Diagnosing deep vein thrombosis (DVT) may appear straightforward when applying established clinical tools, but in practice, patient presentations are often unpredictable. Even with widely used frameworks like the Wells Criteria, findings do not always align with the scoring system.
In a recent co-authored work, Identification of a Deep Vein Thrombosis in a Dark-Skinned Male: Finding Limitations in the Wells Criteria, Devon Morris, PT, DPT, OCS, and her colleagues, explore this gap between protocol and real-world practice by pairing a patient case with broader clinical analysis, cautioning against overreliance on scoring systems that can create a false sense of security. Morris doesn’t argue against the tools, but she does raise concerns about letting the tool criteria overshadow clinical judgment.
Morris is a licensed physical therapist and board-certified orthopedic specialist who treats sports-related injuries in youth and professional athletes. During her residency, she encountered a DVT that did not align with the Wells Criteria, underscoring how erythema can be less apparent in patients with darker skin.
Her patient, a 31-year-old Black male, began physical therapy after undergoing Achilles tendon surgery to repair a sports injury. After weeks of physical therapy, the patient experienced severe calf pain described as “sharp, throbbing, and tight,” with decreased weight-bearing capability.
Upon initial muscle and movement testing, the patient was screened with the Wells Criteria for DVT risk, which indicated a low pretest probability of DVT. A second therapist checked Wells, performed Homan’s sign, and a Thompson’s test, and concluded that no referral was necessary.
Dr. Morris, however, remained concerned based on the severity of new symptoms: calf tenderness, recent immobilization, and surgery as risk factors for DVT, and referred the patient to their surgeon for an ultrasound. The ultrasound revealed several blood clots throughout the patient’s lower leg. Treatment consisted of anticoagulants for three months, followed by follow-up imaging. The patient was informed by their healthcare team that if the clot had gone undetected, they might have experienced a potentially life-threatening pulmonary embolism.
DVT carries a significant mortality risk due to its potential to progress to pulmonary embolism. Black patients have a higher prevalence of DVT than their white counterparts, indicating an urgent need for adequate screening.
“One of the challenges with conditions like DVT is that our most widely used screening tools, such as the Wells Criteria, were developed and validated in populations that did not reflect the diversity we see in practice today,” Morris explained.
Dr. Morris added that well-established genetic conditions, such as Factor V Leiden, and increased prothrombin generation (Zakai 2011, Lara 2013, Folsom 2019), increase the risk of clot development. “These conditions can affect anyone, but the distribution and interplay of genetic and environmental factors in Black populations are not as well studied,” Morris told BlackDoctor Pro, underscoring the need for more inclusive research.
Dr. Morris’ work emphasizes the importance of timely evaluation and advocacy within the healthcare system. Her and her colleagues’ full analysis can be found in the Journal of Orthopaedic & Sports Physical Therapy, where they provide a detailed exploration of both the patient case and the clinical decision-making involved.
“In clinical practice, it can be difficult to speak up when clinical judgment suggests something different from standard criteria or majority opinion,” Dr. Morris asserted. “For Black clinicians, that pressure can feel even greater. But advocating for our patients is essential, even when it means questioning existing guidelines.” In Dr. Morris’ case, persistence made the difference between dismissal and a diagnosis that led to life-saving treatment.
While the Wells Criteria remain a widely used tool for estimating DVT probability, its foundation was largely based on patients of European ancestry. This, coupled with the fact that key visual signs like redness or discoloration may be less apparent in patients with darker skin, underscores the need for more inclusive screening practices.
“My hope is that this case report is one of many that push the medical and research communities to re-examine the tools we use, ensure they are effective across all skin tones and populations, and commit to greater inclusivity in clinical research,” Dr. Morris encouraged.
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