What are the traditional physical finding of DVT? How valuable are they?
Based on traditional teaching, the physical exam of patients with suspected DVT should include: (1)
careful inspection of the leg (looking for pitting edema, warmth, dilated superficial veins, and erythema); (2)
measurement of leg circumference; (3) appreciation of a palpable cord; and (4) elicitation of Homans’ sign
(development of calf pain following the forceful and abrupt dorsi-flexion of the foot). Yet, all these
signs/maneuvers are quite inaccurate. Tenderness, swelling, warmth, and redness of the limb cannot
adequately separate patients with or without DVT.
In fact, warmth and color of the skin reflect superficial, rather than deep, circulation. A “palpable cord” is also indicative of superficial thrombophlebitis—which has no relationship to the deep vein system. Finally, skin changes, pitting edema, and dilated superficial veins may all be caused by other processes, such as venous insufficiency, leg trauma, cellulitis, obstructive lymphadenopathy, superficial venous thrombosis,
postphlebitic syndrome, or a Baker (popliteal) cyst—a distended gastrocnemius-semimembranosus bursa that has ruptured into the calf, thus creating a perimalleolar crescent-shaped ecchymosis (pseudothrombophlebitis). And as for Homans’ sign, it has a low sensitivity and poor specificity.
Based on traditional teaching, the physical exam of patients with suspected DVT should include: (1)
careful inspection of the leg (looking for pitting edema, warmth, dilated superficial veins, and erythema); (2)
measurement of leg circumference; (3) appreciation of a palpable cord; and (4) elicitation of Homans’ sign
(development of calf pain following the forceful and abrupt dorsi-flexion of the foot). Yet, all these
signs/maneuvers are quite inaccurate. Tenderness, swelling, warmth, and redness of the limb cannot
adequately separate patients with or without DVT.
In fact, warmth and color of the skin reflect superficial, rather than deep, circulation. A “palpable cord” is also indicative of superficial thrombophlebitis—which has no relationship to the deep vein system. Finally, skin changes, pitting edema, and dilated superficial veins may all be caused by other processes, such as venous insufficiency, leg trauma, cellulitis, obstructive lymphadenopathy, superficial venous thrombosis,
postphlebitic syndrome, or a Baker (popliteal) cyst—a distended gastrocnemius-semimembranosus bursa that has ruptured into the calf, thus creating a perimalleolar crescent-shaped ecchymosis (pseudothrombophlebitis). And as for Homans’ sign, it has a low sensitivity and poor specificity.