Homan’s sign is positive when the dorsiflexion of the ankle causes a deep pain in the calf region. This occur as a result of inflammation of the calf muscle or due to deep vein thrombosis.
Only 35% of patients who suffer from these conditions ( deep vein thrombosis or inflammation of the calf muscle) may present with positive Homan’s sign. This make Homan’s sign as an unreliable indicator to indicate the present of those conditions. The extent of the venous disorder cannot be detected while performing a Homan’s test even though the test produce a positive Homan’s sign. It is easy to get confused of positive Homan’s sign compare to other pathology such as contusion, continuous calf pain , strains, cellulitis, arterial occlusion , Achilles tendon pain (common in woman who has a shorter Achilles tendon from wearing high heel) and posterior ankle pain.
If the patient is presented with positive Homan’s sign,the next step is to focus on the history which may include the symptoms and signs of thrombophlebitis or deep vein thrombosis.
The common signs and symptoms of deep vein thrombosis and thrombophlebitis are tight sensation in the calf, pain in the leg during routine activity or during and after exercise as well as aching, heavy and throbbing feeling in the calf region.
It is also important to ask about any symptoms and signs of pulmonary embolism that occur as a result of deep vein thrombosis. These may include feeling of acute breathlessness, pleuritic chest pain, cough or hemoptysis.
It is recommended that the patient is asked regarding the predisposing factors of pulmonary embolism. The predisposing factors may include the use of oral contraceptive pill, childbirth, recent surgery, leg injury and associated condition ( such as nephrosis, cancer and hyper coagulation states). Prolonged inactivity is also one of the predisposing factor.
The examination is initiated by inspection and palpation of the patient’s calf . It is important to notice any tenderness, warmth, swelling and the presence of any vein which is palpable.
Homan’s sign is elicited if deep vein thrombosis is strongly suggested.The Homan’s sign should be performed carefully to prevent any detachment of the blood clot which will finally leads to pulmonary embolism that is a life threatening condition.
Other additional test may include the measurement of the circumference of the affected calf (positive Homan’s sign) and compare it to the normal calf. The calf that is presented with positive Homan’s sign may appear larger due to the swelling and edema.
The differential diagnosis of positive Homan’s sign may include superficial cellulitis, ruptured of popliteal cyst deep vein thrombosis and deep vein thrombophlebitis.
Superficial cellulitis is commonly affecting the legs but it is also affect the arms. Locally the symptoms and signs may include pain, tenderness, redness and edema. Some patient may also suffer from general signs and symptoms which includes tachycardia, chills, fever, hypotension and headache.
Rupture of the popliteal cyst may present with acute onset of swelling, tenderness and redness of the calf as well as positive Homan’s sign.
Besides a positive Homan’s sign , patient who suffer from deep vein thrombosis may also present with tachycardia, low grade fever, slight edematous appearance of the thigh and the calves as well as the tenderness over the deep calf veins. Local tenderness and swelling are more apparent if deep vein thrombosis affecting the iliac veins and femoral veins. The deep vein thrombosis may cause venous obstruction. Venous obstruction may present with cool skin and cyanosis on the affected leg.
The most common signs of deep vein thrombophlebitis are calf tenderness and positive Homan’s sign. Besides that, the patient who suffer from deep vein thrombophlebitis may present with general malaise, chills, fever, engorged and visible superficial veins and swelling, warmth, heaviness as well as severe pain on the affected leg.
Homan’s sign is rarely performed on children based on the fact that deep vein thrombosis and deep vein thrombophlebitis are rarely occur at this age.
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