The Homans' sign test is a physical examination technique taught in many healthcare profession curriculums, typically as a component of lower extremity vascular assessment. The test is named for John Homans,1 a vascular surgeon who noticed that many patients with posterior calf muscle irritation closely correlated to patients with early deep vein thrombosis (DVT) of the lower leg.1 During the period of time in which Homans practiced (early 1900s into the 1950s), this test was indeed a useful indicator of the classic presentation for DVT. But medical diagnostic techniques often need be tailored to current evidence-based knowledge and practice guidelines.
The Homans' sign test was originally described to be conducted in the following order:
- In the supine position, the knee of the suspected leg of the patient should be flexed (Figure 1).
- The examiner should then forcibly and abruptly dorsiflex the patient's ankle (Figure 2).
- The examiner observes whether or not the patient reports pain in this calf and popliteal region. Pain indicates a positive sign.
In the original description of the technique, it is emphasized that ankle dorsiflexion must be "forceful," as shown in Figure 2. Otherwise, inaccurate results (most commonly false-positive results) may be obtained.1 Although the Homans' sign was intended to identify the presence of DVT, it has historically been skewed because many other medical conditions can lead to calf pain with ankle dorsiflexion. Conditions that can cause calf pain include herniated vertebral discs,1 cellulitis, Baker's cysts, muscle spasms, tears, strains or neurologic disorders.2,3
Along with many inaccurate results in light of the presence of different disease states, the Homans' sign is plagued by misinterpretation and inaccurate elicitation of the sign. Homans intended for a positive test response to result in calf and popliteal pain. Many clinicians misinterpret a positive result to be the increased resistance to dorsiflexion of the foot without the association of pain or discomfort.4,5 There is also the problematic issue of improper elicitation of the sign.
Homans required forceful and abrupt dorsiflexion of the foot, with the knee flexed. Many clinicians incorrectly perform this by using gentle passive dorsiflexion with or without knee flexion or by placing the patient prone without knee flexion.6-9 Also, some textbooks do not describe the amount of force required to properly perform this maneuver as intended, leading to incorrect use and misinterpretation of the Homans' sign.7,10
What Does the Evidence Say?
In 1962, a group of physicians devised a study to ascertain which physical assessment tools were clinically significant in the assessment of patients with suspected DVT.11 One of these was the Homans' sign. The study was conducted in a group of hospitalized critically ill men (number of patients not identified). Twice a week, they were assessed for calf edema, calf tenderness, leg skin temperature, Homans' test, and venous dilation. During the hospitalization course, one study coordinator, blinded to patient data, conducted the above physical assessment parameters.
A separate study coordinator, blinded to patient data, performed autopsies to determine the presence and location of thrombus in the 15 patients who died during the study. Autopsy results found that the Homans' sign only provided an 8% true positive test and conversely, a 6% false positive test. This translates to only 1 in 5 patients with DVT being identified using the Homans' sign as confirmed by autopsy.11 Although this was a small study performed many years ago, it sheds light on the unreliability of this physical assessment tool early in its existence.
In 2001, Ebell12 reviewed the accuracy of the history and physical exam in relation to diagnosis of suspected DVT. The Homans' sign was studied in a group of 102 participants. The researchers documented 56% sensitivity and 39% specificity for the Homans' sign. If the Homans' sign was positive, the probability of DVT was only 15%. Conversely, if the Homans' sign was negative, it was only correct 17% of the time. Based on these findings, the article suggested that the Homans' sign test be omitted from the physical examination of a patient with suspected DVT.12
While there have been some case reports of patients developing DVT with deep tissue massage,13 no published studies demonstrate that the Homans' sign can mobilize a clot. Arguably, this maneuver could potentiate the mobilization of an embolus depending on how vigorously the clinician carried out the exam or how fragile the thrombosis is in the vein. Homans recommended a forceful and abrupt manner for an accurate test.1
In light of this evidence, clinicians need to consider: Could this maneuver potentially do more harm than good? In today's medical environment, the diagnosis of a DVT will not be determined by physical assessment alone.12,14-16
John Homans was considered a medical authority in his time period, known for his contribution to the body of knowledge about venous thrombosis.17 Now 60 years later, the limited amount of evidence and the physical reality of conducting a correct Homans' sign test determine its fate. We suggest that the Homans' sign be omitted from the physical assessment of patients with suspected DVT in light of its incorrect elicitation, misinterpretation of results, poor testing efficacy, and potential for clot mobilization.
