1. Paediatric musculoskeletal (MSK) examination is unique and focuses on differentiating normal from abnormal findings. It relies on inspection, palpation, and assessment of range of motion. 2. The paediatric MSK evaluation includes observation, palpation, range of motion testing, strength testing, and functional assessment. It follows the "look, feel, move" approach. 3. The paediatric Gait, Arms, Legs, and Spine (pGALS) assessment is a simple and rapid screening tool to detect musculoskeletal problems in children. It involves observation of gait and movement of various joints followed by focused examination of affected areas.

1. PAEDIATRIC
MUSCULOSKELETAL
EXAMINATION
INCLUDING
P-GALS
SPEAKER: DR. ARNAB
NANDY
MBBS(H), MD
YUVA CME
W.B.A.P.

2. PRELUDE
• Paediatric musculoskeletal (MSK) examination stands out to be unique by its’
essence.
• The key is to differentiate NORMAL from ABNORMAL.
• Universal challenges: - Three way communication
- Age appropriate interpretation of results
• Manifestation of musculoskeletal problems: - Primary diseases
- Secondary afflictions
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3. • Importance of history taking before MSK examination:
- Ante-natal history
- Birth history
- Developmental history
- Family history
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Figure 1.
Figure 2.

4. SALIENT FEATURES
• It is of utmost importance to know the developmental status of the child.
• The status quo for MSK examination primarily relies upon:
– Inspection (Observation)
– Palpation (Functional assessment)
• Fundamental operational principle for MSK examination is based on:
“Look, Feel & Move”
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Foster H, Kay L, May C, Rapley T. Pediatric regional examination of the musculoskeletal system: A practice‐and consensus‐based approach. Arthritis Care Res. 2011;63:1503-
10.

5. LOOK FEEL MOVE
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6. • Age dependent normal appearance of joints shall be kept in view while
documenting locomotor history and examination findings.
• Pediatric MSK evaluation includes observation, palpation, range of motion,
strength testing, and functional assessment.
• Observation (look) focuses on swelling, rashes, nail changes, wasting, posture,
body symmetry, disproportions, deformities, dysmorphism and different
movements.
• Palpation (feel. move and functional assessment) includes the skin, muscles,
spine and joints.
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Foster HE, Cabral DA. Is musculoskeletal history and examination so different in paediatrics?. Best Pract Res Clin Rheumatol. 2006;20:241-62.

7. Spine and joints
• Tenderness,
• Swelling,
• Temperature,
• Synovial thickening,
• Range of motion: active &
passive.
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Palpation
Muscles
• Size,
• Bulk,
• Tenderness,
• Tone.
Skin
• Elasticity,
• Rashes,
• Nodules,
papules etc.

8. CLINICAL
VIGNETTE
Figure 3.
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9. CLINICAL
VIGNETTE
Figure 4.
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10. CLINICAL
VIGNETTE
Figure 5.
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11. • The spine and back examination:
- It includes an assessment of the bones and muscular components,
along with the postural assessment.
- Evaluation includes, having the child stand and/or sit while the
back is examined.
- The height of the shoulders, position of scapula, and height of the
pelvis should be assessed.
- The child is asked to bend forward in order to look for rib and back
asymmetries.
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12. APPROACH
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Preliminary
Screening
examination (triage)
Focussed formal
assessment of the
involved joint or limb

13. SCREENING
pMSK screening in Neonates and Infants:
• The Infants are usually examined on the Mother's lap.
• Observation of the general body contour, symmetry and proportion, and record
anthropometry.
• Evaluation of tone and reflexes.
• Observation of spontaneous movements.
• ‘Toe to tip’ examination including the back to look for congenital anomaly.
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14. pMSK screening in Children and adolescents:
• The child shall be adequately exposed, bare footed and preferably in presence
of a parent.
• ‘Top to toe’ examination including assessment of mobility of different axial and
peripheral joints.
• Forward bending test – mobility and symmetry.
• Assessment of gait, Trendelenberg’s test.
• Evaluation of the arch of the foot with toe walking.
• Look for limb length discrepancy by Coleman Block Test.
• Evidence of signs of any acute or chronic inflammation.
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15. P-GALS
• While only a few decades ago where we were in a desperate search of a
comprehensible schedule for MSK examination in children, pGALS has turned
out to be the one to look forward for the purpose since the earlier part of this
century.
• It has come out of age to its’ present state from the adult counterpart of this
scheme.
• The clinical scheme has been validated through different multicentric study
and has shown to have formidable sensitivity as a screening tool in detecting
various joint pathologies.
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16. • Paediatric Gait, Arms, Leg and Spine (pGALS) assessment is a simple and
rapid scheme of MSK examination.
• It helps in quick detection of musculoskeletal problems in a child and
warrants for in detail examination of the afflicted joint or region.
• The clinical tool comprises of a set questionnaires and some sequential
steps to perform.
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17. SCREENING QUESTIONS:
• Do you have any pain or stiffness in your joints, muscles or your back?
• Do you have any difficulty getting yourself dressed without any help?
• Do you have any difficulty going up and down stairs?
GAIT:
• Observe the child standing (front, side and back).
• Observe the child walking.
• “Walk on your heels / walk on your tip-toes ”
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Figure 6.
Foster HE, Jandial S. pGALS–paediatric Gait Arms Legs and Spine: a simple examination of the musculoskeletal system. Pediatr Rheumatol.
2013;11:1-7.

