Homans Sign is a screening test used to check for deep vein thrombosis (DVT) of the calf. It’s sometimes called dorsiflexion sign.
It was first describes by John Homans in 1941 who was an American surgeon1.
How do you do a DVT Test or Homans Sign?
The patient is supine.
The examiner lifts the affected leg and rapidly dorsiflexes the patient’s foot with the knee extended.
This maneuver is repeated with the patient’s knee flexed while the examiner simultaneously palpates the calf.
What does a positive Homans Sign mean?
Homans Sign is positive if pain is occurring upon dorsiflexion of the foot with the knee extended and flexed indicating deep vein thrombosis (DVT).
Sensitivity & Specificity
Homans sign has low sensitivity and specificity in diagnosing DVT; it can be of value if used in addition to more accurate diagnostic procedures like ultrasonography and venography 2.
Calf pain with the knee extended can also be caused by intervertebral disk disease (radicular symptoms) or muscle contractures.
The performance of the test may increase the risk of producing a pulmonary embolism (PE).
More accurate diagnostic procedures for DVT include:
Doppler and B-mode ultrasound,
venous duplex imaging,
I-125 fibrinogen uptake
Deep venous thrombosis (DVT)
Acute deep venous thrombosis ranks with acute arterial occlusion as one of the most serious and dramatic vascular emergencies.
Factors contributing to thrombosis include:
and coagulation characteristics.
A DVT most commonly appears in the lower extremity and is typically classified as being either:
proximal (affecting the popliteal and thigh veins)
or distal (affecting the calf veins).
Proximal DVT is the more dangerous form of lower extremity DVT because it is more likely to cause lifethreatening PE.
Thrombosis in the deep veins of the leg is less symptomatic yet involves a far greater risk of embolism than thrombosis in the superficial veins.
DVT Symptoms include:
Swelling in the extremity (primarily in the left leg at the vascular spur in the pelvic veins),
often associated with spontaneous pain in the groin,
pain radiating into the leg upon coughing or straining,
local blue discoloration of the skin,
in some cases elevated temperature and pulse are important signs.
A pulmonary infarction will often be the first clinical symptom, but typical early signs of deep venous thrombosis may also occur, these include: spots that are painful to palpation, extending from the sole of the foot (Payr) to, in certain cases, the groin (Rielander), and pain upon compression of the calf (Lowenberg) when a blood pressure cuff is applied and pumped up to 100 mm Hg (13.3 kPa). However, these thrombosis signs are nonspecific and should by no means be regarded as conclusive.
The unilateral edema that usually occurs develops gradually and begins in the malleolar region.
Additional characteristic findings include distended congested peripheral veins in the affected extremity (Pratt “warning” veins), evidence of superficial collateral veins, and an expanding edema, which is dependent on the size and localization of the thrombosis.
In patients with chronic venous disease, a number of test methods are helpful in evaluating the function of the deep veins and perforating veins.
What are the warning signs of deep vein thrombosis?
Early signs of deep venous thrombosis include:
Tenderness to palpation on the medial aspect of the thigh (sartorius, gracilis).
Tenderness to palpation in the knee (muscular insertions and medial joint cavity).
Pain on compression of the calf (Lowenberg).
Pain in the calf on dorsi exion of the foot (Homans sign).
Tenderness to palpation.
Tenderness to palpation along the adductor canal.
Pratt warning sign.
Meyer pressure points along the greater saphenous vein.
Pain in the sole of the foot, Payr sign: pressing or tapping the sole of the foot with the edge of the hand.
Certain patients are at increased risk for DVT:
Strong risk factors include:
fracture (pelvis, femur, and tibia),
hip or knee replacement:
major general surgery,
spinal cord injury.
Moderate risk factors include:
arthroscopic knee surgery,
central venous lines,
congestive heart or respiratory failure,
hormone replacement therapy,
oral contraceptive therapy,
previous venous thromboembolism,
Weak risk factors include:
bed rest greater than 3 days immobility due to sitting (e.g., prolonged air travel),
A recent study indicated that up to 60% of patients undergoing total hip replacement surgery may develop a DVT without preventative treatment.
Musculoskeletal conditions that may mimic symptoms associated with DVT include:
Prevention of DVT:
Methods of prevention may be classified as pharmacological and nonpharmacological.
Pharmacological prevention includes:
anticoagulant drugs such as low-dose Coumadin (warfarin),
heparinantithrombin III combination.
These drugs work by altering the body’s normal blood-clotting process.
Second tier drugs include dextran, aspirin, and low-dose subcutaneous heparin.
Nonpharmacological prevention attempts to counteract the effects of immobility, including:
calf and foot/ankle exercises,
A recent study has shown that substantial hyperemia (a mean 22% increase in venous outflow) occurs after the performance of active ankle pumps for 1 minute, and venous outflow remains greater than the baseline level for 30 minutes reaching a maximum 12 minutes after these exercises.
Although this does not provide sufficient evidence that exercise alone prevents DVT, it suggests that the active ankle pump does influence venous hemodynamics.
Finally, inferior vena caval (IVC) filters and Greenfield filters may be employed with a patient who has a contraindication to anticoagulation, previous complications with anticoagulants, or if anticoagulants have proved ineffective in the past.
McGee, Steven (2012). Evidence-Based Physical Diagnosis. Philadelphia, USA: Saunders. pp. 472–473.
Ambesh P, Obiagwu C, Shetty V. Homans 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.
Clinical Tests for the Musculoskeletal System 3rd Edition.
Dutton’s Orthopaedic Examination, Evaluation, And Intervention 3rd Edition.
Sarvdeep S. Dhatt, Sharad Prabhakar – Handbook of Clinical Examination in Orthopedics.