Homan's sign

Case: 24 years old athletic male presented to the Emergency Room (ER) with severe acute pain in the right calf associated with unilateral leg edema and redness. Homans’ sign is positive. The presence of the Homans’ sign confirms Deep Vein Thrombosis (DVT) unless proven otherwise.

A) True

B) False

Answer: B

This question emphasizes that the widely used Homans sign, calf pain upon passive dorsiflexion of the foot, is not a 'very reliable' sign of DVT. It just suggests DVT. History, patient profile, lab, and imaging testing should be used to confirm the diagnosis.

Our patient is a young athlete who may have DVT due to possible steroid abuse, but most likely, he may have merely muscle strain, tear, or injury to the leg. Other differential diagnoses include cellulitis, lymphangitis or lymph obstruction, venous insufficiency, or popliteal (Baker's) cyst. It may be interesting to know that one-quarter of patients with unilateral calf pain, redness, swelling, and tenderness may not have any established diagnosis, which can be very frustrating for a clinician.

One of the physical exam techniques in such patients is to look for pain or firmness along the course of a vein. More than Homan's sign, a more reliable finding for DVT is a larger calf circumference in the affected leg.

Well's score is another way to calculate the risk factor for DVT. A negative D-Dimer can be an important test to rule out DVT.

#hematology

#physical-exam

References:

1. Hull R, Hirsh J, Sackett DL, et al. Clinical validity of a negative venogram in patients with clinically suspected venous thrombosis. Circulation 1981; 64:622.

2. Gorman WP, Davis KR, Donnelly R. ABC of arterial and venous disease. Swollen lower limb-1: general assessment and deep vein thrombosis. BMJ 2000; 320:1453.

3. Ambesh P, Obiagwu C, Shetty V. Homan's sign for deep vein thrombosis: A grain of salt? Indian Heart J. 2017 May-Jun;69(3):418-419. doi: 10.1016/j.ihj.2017.01.013. Epub 2017 Jan 23. PMID: 28648447; PMCID: PMC5485383.

4. Heick JD, Farris JW. Survey of methods used to determine if a patient has a deep vein thrombosis: An exploratory research report. Physiother Theory Pract. 2017 Sep;33(9):733-742. doi: 10.1080/09593985.2017.1345023. Epub 2017 Jul 17. PMID: 28715289.