Comparison of examination techniques of anterior and posterior compartments of the leg for the diagnosis of deep vein thrombosis: A new examination technique

Abstract

Objectives

Several examination techniques have been described for the diagnosis of leg deep vein thrombosis. These previously described examination techniques aim to detect muscle pain that occurs secondary to increased pressure in the posterior compartment of the leg. However, to the best of our knowledge no studies investigated the frequency of muscle pain on the anterior compartment in patients with leg deep vein thrombosis the objective of this study is to investigate the prevalence of muscle pain in the anterior compartment.

Methods

The patients who were diagnosed with acute deep vein thrombosis were included in this prospective cross-sectional study. Each patient was examined using the techniques that determine the pain on the posterior compartment as well as using the technique we described to detect muscle pain on the anterior compartment.

Results

Two hunderd forty three patients were enrolled in the study. Among those, both distal and proximal deep vein thrombosis was present in 128 (52.7%) patients. 75% of them had muscle pain in the anterior compartment.

Conclusion

The results suggested that examination of muscle pain in anterior compartment of leg in patients with both proximal and distal deep vein thrombosis can be used as an additional physical examination techniques for early diagnosis.

Keywords

deep vein thrombosis leg anterior compartment physical examination technique

Introduction

All pathological thrombosis in the venous system are called venous thromboembolism (VTE). Deep vein thrombosis (DVT) is a manifestation of venous thromboembolism. Deep vein thrombosis is mostly seen in the deep veins of the legs and rarely in the upper extremities.^1,2

Medical history and physical examination alone are not sufficient in the diagnosis of DVT. However, due to medical history and physical examination, clinical suspicion arises and then the final diagnosis can be made using prediction rule scoring criteria, laboratory and imaging method.³ Examination techniques (ET), which are performed in order to reveal pain are very important in terms of assisting the clinician in the thought of venous thrombosis. Because physical examination is essential to have clinical suspicion.^4–7 The importance of ET triggering pain becomes more evident, considering the facts that swelling, cyanosis and pain which are the classic triad of clinical symptoms that may cause clinical suspicion, occur only 50% of cases and up to 16.5% of cases may be asymptomatic.⁸

Compartmens and veins of leg are shown in Figure 1 and Figure 2. Thrombosis in these veins causes an increased pressure in the relevant compartments. Anterior compartment is reported as the most sensitive compartment to the increased pressure in the leg.^9–11 To best to our knowledge, there are no studies in the literature investigating the frequency of muscle pain on the anterior compartment in the leg of DVT patients. All previously described traditional ETs for DVT reveal sensitivity in the posterior compartment.

This traditional ETs for detecting sensitivity in the posterior compartment are:

Homan’s sign; Pain in the calf when forcing the foot to dorsiflexion.

Rosenthal sign; Pain in the calf with plantar flexion of the foot.

Sigg’s sign: Knee extended and downward pressure is applied to the patella using the palmar aspect of one hand while the other hand lifts the heel. A positive test is the presence of a strong pain in the popliteal fossa.

Pataro sign: tenderness in the calf when touching

Tschmarke sign: Pain in the calf when squeezing the calf.

Ducuing sign: Pain in the calf with calf ballotman.

Bisgard sign: Infiltration of the calcaneo-malleolar region manifested as a deep pressure pain.

Olow sign: Pain with applying pressure to the Achilles tendon

Louvel sign: Pain in the leg when coughing.^4–6

The new ET we described as a Hocagil sign is based on the principle of triggering pain formation on the tibialis anterior and extansor digitorum longus muscle when patting on these muscles from the proximal to the distal (Figure 3)

Figure 1.

Compartments of the lower leg.

Figure 2.

Deep veins of the right leg.

Figure 3.

The new examination technique (Hocagil sign): pain on the tibialis anterior and extansor digitorum longus muscle when patting on these muscles from the proximal to the distal.

The aim of this study is to investigate the prevalence of new ET.

Methods

This study is a prospective cross-sectional study which is conducted at the Emergency Department of Zonguldak Bülent Ecevit University, Faculty of Medicine. Patients who were admitted to the emergency department between 2018/04/15–2019/12/31 and diagnosed with acute DVT were included in this study.

Information on age, gender, clinical information such as redness of the leg, edema, skin temperature of the leg, cyanosis and pain for each patient have been collected.

For each patient, DVT Wells scores were calculated. Diameters of both legs with and without DVT were measured 10 cm below the tuberositas tibia.

Patients were classified based on the diameter difference as; (1) no difference, (2) difference < 3 cm, (3) difference:3–5 cm, (4) difference > 5 cm.

Each patient was examined using the traditional ET that determine the pain on the posterior compartment as well as using the new ET we described to detect muscle pain on the anterior compartment. We compare and contrast findings from these examinations.