Over time, the Homans' sign has not proven to be a clinically significant physical assessment tool. While it can be difficult to change old traditions and practice habits, physician assistants and nurse practitioners need to be cognizant of evidence-based progressions in the field of medicine. The Homans' sign test should be allowed to rest peacefully in the archives of medicine.
In his article reviewing the history of the Homans' sign, Frank Urbano, MD,1 concluded:
"The Homans' sign is generally unreliable as a clinical sign of DVT, but it remains part of the traditional physical examination of patients with suspected DVT, perhaps because of its ease of performing and its historical role in the evaluation of patients with suspected DVT."1
1. Urbano F. Homans' sign in the diagnosis of deep venous thrombosis. Hosp Physician. 2001(3):22-24.
2. Riddle DL, et al. Improving the diagnostic process for deep vein thrombosis in orthopaedic outpatients. Clin Orthop Relat Res. 2005;432:258-266.
3. Landaw SA, Bauer KA. UpToDate. Approach to the diagnosis and therapy of
lower extremity deep vein thrombosis. May 2012. http://www.uptodate.com/contents/approach-to-the-diagnosis-and-therapy-of-lower-extremity-deep-vein-thrombosis
4. Gorman WP, et al. Case Management Adherence Guidelines website.
ABC of arterial and venous disease. Swollen lower limb-1: General assessment and deep vein
thrombosis. BMJ. 2000;320(7247):1453-1456.
5. Bauer KA, Lip GYH. UpToDate. Evaluation of the Patient with Established Venous Thrombosis. November 2012. http://www.uptodate.com/contents/evaluation-of-the-patient-with-established-venous-thrombosis
6. Walton T. Cancer massage therapy: essential contraindications. Massage Therapy Journal. Summer 2006:119-134.
7. Siedel H, et al. Blood vessels. In: Mosby's Guide to Physical Examination.7th ed. St. Louis, MO; Mosby Elsevier. 2011:444,845.
8. Kline JA. Thromboembolism. In: Tintinalli JE, et al, eds. Tintinalli's Emergency Medicine: A Comprehensive Study Guide. 7th ed. New York: McGraw-Hill; 2011.
9. Sailor S. Homan's Sign. http://www.youtube.com/watch?v=MQ435Ua3Hfg&feature=em-share_video_user
10. Ginsberg J. Peripheral venous disease. In: Goldman xx, ed. Goldman's Cecil Medicine. 24th ed. Philadelphia, PA: Saunders Elsevier; 2011:499-506.
11. McLachlin J, et al. An evaluation of clinical signs in the diagnosis of venous thrombosis. Arch Surg. 1962;85(5):738-744.
12. Ebell M. Evaluation of the patient with suspected deep vein thrombosis. J Fam Pract. 2001;50(2):167-171.
13. Crump C, Paluska SA. Venous thromboembolism following vigorous deep tissue massage.
Phys Sportsmed. 2010;38(4):136-139.
14. Tovey C, Wyatt S. Diagnosis, investigation, and management of deep vein thrombosis. BMJ. 2003;326(7400):1180-1184.
15. Bounameaux H, et al. Diagnosis of venous thromboembolism: an update. Vasc Med. 2010;15(5):399-406.
16. Grant B. Up To Date. Diagnosis of suspected deep vein thrombosis of the lower extremity. January 2012. http://www.uptodate.com/contents/diagnosis-of-suspected-deep-vein-thrombosis-of-the-lower-extremity
17. Baker WF. John Homans, MD, 1877-1954: Indomitable and Irrepressible. Arch Surg. 1999;134(9):1019-1020.
Jennifer A. Grinate is a student in the physician assistant program at Saint Louis University in St. Louis. Christine M. Werner is physician assistant who is an associate professor in the Department of Physician Assistant Education at Saint Louis University. The authors have completed disclosure statements and report no relationships related to this article.