What are the signs and symptoms of Deep Vein Thrombosis (DVT)?

Signs and Symptoms of Deep Vein Thrombosis (DVT)

The classic signs and symptoms of DVT include unilateral extremity pain, swelling, edema, erythema, and warmth in the affected limb, though approximately one-third of patients with DVT may be asymptomatic. 1

Common Clinical Manifestations

Lower Extremity DVT

• Pain:

  • Typically unilateral calf, leg, or thigh pain
  • Often described as deep tension, heaviness, or a feeling of "dead weight" 2
  • May also present as dull cramping or an "undefinable" odd, heavy leg sensation
  • Increases with standing and walking
  • Can sometimes involve the sole of the foot, heel, thigh, or groin

• Swelling:

  • Unilateral edema of the affected limb
  • Often worsens throughout the day
  • Improves with rest and limb elevation 1

• Skin changes:

  • Erythema (redness)
  • Warmth over the affected area
  • Dilated superficial veins 3

• Physical examination findings:

  • Tenderness on palpation along venous tracts
  • Positive Homans' sign (pain in calf with passive dorsiflexion of foot)
  • Neuhof's sign (feeling of tender fullness in the calf) 2

Upper Extremity DVT

• Ipsilateral upper extremity swelling
• Pain
• Cervical edema
• Dilation of superficial collateral venous circulation 1

Variations in Presentation

Asymptomatic DVT

• Up to 80% of DVTs may be clinically asymptomatic 4
• Often discovered incidentally during imaging for other conditions
• May still lead to complications if untreated

Severe Presentations

• Phlegmasia cerulea dolens ("blue leg")
  • Severe, sometimes "intolerable" pain
  • Rapid onset
  • Bluish discoloration
  • Significant swelling 2

Post-thrombotic Syndrome (PTS)

PTS can develop months to years after DVT and presents with:

• Chronic pain
• Persistent swelling
• Hyperpigmentation
• Venous ectasia
• Lipodermatosclerosis
• Venous ulceration in severe cases 1

Location-Specific Symptoms

Iliofemoral DVT

• More pronounced swelling of entire limb
• Venous claudication (bursting leg pain during exercise)
• May resemble arterial claudication 1

Popliteal DVT

• Swelling and pain primarily in the calf region
• May extend to cause more extensive symptoms 4

Clinical Assessment

The Wells score is commonly used to assess pre-test probability of DVT, considering:

• Active cancer
• Paralysis or recent immobilization
• Recently bedridden or major surgery
• Localized tenderness along deep veins
• Entire leg swelling
• Calf swelling >3 cm compared to asymptomatic leg
• Pitting edema
• Collateral superficial veins
• Previous DVT
• Alternative diagnosis as likely as DVT 3

Special Considerations

Cancer Patients

Cancer patients may have additional risk factors for DVT, particularly with:

• Specific cancer types (stomach, pancreas, lung, lymphoma, gynecologic, brain)
• Recent diagnosis (within 3-6 months)
• Metastatic disease
• Active chemotherapy or hormonal therapy 1

Chronic Venous Insufficiency vs. Acute DVT

It's important to distinguish between:

• Acute DVT: Sudden onset, unilateral symptoms, tenderness
• Chronic venous disease: Bilateral symptoms, skin changes develop gradually, less acute pain

Clinical Pitfalls

1. Misdiagnosis: 20% of symptomatic DVTs can be confused with musculoskeletal disorders 4

2. Delayed diagnosis: Symptoms may not be apparent until there is involvement above the knee 1

3. Overlooking asymptomatic DVT: Particularly in high-risk hospitalized patients 1

4. Confusing with other conditions: Baker's cyst, cellulitis, lymphedema, and musculoskeletal disorders can mimic DVT 1

5. Relying solely on clinical assessment: The clinical diagnosis of DVT using risk-stratification scores alone has been less than ideal, necessitating confirmatory imaging 1

When DVT is suspected based on signs and symptoms, prompt objective diagnostic testing with compression ultrasound is recommended, as early diagnosis and treatment significantly reduce the risk of pulmonary embolism and post-thrombotic syndrome 3.