18. ARMS:
• “Put your hands out in front of you”
• “Turn your hands over and make a fist”
• “Pinch your index finger and thumb together”
• “Touch the tips of your fingers with your thumb”
• Squeeze the metacarpophalangeal joints.
• “Put your hands together and back to back”
• “Reach up and touch the sky”
• “Look at the ceiling”
• “Put your hands behind your neck”
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Figure 7.

19. LEGS:
• Feel for effusion at the knee.
• “Bend and then straighten your knee”
(Active movement of knees while examiner
feels for crepitus)
• Passive flexion of 90º with internal rotation of
hip
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Figure 8.

20. SPINE:
• “Open your mouth and put 3 of your (child’s own)
fingers in your mouth”
• Lateral flexion of cervical spine – “Try and touch
your shoulder with your ear”
• Observe the spine from behind.
• “Can you bend and touch your toes?” Observe
curve of the spine from side and behind
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Figure 9.

21. For the ease of executing the pGALS examination:
• Check that the child is comfortable, ask about pain, and explain what you intend to
do.
• Observe the child walking in the room, getting undressed, & at play with adequate
exposure.
• Get the child to copy you doing the manoeuvres.
• Look for verbal and non-verbal clues of discomfort.
• Look for asymmetry and consider clinical patterns
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22. Red flag signs:
• Fever and systemic signs
• Lymphadenopathy
• Organomegaly
• Bone pain
• Persistent night waking
• Dysmorphic features
• Incongruence between
history and physical
findings
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23. YUVA CME, W.B.A.P. 23
Growing pain in pMSK screening
Inclusion criteria Exclusion criteria
Frequency and
duration
Intermittent pains once or
twice per week, individual
episodes lasting for 30 min to 2
hours
Persisting pain or
increasing in severity
with time
Site Usually in the calf muscles,
sometimes anterior thigh
muscles, shins and popliteal
fossa and affects both the limbs
Pain involving joints
Or occurring only in one limb
Time Evening and nights Day time pain and persisting
nocturnal pains
Physical
examination
Normal Signs of inflammation

24. YUVA CME, W.B.A.P. 24
• M/C pMSK complaint:
Growing pain
• M/C functional abnormality:
Hypermobility
Sabui TK, Samanta M, Mondal RK, Banerjee I, Saren A, Hazra A. Survey of musculoskeletal abnormalities in school‐going children of
hilly and foothill regions of Eastern Himalayas using the pediatric Gait, Arms, Legs, Spine screening method. Int J Rheum Dis.
2018;21:1127-34.

25. BEIGHTON SCORE
• One point if while standing forward bending
you can place palms on the ground with legs
straight
• One point for each elbow that bends
backwards
• One point for each knee that bends backwards
• One point for each thumb that touches the
forearm when bent backwards
• One point for each little finger that bends
backwards beyond 90 degrees.
• Can you now (or could you ever) place your
hands flat on the floor without bending your
knees?
• Can you now (or could you ever) bend your
thumb to touch your forearm?
• As a child did you amuse your friends by
contorting your body into strange shapes OR
could you do the splits?
• Dislocation of shoulder or kneecap on more
than one occasion?
• Do you consider yourself double-jointed?
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Total score: 0-9; Cut-off score: 4
Beighton P, Solomon L, Soskolne CL. Articular mobility in an African population. Ann Rheum Dis.
1973;32:413–8.

26. FOCUSSED ASSESSMENT
• A through inspection shall be done relevant to the clues obtained from the
pMSK screening examination.
• Observation of the child from
- Front: Posture, Symmetry (limb length discrepancy)
- Sides: Curvature of spine
- Back: Posture, Symmetry (Shoulder level, Scapula, Iliac crest,
Sacral dimples), Central abnormalities
• The child is asked to squat on the floor and then to stand up.
• Assessing the gait and mechanics of walking: Push off, follow through & heel
strike.
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27. Measuring limb length:
Δ Apparent leg length – Umbilicus → Medial malleolus/heel
Δ Actual leg length – ASIS → Medial malleolus/heel
Δ Arm length – Acromion process → Olecranon process
Δ Total (Upper) limb length – Acromion process → Tip of middle finger
Δ Arm span, US:LS
Δ Proximal segment of upper limb – Asking the child to touch the shoulder with the
thumb with flexed elbow
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28. Examination of hand and wrist:
All the small joints of hand (PIP, DIP, MCP joints) including wrist joint shall
be examined
Δ Look – Nail changes, muscle wasting, swelling and effusion of joint,
deformity.
Δ Feel – Skin temperature, eliciting tenderness, tendon thickening and
bulk of thenar and hypothenar eminences, nodules, crepitations on joint
movement.
Δ Move – ROM (active & passive), Restriction of movement, stress
pain.
Δ Functional assessment - Grip and pinch, picking up small object,
writing or drawing, testing individual muscle power, hypermobility
assessment.
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*nail fold capillaroscopy

