about 10  cm above. As
the patient bends forwards, watch how your fingers move apart.
This is the modified Schober’s test.
Figure 7
Assessment of
lateral flexion of
the neck.
342 © 2006 Published by Elsevier Ltd.
 Assessment of the rheumatological patient
Percuss the spine gently with the side of your closed fist. This
may elicit local tenderness in patients with metastases or infec-
tion in the bone.
Assess cervical spine movements by asking the patient to
bring their ear towards each shoulder in turn (Figure 7), then
turn their head to look over each shoulder, then put their chin on
their chest, then look up at the ceiling.
Supine: with the patient on the couch, assess movements at
both hips (see below) before performing the sciatic stretch
test – straight-leg raising may be restricted by hip disease in
addition to muscle spasm in sciatica.
To assess straight-leg raising, lift the leg from underneath
the ankle (not by grasping the leg from above, which can cause
pain), keeping the knee extended. When the limit is reached,
perform the sciatic stretch test by passively dorsiflexing the ankle
(Figure 8). The test assesses irritation of the lower lumbar and
upper sacral nerve roots (L5–S1). If the patient complains of sen-
sory disturbance (pain, pins and needles or numbness) anywhere
below the knee, the test is positive. Pain in the lumbar spine or at
the back of the knee, usually caused by tight hamstrings, is not
relevant to the test.
Gaenslen’s test should be performed with the patient supine;
this stresses the sacroiliac joints and provokes pain in the affected
joint when sacroiliitis is present. To perform the test, passively
flex the hip and knee on one side, bringing the knee onto the
patient’s trunk, then externally rotate and abduct the hip. While
holding the leg in this position, grasp the contra-lateral iliac crest
and attempt to distract it laterally. This stresses the sacroiliac
joint on that side and, if the joint is inflamed, the patient com-
plains of pain in the low back, over that joint.
A brief neurological examination of the legs should also be
performed with the patient supine (see MEDICINE 32:9: 27–30).
Prone: ask the patient to turn over, remove the pillow from the
head of the couch and place it under the pelvis and abdomen.
This slightly flexes the lumbar spine and is a comfortable ­position
for the patient.
Sciatic stretch
b Femoral stretch
Lift the leg with the knee flexed and then extend the knee (a);
in patients with sciatic root irritation, this induces pain. Lift the
straight leg to induce pain and confirm root irritation by lowering
the leg slightly then dorsiflexing the ankle (b).
Figure 8
MEDICINE 34:9
Palpate down the spinous processes in turn and along the
erector spinae muscles to assess tenderness, then perform the
femoral stretch test (Figure 9) to assess irritation of the upper
lumbar nerve roots (L2 and L3), which contribute to the femo-
ral nerve. Passively flex the knee and, holding the foot, gently
extend the hip. If this provokes spasm of the quadriceps and the
patient complains of sensory disturbance over the front of the
thigh, the test is positive.
Hip pain
Disease of the hip joint causes pain in the groin that may radiate
down the anterior thigh to the knee. There may be associated
muscle wasting on inspection. Pain over the lateral pelvis and
thigh generally results from trochanteric bursitis, whereas pain
in the buttock may be caused by ischial bursitis, sacroiliitis or
lumbar spine disease.
To assess the hip joints, ask the patient to lie supine on the
couch. Look for flexion deformity at the hip. The hip joints are
deep and cannot be palpated directly. Trochanteric bursitis, how-
ever, can be identified by an area of tenderness over, and distal
to, the greater trochanter. Assess flexion at the hip with the knee
flexed to relax the hamstrings, then assess internal and external
rotation in flexion (Figure 6); internal rotation is often restricted
early in hip disease. Place the hip in the neutral position, extend
the knee, and abduct and adduct the hip in turn (take care in
patients who have undergone hip replacement, because forced
adduction may cause dislocation). Extension is assessed by
hanging the leg over the side of the couch or with the patient in
the prone position.
Perform Thomas’s test by placing one hand under the patient’s
lumbar spine and fully flexing one hip. Look at the opposite leg
which will lift off the couch if there is a fixed flexion deformity
at the hip.
Knee pain
Ensure that the patient is sitting propped up on the couch with
the knees extended and the legs relaxed. Look for flexion defor-
mity and for valgus and varus deformities. Look at the quadri-
ceps muscles, which may be wasted in significant knee disease.
With the patient prone, flex the knee to 90˚ (a) then lift the leg (b)
passively extending the hip. If the test is positive, pain is felt over
the anterior thigh.
Figure 9
343 © 2006 Published by Elsevier Ltd.
 Assessment of the rheumatological patient
Look for swelling. Normal knees have a hollow on the side of
the patella; disappearance of this in patients with a large effusion
causes obvious suprapatellar swelling (Figure 10). The infrapa-
tellar fat pads may be prominent but are normal. Depress the
patella with your fingertips; when the pressure is released, it
bounces up (the patella tap) when a large effusion is present. A
small effusion may be detected by the ‘bulge’ test. Empty the hol-
low next to the medial aspect of the patella by stroking it firmly,
then push with the flat of your hand against the lateral aspect
of the knee. If the medial hollow is filled by a bulge, an effusion
is present (the normal knee contains only 1–2  ml of fluid, insuf-
ficient to cause a bulge).
Feel the knee for warmth and palpate the popliteal fossa for
swelling, which is most often caused by a Baker’s cyst. Effusions
and Baker’s cysts are most commonly found in inflammatory dis-
ease, but may also occur in osteoarthritis of the knee.
Flex and extend the knee to its fullest extent in both direc-
tions, with your hand placed on the knee to feel for crepitus. Lift
the foot off the couch to look for hyperextension beyond 10°; this
is a feature of hypermobility syndrome and is commonly associ-
ated with mechanical knee pain. Assess stability by attempting to
stretch the knee medially and laterally while holding it in a few
degrees of flexion. If there is abnormal movement, the collateral
ligaments are lax.
Examine the anterior cruciate ligament using the Lachman
test. Pull the tibia forwards on the femur with the knee flexed at
20–30°. Anterior movement suggests anterior cruciate instability.
The anterior and posterior cruciate ligaments can also be tested
by flexing the knee and stabilizing the foot on the bed. Hold
the knee circumferentially just below the joint, with the thumbs
anteriorly. Pull forwards to test the integrity of the anterior cruci-
ate ligament, then push to test the posterior cruciate ligament.
Instability is revealed as abnormal movement of the tibia in an
anterior or a posterior direction.
Shoulder pain
Shoulder pain has many causes. Pain from the glenohumeral
joint (the shoulder joint proper) radiates to the front and side
of the upper arm. Pain over the top of the shoulder suggests
acromioclavicular joint disease, which is confirmed by point
tenderness over the joint and pain on forced extension of the
shoulder.
Figure 10 Suprapatellar swelling.
MEDICINE 34:9
With the patient sitting and facing you, observe the shoulders
for asymmetry and swelling. Effusions point anteriorly. Palpate
the capsule over the anterior humeral head and the supraspina-
tus tendon over the lateral upper humerus for tenderness. Assess
flexion, extension, abduction, adduction and internal and exter-
nal rotation actively and passively. In glenohumeral joint disease
such as adhesive capsulitis and RA (degenerative disease of this
joint is not common), passive and active movements are equally
restricted. In contrast, disease of the rotator cuff (e.g. calcific
tendinitis, degenerative rupture) causes restricted active move-
ments, but passive movements remain full.
Painful arc syndrome is a feature of rotator cuff disease. It
is detected by asking the patient to raise the arms above the
head, close to the ears, with the palms turned outwards (i.e.
with the shoulders internally rotated), then asking him or her
to slowly lower the arms sideways. Increased pain, caused by
compression of the inflamed tendon between the acromion and
the rotating humeral head, occurs at some point in the arc of
movement.
Elbow pain
The elbow is seldom affected by degenerative disease but is often
involved in inflammatory arthritis, particularly rheumatoid.
Carefully inspect the extensor aspect of both elbows; this is a
common site for psoriasis, gouty tophi and rheumatoid nodules,
and an inflamed olecranon bursa may be found. Elbow effusions
may be detected by loss of the gutters normally present between
the olecranon and the medial and lateral epicondyles respec-
tively. Ask the patient to hold the arms out sideways with the
elbows fully extended and look for flexion deformities, then ask
him or her to bend the elbows fully. The radio-ulnar joint has
been assessed in the GALS screen, but if pronation or supination
is painful or restricted, ask the patient to repeat the movement
while you palpate the radial head on the lateral side of the elbow;
you may feel crepitus.
Pain in the hand and wrist
The hand is examined in detail in the GALS screen (see above),
but the following tests should also be performed.
When examining the hands, stand in front of the patient and
examine both hands simultaneously, comparing the two sides.
When you ask patients to hold out their hands, ensure they
Figure 11 Dropped fingers in rheumatoid arthritis as a result of
extensor tendon rupture.
344 © 2006 Published by Elsevier Ltd.
 Assessment of the rheumatological patient

