MSK Examination …

pGALS is an important part of basic clinical skills to be acquired by all involved in the care of children. 

MSK symptoms can be presenting features of Juvenile Idiopathic Arthritis (JIA), and potentially life-threatening conditions such as malignancy, infection, vasculitis and non-accidental injury. 

Inflammatory arthritis is an associated feature of many chronic paediatric conditions such as inflammatory bowel disease, cystic fibrosis, and psoriasis. 


  • Wash hands
  • Introduce yourself to both the parents and the child
  • Confirm the child’s details (e.g. name and date of birth)
  • Explain the examination: “Today I’m going to ask you to do a number of different movements with your head, arms and legs.”
  • Gain consent (from parents and child): “Does that sound ok?”
  • Expose the child’s chest, upper and lower body (ideally, the child should be wearing shorts)
  • Ask if the child has any pain anywhere before you begin the examination
  • Throughout the pGALS assessment, you should adopt a 
  • “Copy me” approach, where you first demonstrate what you want the child to do (this can be easier for the child to follow than simply a sequence of verbal instructions)
  • Look for non-verbal clues of discomfort (e.g. grimacing)

Screening questions

  • Do you (or does your child) have any pain or stiffness in your (their) muscles, joints or back?
  • Do you (or does your child) have any difficulty getting yourself (him/herself) dressed without any help?
  • Do you (or does your child) have any problem going up and down stairs?

Practical tips in performing pGALS

  •  Look for verbal and non-verbal clues of discomfort (e.g. facial expression, withdrawal)
  •  Do the full screen as extent of joint involvement may not be obvious from the history
  •  Look for asymmetry (e.g. muscle bulk, joint swelling, range of joint movement)
  •  Consider clinical patterns (e.g. non-benign hypermobility and Marfanoid habitus or skin elasticity) and association of leg length discrepancy and scoliosis)

Paediatric Regional Examination of the Musculoskeletal System (pREMS)

Following pGALS – a more detailed examination of the relevant area(s).

Paediatric Regional Examination of the Musculoskeletal System pREMS is based on:

‘look – feel – move – function’ for each joint.

active movements performed first and then passively by the examiner.

‘measure’ for some joints is included pending the clinical scenario (e.g. leg length discrepancy or thigh wasting).

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