Homans’ sign is elicited when deep calf pain occurs after abrupt dorsiflexion of the ankle, suggesting venous thrombosis or calf muscle inflammation. Despite its historical use, it is an unreliable indicator, present in only about 35% of patients with deep vein thrombosis (DVT) or thrombophlebitis. The sign may be confused with calf pain from strains, contusions, cellulitis, arterial occlusion, or Achilles tendon disorders.

Pathophysiology

Pain on dorsiflexion arises from:

• Venous thrombosis causing inflammation and distention of deep veins.

• Thrombophlebitis with localized inflammatory response in the calf.

• Rupture of a popliteal (Baker’s) cyst, which mimics DVT.

• Superficial infections or trauma producing secondary discomfort in the calf.

History and Physical Examination

History

Inquire about calf pain (throbbing, aching, heavy, tight), exercise-induced pain, shortness of breath, chest pain (possible pulmonary embolism), recent surgery, immobilization, pregnancy, childbirth, contraceptive use, cancer, nephrotic syndrome, or hypercoagulable states.

Physical examination

• Inspection and Palpation: Examine for redness, warmth, swelling, tenderness, palpable veins, and compare calf circumferences. Assess for fever, malaise, and signs of systemic illness.

• Eliciting Homans’ Sign: Support the thigh and foot, slightly bend the knee, then abruptly dorsiflex the ankle. Positive if deep calf pain occurs; note that involuntary knee flexion or resistance may also indicate positivity. Exercise caution to prevent dislodging a clot.

Medical causes

Special considerations

• Place the patient on bed rest with the affected leg elevated above heart level.

• Apply warm, moist compresses and administer mild oral analgesics.

• Prepare for diagnostic tests such as Doppler ultrasonography or venography.

• Once ambulatory, use elastic support stockings for at least 3 months.

• Advise leg elevation when sitting and avoid crossing legs at the knees.

Patient counseling

• Educate about signs of prolonged clotting if on anticoagulants.

• Explain proper use and benefits of elastic support stockings.

• Emphasize dietary restrictions (e.g., green leafy vegetables) and alcohol avoidance.

• Stress follow-up appointments and checking with the practitioner before taking new medications.

Pediatric pointers

Homans’ sign is rarely assessed in children due to the low incidence of DVT or thrombophlebitis.

References

1. Kuipers, S., Cannegieter, S. C., Doggen, C. M., & Rosendaal, F. R. (2009). Effect of elevated levels of coagulation factors on the risk of venous thrombosis in long-distance travelers. Blood, 113, 2064–2069.

2. Silverman, D., & Gendreau, M. (2009). Medical issues associated with commercial flights. Lancet, 373, 2067–2077.