Homan Sign · What Is It, Uses, and More

The Homan sign is the clinical finding of calf pain upon forced dorsiflexion of the foot. This sign was initially described by the American surgeon John Homans in 1994 and has been traditionally performed as part of the physical examination in individuals with unilateral swelling and redness of the lower extremity, when suspecting deep vein thrombosis (DVT). 

It’s thought that the mechanism underlying the Homan sign is flexion of the knee and forced dorsiflexion of the ankle causes traction on the posterior tibial vein, causing pain in the calf.   

When evaluating Homan sign, the individual’s knee should be in a flexed position, in order to identify discomfort originating from vascular involvement rather than muscle tension. The examiner will then forcibly and abruptly dorsiflex the individual’s ankle and observe for pain behind the calf or knee, which constitutes a positive Homan sign. If the dorsiflexion isn’t forceful enough, an accurate result may not be obtained.  

For many years, a positive Homan sign was thought to be a clinical sign of DVT of the lower extremity; however, evidence shows that not all individuals with DVT exhibit a positive Homan sign at evaluation. Therefore, the Homan sign is considered insensitive and nonspecific for DVT.  

Some conditions that may result in a positive Homan sign include intervertebral disc herniation, a ruptured Baker cyst, neurogenic claudication, calf muscle spasms, and cellulitis of the lower leg. Interestingly, individuals with a short Achilles tendon who usually wear high heels may experience a positive Homan sign when they start wearing flat shoes. 

Because of the unreliability of the Homan sign in diagnosing DVT, additional diagnostic procedures are typically performed if DVT is suspected. Current guidelines support clinical predictive scores (e.g., Wells score) for diagnosing DVT and non-invasive methods like a compression ultrasound with a doppler and a D-dimer blood test. If the diagnosis is inconclusive, more invasive venography can be performed, where a dye is injected into the veins. An X-ray may also be obtained to identify blockages.