All patients diagnosed with acute DVT with duplex ultrasonography were included in this study.

Based on the location of veins with DVT:

1. Common femoral vein (CFV), superficial femoral vein (SFV), deep femoral vein (DFV) are classified as proximal

2. Popliteal vein (PV), tibial veins (TV) are classified as distal

3. Both distal and proximal veins are classified as mixed-type.¹²

Data analysis

Categorical variables were expressed as the absolute and relative frequencies and compared using the chi‐squared test and fisher’s exact test as appropriate. Continuous variables were expressed as mean and standard deviation. Categorical clinicopathological risk factors for DVT were evaluated using Fisher’s Exact test and Chi-square test as appropriate. For continuous risk factors, we used Student’s t-test and One-way ANOVA test as appropriate.

Analyses were done using the software package SPSS 22 (SPSS Inc. Chicago, IL, USA).

Ethical approval

The research was submitted to the Research Ethics Committee at the Zonguldak Bülent Ecevit University, and approved under certificate number 2018–120-11/04. Informed consent was received from all patients in the study.

Results

Two hunderd forty three patients were included in this study. 51.4% of them (n = 125) were female. Average age of women was 57.03 ± 20.63 (min: 17.00 max: 94.00), while the average age of men was 56.09 ± 15.31 (min: 19.00 max: 88.00).

In 156 patients (64.2%), DVT was located on the left leg. By the time patients were admitted to the emergency department, the symptoms they have were unilateral swelling (n = 217, 89.3%), pain in the leg (n = 173, 71.2%), increased skin temparature of the leg (n = 113, 47.1%), redness (n = 104, 42.8%), and cyanosis (n = 5, 2.1%). Among all 243 patients, 70 patients (28.8%) reported that they have no pain at the time of admission. Pain detected by at least one ET in 64 of these 70 patients without pain, while pain detected by at least one ET in 165 of 173 patients with pain at the time of admission (Table 1).

Table 1.

The relationship between pain at the time of admission and pain provoked by examination techniques.

While 217 of the patients (89.3%) had an increase in the diameter of the leg with DVT, in 26 patients (10.7%) increase in the diameter of the leg have not been observed. The mean diameter increase was 2.98 ± 2.02. Among all patients with increase on the diameter of the leg, 70 of them (28.8%) had < 3 cm increase, 113 of them (46.5%) had increase between 3-5 cm and 26 of them (10.7%) had increase > 5 cm.

Forty patients (16.5%) had isolated proximal DVT, 75 patients (30.9%) had isolated distal DVT and 128 patients (52.7%) had mixed-type DVT. In these patients, PV was the most common vein with DVT (n = 198, 81F.5%), and TV was the least common vein with DVT (n = 8, 3.3%).

The relationship between thrombus localization and ET and whether pain is detected or not is shown in Table 2. The most common positive techniques for detecting pain in patients were Ducuing sign and Tschmarke sign in isolated proximal DVT, Homan’s sign and Tschmarke sign in isolated distal DVT, Tschmarke sign and Hocagil sign in mixed type DVT.

Table 2.

The relationship between thrombus localization and presence of pain in examination techniques.

Both distal and proximal DVT was present in 128 (52.7%) patients. 75% of them had muscle pain in the anterior compartment.

When the DVT-Wells scores were evaluated in patients, it was determined that 61 (25.1%) patients had low probability, 43 (17.7%) patients had a medium probability, and 129 (53.1%) patients had a high probability scores. 10 patients (4.1%) could not describe the severity of the pain. 93.4% (n = 57) of patients with low probability of DVT-Wells score, 97.7% of patients with medium probability (n = 42), and 93% of patients with high probability (n = 120) had pain on physical examination.

Discussion

Many of the physical ET developed to detect pain in the leg reveal increased pain in the posterior compartments of the leg. However, the most sensitive compartment to pressure increase in the leg is the anterior compartment which is limited by the tibia, fibula, and interosseous membrane.¹³ A physical examination finding used to detect the increased pressure in the anterior compartment has not been described before. A new ET we described in this paper for the first time, the formation of muscle pain on the anterior compartment by gentle patting of the tibialis anterior and extensor digitorum longus muscles may assist the clinician in early detection of DVT. In this study, pain were detected in 75% of patients with DVT mixed-type with this ET.

