What Patient Facial Expressions Can Reveal During The Physical Exam

During a patient encounter with history taking and physical exam, physicians use various techniques to assess the symptom. We depend on our senses such as touch, hearing, smell or sight to help aid in the diagnosis. While we focus down at one end of the body to perform our exam, we should still use our senses to take a global survey of the patient, especially during a lower extremity physical exam.

One helpful technique is to watch the patient’s facial expressions during the exam, especially when palpating areas of concern. In today's world, much of our communication takes place through methods like email and text messages without facial observation. Whether reading people’s expressions is a dying mode of communication or a lost art due to this factor, facial expressions are important in boosting our understanding and ability to treat.

I find this important to do especially in the pediatric or younger athletic population. Sometimes, patients are going to be less verbal with you during an exam so palpating a region that hurts may elicit a facial expression (i.e., a grimace or twitch) that may help in the diagnosis.

The same can be said for our young athletes, who state their pain is minimal on a Visual Analogue Scale (VAS, 0-10). They often will show pain visually through facial expression during an exam but don’t want to show it so they can get back to their sport/season quicker. I see this constantly when asking athletes their pain level or improvement from the last evaluation. Patients state the pain level is low with great improvement and the parents encourage them along during the exam, hearing that pain is much improved. Then I directly palpate the injured structure and while the foot may not flinch, the athlete’s face does.

Some cues to look out for include components of the Facial Action Coding System (FACS) or Child Facial Coding System (CFCS).¹ These include lowered brows, raised cheeks, tightened eyelids/squinting, eye squeeze or closing, a raised upper lip or opened mouth, vertical mouth stretch, flared nostril, nose wrinkling, horizontal mouth stretch and lip corner pull. Paying attention to facial expressive behaviors during a physical exam can help provide a sensitive index of pain in your patient to help in your overall assessment of progress, healing and return to activity.

While specific literature on this topic in the podiatric and orthopedic world is scarce, we need to keep these principles in mind when evaluating or assessing the critically ill and/or non-communicative patient.

Reference

1. Prkachin KM. Assessing pain by facial expression: facial expression as nexus. Pain Res Manage. 2009; 14(1):53-58.