From the Guidelines
A positive Homans' sign is not a reliable indicator of deep vein thrombosis (DVT) and should be interpreted with caution, as it has limited sensitivity and specificity, and further evaluation with imaging and D-dimer testing is necessary to confirm DVT. The Homans' sign is a clinical test that is performed by having the patient's knee flexed and then passively dorsiflexing the foot, which stretches the calf muscles and veins, and pain during this maneuver suggests inflammation or thrombosis in the deep veins of the leg 1. However, this sign can be positive in other conditions like muscle strain, cellulitis, or Baker's cyst, and can also be negative in patients with DVT, particularly those with distal or below-the-knee DVT 1.
Key Points to Consider
- The clinical diagnosis of DVT using clinical risk-stratification scores alone has been less than ideal, and the Wells score, which is a clinical DVT-prediction score, should be used in combination with a blood evaluation for plasma D-dimer to improve diagnostic accuracy 1.
- Imaging, such as lower extremity ultrasound, is frequently required to definitively exclude DVT and properly document the extent of venous thrombosis, which is critical for proper therapeutic management of DVT 1.
- The treatment of choice for DVT is anticoagulation to reduce the risk of DVT extension, recurrent DVT, pulmonary embolism, and post-thrombotic syndrome, and the benefits of anticoagulation therapy in patients with proximal DVT outweigh its risks 1.
Recommendations for Clinical Practice
- Clinicians should consider the entire clinical picture, including risk factors like immobility, recent surgery, cancer, or pregnancy, when interpreting the Homans' sign and other physical examination findings 1.
- Further evaluation with ultrasound and D-dimer testing is necessary to confirm DVT in patients with a positive Homans' sign or other suspicious clinical findings 1.
- Serial imaging to exclude proximal DVT extension is recommended at 1 week if anticoagulation therapy is not initiated at presentation in patients with distal or below-the-knee DVT 1.
From the Research
Positive Homans' Sign
- A positive Homans' sign is often associated with deep vein thrombosis (DVT) 2
- However, the use of Homans' sign as a screening method for DVT is considered outdated and not evidence-based 2
- According to a survey of physical therapy clinical instructors, 80.5% were taught to use Homans' sign to screen for DVT in their entry-level education, and 67.9% continued to use it in clinical practice 2
- The survey also found that nearly two-thirds of respondents failed to correctly identify one or more of the major risk factors for developing DVT/venous thromboembolism (VTE) 2
- Current guidelines recommend the use of clinical decision rules and diagnostic tests such as D-dimer and compression ultrasound for diagnosing DVT 3, 4, 5
- Anticoagulation therapy is the mainstay of treatment for DVT, with options including vitamin K antagonists, direct oral anticoagulants, and parenteral anticoagulants 3, 4, 5, 6