29. Examination of elbow:
Δ Look – Carrying angle, scars, rashes, deformity, muscle wasting,
contracture, swelling and effusion of joint.
Δ Feel – Skin temperature, tenderness, tendon thickening, nodules,
crepitations on joint movement. Palpate joint line, head of radius, ulnar
border, medial and lateral epicondyles.
Δ Move – ROM (active & passive), Restriction of movement.
Δ Functional assessment - Hand to nose or mouth, hands behind head,
testing power of individual muscle groups.
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30. Examination of shoulder:
Δ Look (front & back) – Normal contour, scars, rashes, muscle wasting,
swelling and joint effusion, shoulder height, position of scapula.
Δ Feel – Skin temperature, tenderness, bony landmarks, nodules,
crepitations on joint movement. Palpate clavicle, costochondral,
sternoclavicular and acromioclavicular joint, axilla.
Δ Move – ROM (active & passive), Restriction of movement.
Δ Functional assessment – Raise arms over the head, hands behind the
neck, hands behind the back, abduction against resistance, testing power of
individual muscle groups.
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31. Examination of temporomandibular (TM) joint and spine:
Δ Look – Swelling anterior to the tragus of ear, normal curvatures of
spine from side and behind, lumber hollow, symmetry, scars, sinus, swelling
and muscle wasting, natal cleft, breach in continuity of skin and deformities.
Δ Feel – Skin temperature, tenderness, crepitations on joint movement,
paraspinal muscles spasm. Palpate mandibular condyles, spinal processes,
sacroiliac joint and other bony landmarks.
Δ Move – ROM (active & passive), Restriction of movement.
Δ Functional assessment – Putting child’s own three fingers into
mouth, look at the celling, bend the neck laterally to touch the shoulder with
ear, thoracic rotation, touch the toes with finger, stork test.
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32. Examination of hip:
Δ Look (front, side & back) – Scars, sinus, rashes, muscle wasting,
contracture, swelling, asymmetry, sub gluteal skin crease, fixed deformity.
Δ Feel – Skin temperature, tenderness, muscle bulk, crepitation on
joint movement, muscle spasm. Palpation of grater trochanter, sacroiliac
joint and other bony landmarks.
Δ Move – ROM (active & passive), Restriction of movement.
Δ Functional assessment – Straight leg rising test, Trendelenberg test,
Thomas test, gait with turning and running, ancillary movements.
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*Ortolani test for new-born

33. YUVA CME, W.B.A.P. 33
External rotation of
hip
Internal rotation of hip
Figure 10. Figure 11.
Available from: https://musculoskeletalkey.com/examination-of-the-pediatric-patient/

34. Examination of knee:
Δ Look – Scars, sinus, rashes, muscle wasting, contracture, swelling,
joint effusion, fixed deformity.
Δ Feel – Skin temperature, joint line tenderness, muscle bulk,
crepitation on joint movement, synovial thickening, joint stability. Palpation
of patellar border, tibial tuberosity, popliteal fossa.
Δ Move – ROM (active & passive), Restriction of movement.
Δ Functional assessment – Drawyer test, patellar tap and cross
fluctuation.
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35. Examination of ankle and feet:
Δ Look – Skin changes, muscle wasting, contracture, swelling, joint
effusion, arch of the foot, fixed deformity.
Δ Feel – Skin temperature, elicit tenderness, nodules, crepitation on
joint movement, muscle bulk, tendon thickening and bony landmarks.
Palpation of ankle joint line, subtalar, mid-tarsal, metatarsophalangeal
(MTP) joints and Achilles tendon at the insertion.
Δ Move – ROM (active & passive), Restriction of movement.
Δ Functional assessment - Thigh-foot angle, Gait cycle (heel strike,
stance, toe off or push off), running and turning, ancillary movement.
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36. YUVA CME, W.B.A.P. 36
Thigh-foot angle
Figure 12.

37. LIMITATIONS
• Age appropriate pMSK examination scheme
• Appearance of secondary ossification centres
• Overlap in mode of presentation of diseases
• Subtle signs and symptoms
• Apprehensive parents
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Kay LJ, Baggott G, Coady DA, Foster HE. Musculoskeletal examination for children and adolescents: do standard textbooks contain enough information?. Rheumatol (Oxford). 2003;42:1423-
5.

38. CONCLUSION
Hints from pMSK examination
• Joint involvement
• Nails, skin & mucosal
changes
• Muscle & tendon affliction
• Systemic involvement
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- Duration & episodes
- Number:
Mono/Oligo/Poly
- Type: Large/Small
- Distribution:
Axial/Peripheral
- Symmetry
- Nature:
Static/Additive/Migratory
- Deforming/non-
deforming
- Precipitating/reliving
factors

39. THANK YOU
nandy.arnab55@gmail.com
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- Practice is the best of all instructors
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