When thrombosis is localized in calf veins and PVs, venous pressure may usually be normal, whereas in femoral veins venous pressure is 2–5 times higher than normal.¹⁴ Blocking of venous flow causes fluid to pass into the third space and cause edema. Progress of edema results in an increase in compartment pressure.^15,16 Due to rapidly expanding collaterals in the leg, increased pressure often does not progress to compartment syndrome. However, increased pressure within the compartment causes muscle pain detected by physical examination in the early period of occlusion. When intra-compartment pressure increases, active or passive stretching of these muscles increases the pain due to edema in the muscles.^17–19

Early diagnosis of DVT is critically important because approximately 50% of untreated proximal DVT cases result in pulmonary embolism. However, it may be difficult to diagnose DVT because the symptoms and signs are not specific to the diagnosis.^20,21 Patients with DVT may show different symptoms and signs depending on the degree of obstruction, the size and location of DVT and the comorbidities the patient has.²² The most important step in the diagnosis is the formation of sufficient clinical suspicion. History and physical examination are important because they initiate diagnostic algorithms by creating clinical suspicion.²³

Early diagnosis of thrombosis is much easier in patients who can receive outpatient care.

In these patients, calf pains and unilateral leg edema occur as the initial symptoms of venous thrombosis.⁷

In this study, results showed that there is a significant association between the increase in diameter and the presence of pain at the time of admission (Table 3). But there is no significant relationship between the presence of ET in the leg and dimeter difference.

Table 3.

The relationship between examination techniques.and leg diameter increase.

There may be no symptoms in DVT in bedridden patients, postoperative patients, and patients with mental disabilities. Deep vein thrombosis is often diagnosed with delay in these asymptomatic patients.

For this reason, careful and detailed physical examination of bedridden patients in the risk group becomes even more important.^{1,14,22,24,25} In this study, pain are found to be triggered by at least one ET in 64 of 70 patients who did not have pain at the time of admission. The relation between the presence of pain at the time of admission and the number of ET the pain provoked was statistically significant (p value = .04).

One of the striking results of this study is that there is no relationship between the detection of pain using ET and the DVT-Wells probability score. In other words, high pain rate (93.4%, 93.0%) was found in both patient groups with low DVT-Wells high DVT-Wells score. In a systematic review of 54 cohort studies in the literature, it was determined that the calculation of the DVT-Wells score is more valuable than the clinical features, and the predictive power of the DVT-Wells score changes according to the DVT localizations.²¹

In another study in which DVT-Wells criteria is defined as the best screning score, it is reported that DVT risk is 40% when DVT-Wells criteria is greater than two and DVT risk is 15% when DVT-Wells criteria is less than 2.²⁶

In this study, pain is detected in 57 (93.4%) of 61 patients with a low probability of DVT-Wells score. This finding emphasize the importance of performing the examinations to provoke pain in patients with low probability of DVT-Wells score.

The left common iliac artery crosses the left common iliac vein and arterial pulsations cause chronic damage to the left iliac vein. This causes increased susceptibility to thrombosis on the left side.^3,12,27 In this study, left leg is the most common localization of DVT with a rate of 64.2%. This finding is consistent with findings of other studies in the literature.^28,29

Deep vein thrombosis usually occurs in the deep veins of the leg or in the proximal veins of the ilio-femoral segment.¹ In this study, among all patients 40 of them (16.5%) had isolated proximal DVT, 75 patients (30.9%) had isolated distal DVT, 128 patients (52.7%) had mixed-type DVT. Zhuang et al. reported these rates as 11.3%, 23.5%, 65.2%’ respectively.¹¹ There is no significant relationship between the localization of DVT and gender (p-value = .242).

In accordance with the literature, it is found that DVT frequently diagnosed in elderly people. The relationship between localization of DVT and mean age is found to be statistically significant (p-value = .03). The high incidence rate of DVT in elderly population may be explained by the higher incidence rate of risk factors such as immobilization, obesity, cancer and previous surgeries.^1,25,30 Furthermore, asymptomatic (silent) DVTs are more commonly reported in older patients.

All these suggest that every patient in the risk group should have a detailed physical examination for DVT, regardless of whether there is a difference in diameter or pain in the leg.

The use of this new technique may contribute to the early recognition of some silent asymptomatic DVT cases.

Limitations

Because this study was conducted on patients diagnosed with acute DVT, the presence of pain was not investigated by ET in patients without DVT, even though they had DVT-like complaints.

Conclusion

Pain in the anterior compartment area described in this study may be a physical examination that will guide the detection of provoked pain in the patient group with mixed-type DVT. Further studies are needed to investigate whether there is muscle pain in the anterior compartment especially in patients at risk for asymptomatic/silent DVT.

Footnotes

Acknowledgements

We would like to thank Behçet Al for her assistance and guidance in this research.

Declaration of conflicting interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The author(s) received no financial support for the research, authorship, and/or publication of this article.

Informed consent

Informed consent was received from the relatives of the all patients in the work

ORCID iD

Halil Hocagil

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