spread their fingers and do not rest their hands on their knees; Doherty M, Dacre J, Dieppe P, Snaith M. The ‘GALS’ locomotor screen.
you will otherwise miss minor degrees of flexion deformity of the Ann Rheum Dis 1992; 51: 1165–9.
fingers and the dropped fingers characteristic of extensor tendon
rupture (Figure 11).
Pain in the fingers may be a result of osteoarthritis; look for
bony swellings on the distal interphalangeal joints (Heberden’s
nodes) and the proximal interphalangeal joints (Bouchard’s Acknowledgement
nodes). Pronounced soft tissue swelling of these joints indicates
inflammatory arthritis. Severe inflammatory arthritis (e.g. rheu- The authors thank Manson Publishing, London, UK for photographs
matoid, psoriatic) with marked bone loss may lead to ‘telescop- of the GALS screen, and the Photography and Illustrations Centre at
ing’ of the fingers, with redundancy of the soft tissues, and to the Archway Campus, Royal Free and University College London, UK.
flail joints, which have lost all integrity. A combination of fixed
joints (caused by bony ankylosis) and flail joints is characteristic
of psoriatic arthritis.
Also assess hand function. Ask the patient to write his or her
name, to fasten and unfasten buttons, and to hold a cup and
bring it to the lips. ◆ Practice points

• A full examination is time-consuming and seldom

Further reading
Coady D, Walker D, Kay L. Regional examination of the musculoskeletal
system (REMS). A core set of clinical skills for medical students.
Rheumatology 2004; 43: 633–9.
Dacre J E, Kopelman P. A Handbook of clinical skills. London: Manson,
2002.
(A guide to history-taking and examination of all systems.)
necessary
• Most rheumatologists perform a short screening examination
(e.g. GALS)
• If an abnormality is detected during the screen, a regional
examination must be performed
• Follow the ‘look, feel, move, function’ protocol

MEDICINE 34:9 345 © 2006 Published by Elsevier Ltd.