What does a positive Homans sign indicate in a patient?

Homans Sign: Clinical Significance and Diagnostic Value

A positive Homans sign—calf pain elicited by passive dorsiflexion of the foot with the leg extended—is an unreliable and outdated clinical test that should NOT be used to diagnose or exclude deep vein thrombosis (DVT). 1, 2, 3

What Homans Sign Indicates (Historically)

• Homans sign was historically thought to indicate DVT when calf pain occurred during passive dorsiflexion of the foot with the lower limb in extension 4
• The maneuver theoretically stretches the posterior tibial venous system, causing pain if thrombosis is present 4
• However, this sign has very poor predictive value for the presence or absence of DVT, performing no better than chance 2

Why Homans Sign Should Not Be Used

Poor Diagnostic Performance

• Homans sign has extremely poor sensitivity and specificity for DVT, making it clinically useless for diagnosis 2, 3
• The sign is positive in only a minority of patients with confirmed DVT and can be positive in many conditions unrelated to thrombosis 2
• Approximately 80% of DVTs are clinically asymptomatic, and among the 20% with symptoms, clinical signs like Homans are easily confused with musculoskeletal disorders 5

More Reliable Clinical Findings

Instead of Homans sign, focus on these more diagnostically valuable findings: 4, 6

• Painful calf pressure (most important sign) 6
• Asymmetric edema (calf circumference difference ≥2 cm between legs) 7, 6
• Positive Meyer sign (tenderness on palpation of venous tracts) 6
• Neuhof's sign (tender fullness of the calf on palpation) is more reliable than Homans sign 4
• Painful Lowenberg test (calf pain with blood pressure cuff inflation to 80-139 mmHg) 6

Modern Diagnostic Approach to Suspected DVT

Clinical Probability Assessment

Use validated clinical prediction rules (Wells score or similar) rather than individual signs: 1, 3

• Low clinical probability: DVT prevalence 5% (95% CI, 4.0%-8.0%) 3
• Moderate clinical probability: DVT prevalence 17% (95% CI, 13%-23%) 3
• High clinical probability: DVT prevalence 53% (95% CI, 44%-61%) 3

Diagnostic Algorithm

For patients with suspected DVT: 1, 3

1. Calculate clinical probability using Wells score or similar validated tool (NOT individual signs like Homans) 3
2. Low probability + negative high-sensitivity D-dimer: DVT excluded without ultrasound (negative LR 0.10,95% CI 0.03-0.37) 3
3. Moderate/high probability OR positive D-dimer: Proceed to proximal compression ultrasound (CUS) as definitive test 1
4. Pregnant patients: Use proximal CUS as first-line test (Grade 1B over D-dimer) 1, 7

Special Considerations in Pregnancy

For pregnant patients with leg swelling: 7

• Perform immediate proximal CUS rather than relying on clinical signs 7
• Assess for left-sided predominance (85% of pregnancy DVTs occur on left) 7
• Measure calf circumference difference ≥2 cm (adjusted OR 26.9 for DVT) 7
• Do not use D-dimer in pregnancy, as levels physiologically increase and are not validated 7

Key Clinical Pitfall to Avoid

Never rely on Homans sign or any single clinical finding to diagnose or exclude DVT. 2, 3 The consequences of missed DVT include fatal pulmonary embolism, making objective testing with validated clinical prediction rules and appropriate imaging essential for all patients with suspected DVT 3