Clinical exam · Cardiovascular system
Signs of deep vein thrombosis: Homans and the Wells score !
- Sign
A swollen, warm, painful leg on one side may be a clot; a simple score helps decide whether to look for it.
Updated 2026-11-01
See it in 3D: Popliteal vein · Femoral vein · Deep femoral vein · Great saphenous vein
What it is
Deep vein thrombosis (DVT) usually affects the calf, popliteal and femoral veins. Single signs are unreliable and about half of cases cause no symptoms. They are therefore combined in the Wells score, which estimates probability and guides D-dimer and ultrasound.
Key facts
- Wells score for DVT, one point each: active cancer; paralysis, paresis or recent cast of the leg; bedridden more than 3 days or major surgery within 12 weeks; tenderness along the deep veins; entire leg swollen; calf more than 3 cm larger than the other; pitting edema only in the symptomatic leg; collateral (non-varicose) superficial veins; previous DVT.
- Subtract 2 points if another diagnosis is at least as likely.
- 2 points or more: DVT likely (ultrasound). Below 2: unlikely (D-dimer; if normal, DVT is excluded in most).
The anatomy it tests
- The clot forms through Virchow triad: stasis, endothelial injury and hypercoagulability.
- The deep leg veins (tibial, popliteal, femoral) drain almost all the limb's blood; when blocked, venous pressure rises and edema follows.
- Homans stretches the calf muscles over inflamed veins, so it can hurt, but it also hurts with other muscle injuries.
How to elicit it
- Ask about risk factors: immobility, recent surgery or trauma, cancer, pregnancy or the postpartum period, estrogen contraceptives, previous thrombosis.
- Inspect both bare legs: asymmetry, redness, cyanosis, dilated superficial collateral veins.
- Measure both calf circumferences 10 cm below the tibial tuberosity.
- Palpate along the deep veins (calf, popliteal fossa, medial thigh, groin) for tenderness and a cord.
- Look for pitting edema confined to the symptomatic leg.
- Homans sign: with the knee slightly flexed, passively dorsiflex the ankle; it is positive if calf pain appears.
What a positive result means
- Positive: a unilateral swollen, warm, red or painful leg, with a circumference difference and tenderness along the vein.
- Suspect pulmonary embolism if there is also sudden dyspnea, pleuritic pain, tachycardia or hemoptysis.
- A massively swollen, cyanotic, painful leg: phlegmasia cerulea dolens, an emergency because of gangrene risk.
- A normal exam does not exclude DVT: half of cases have no symptoms.
Usefulness and limits
- Homans has low sensitivity and low specificity; it is not used alone and forceful dorsiflexion is avoided.
- Differential diagnosis: ruptured Baker cyst, muscle tear, cellulitis, lymphedema, venous insufficiency.
- Compression ultrasound confirms or excludes; D-dimer is mainly useful to exclude when probability is low.
Test yourself
Think of the answer, then tap the question to see it.
How is the Homans sign elicited?
With the knee slightly flexed, the ankle is passively dorsiflexed; it is positive if it causes calf pain.
Why is the Homans sign not trusted to diagnose DVT?
Its sensitivity and specificity are low: it is absent in many thromboses and present in muscle injuries.
Which Wells score makes DVT likely?
2 points or more; compression ultrasound is then requested.
Where is calf circumference measured for the Wells score?
10 cm below the tibial tuberosity on both legs; it counts if the difference exceeds 3 cm.
See it in 3D
The structures of Durgical's 3D anatomy where it is found.
Related
- Edema: pitting, grading and distribution
- Varicose veins: the Trendelenburg (Brodie–Trendelenburg) test
- Peripheral pulses and the ankle–brachial index
- Chest pain: ischemic, pericardial, pleural and other patterns
Related conditions
- Deep vein thrombosis
- Pulmonary embolism
- Inherited thrombophilia
- Antiphospholipid syndrome
- Chronic venous insufficiency
Educational content on the clinical exam; it is learned and practised under supervision. It does not replace assessment by a health professional and is not for self-diagnosis.
Sources: Deep vein thrombosis: MedlinePlus Medical Encyclopedia (MedlinePlus, U.S. National Library of Medicine, 2026); About Venous Thromboembolism (Blood Clots) | Venous Thromboembolism (Blood Clots) | CDC (Centers for Disease Control and Prevention, 2026); 24.3 Nursing Assessment - Clinical Nursing Skills | OpenStax (OpenStax (Rice University), 2024).
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Representative model, for educational purposes only.