Core messages and useful resources

• MSK clinical assessment is an important general paediatric skill for all clinicians who encounter children.
• Many children present with vague complaints so careful assessment is key – knowledge of what is normal is essential to pick up what is abnormal.
• MSK problems can have lots of causes. However, careful assessment often indicates the underlying diagnosis.
• Early diagnosis of MSK pathology can reduce and avoid disability.
• pGALS is the only evidence-based approach to a joint examination in children – validated in school ages but younger ages can do it too.
• pGALS takes approximately 1–2 minutes to perform and can detect a wide range of rheumatological, orthopaedic and neuromuscular issues. Practice is essential.
• pREMS can be performed following pGALS of the affected joint. A number of ‘special tests’ can be carried out depending on the clinical context.

We've created a simple revision checklist to help:

• Revision checklist Word version (Word, 47 KB).
• Revision checklist PDF version (PDF, 107 KB).

pGALS follows the same approach as GALS but with additions as listed in the table below. These were added as adult GALS missed significant joint abnormalities when GALS was tested on school-aged children – this likely reflects the difference in pattern of joint involvement between adults and children.

Movement: Walk on heels and then on tiptoes.
Purpose: Assesses feet and ankles, gives information about balance and co-ordination.

Movement: Open mouth and insert three of the child’s own fingers into their mouth.
Purpose: Assesses temporomandibular joint opening and symmetry.

Movement: Reach up and touch the sky.
Purpose: Assesses full extension at the elbow joints and rotation at the shoulder joints.

Movement: Look at the ceiling.
Purpose: Assesses cervical spine extension.

• Use examples of pathology - patient images from the PMM website. Illustrate positive findings with either patients with signs or use images from the PMM website - what conditions might the patient have?
• Run through in real time with students mirroring. Run through the examination, asking students to mirror your movements. Which joints are being examined with each step?
• Provide ample time for practising and clarification. ‘Safe space’ practice time for students to practise on each other or on patients or volunteers to build confidence and clarify any points they are not clear on.
• If delivering remotely - ask students to watch video first and to critique pGALS. Ask student to watch the video before the session and come prepared to discuss the advantages and disadvantages. When would pGALS be indicated? Are there situations where more detailed investigations are warranted?
• Provide resources - resources can be used as preloading and to help students practise on each other and after the session.

• Paediatric MSK: Red flags and when to worry - WEBINAR – webinar in partnership with Red Whale covering tips for examining children with joint pain, red flags in children with a limp, diagnosis of JIA and how to support children with this condition.
• Paediatric MSK: Red flags and when to worry – PEARL – an evidence-based summary focusing on how to spot JIA and differentiate it from other causes of childhood pain, looking at how to take a good clinical history, pattern recognition and a focused examination.
• Paediatric Musculoskeletal Matters – website aiming to raise awareness and increase knowledge and clinical skills to facilitate early diagnosis and referral, where necessary, to specialist care.
• PMM app link – a study aid that takes you through the pGALS steps with explanatory notes, images and relevant links to additional information including a checklist of the pGALS steps, a revision checklist and examples of how to record the pGALS findings.
• NICE Clinical Knowledge Summaries on developmental rheumatology in children.
• RightPath – triage guidance on appropriate referrals from primary care to specialists in children and young people with a MSK issue. A useful downloadable PDF document containing triaging advice on some of the most common MSK presentations is also available.
• Paediatric Rheumatology European Association – clinical guidelines, resources, courses and further information.
• Geeky Medics – OSCE-focused MSK guides and marking schemes aimed at medical students.
• British Society for Rheumatology – available guidelines on medication, clinical information and much more.

This guide is endorsed by the British Society for Rheumatology.

Rheumatology is a fun, friendly and rewarding specialty, with a strong focus on teamwork and cohesiveness across the entire multi-disciplinary team. Rheumatologists work closely with other specialties to solve difficult diagnoses and often have an active role in research; trainees have plenty of opportunities to get involved in education, clinical governance and management.

The British Society for Rheumatology is there for you from the start of your career in the specialty. We’ll help you progress, collaborate and innovate to deliver the best care for your patients through a wide range of courses, conferences, fellowships, bursaries and awards, as well as a mentoring programme and peer-reviewed e-learning lectures and modules.

To find out more about how we can support you, go to www.rheumatology.org.uk/membership.

We remain indebted to the work of Professor Helen Foster, whose research led to the development of the pGALS and pREMS examination tools which are the focus of this guide. We would also like to acknowledge the work of Professor Paul Dieppe and Dr David Coady in the development of the adult GALS and REMS examinations as their text remains influential in this new paediatric edition.

We would like to thank Professor Helen Foster, Dr Sharmila Jandial, Dr Diarmuid McLaughlin, Dr Matthew Keir and Dr Charlene Foley for their time and commitment in creating the content, and thanks to Maura Scott, Melissa Mulholland, Anna Raczkowycz, Jo-Anne Shaw, David Hanna and William Rafferty who all took the time to review and comment on the draft versions. We would also like to express our gratitude to Dr Barbara Salas Revuelta and Newcastle University for granting Versus Arthritis permission for use of all the illustrations within this guide.