Woltman sign

First described in a formal clinical setting at the Mayo Clinic in the 1920s, Woltman’s Sign became associated with hypothyroid neuromuscular dysfunction and was once considered a nearly pathognomonic feature of untreated myxoedema. The sign remains a visible, tactile clue to thyroid dysfunction, particularly in patients presenting with fatigue, bradykinesia, or cold intolerance.

However, its specificity has diminished over time. Delayed reflex relaxation can also occur in euthyroid elderly patients, those taking β-blockers, or in cases of anorexia nervosa, diabetes mellitus, and even late pregnancy. This broader differential means Woltman’s Sign, while historically evocative, is now better viewed as a suggestive rather than definitive neurological finding.

With the routine availability of thyroid function tests, the sign has declined in diagnostic prominence, yet it endures in physical examination lore as a reminder of the deep interplay between endocrine and neuromuscular physiology.

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History of the Woltman sign of myxoedema

1873 – Sir William Withey Gull (1816–1890) publishes a seminal case of “cretinoid” features in an adult woman following menopause, noting muscular languor, broad tongue, altered reflexes, and mental dulling. He hypothesises that atrophy of the thyroid gland is responsible, one of the first links between thyroid dysfunction and systemic neurological change.

1878 – William Miller Ord (1834–1902) coins the term myxoedema and observes delayed reflexes in hypothyroid patients, noting “there was a marked slowness of perception, and a marked slowness of response of muscles to voluntary or reflex nerve-impulse,” but without formal quantification.

1924 – William Calvert Chaney (1889-1965) as a Mayo Clinic fellow under Henry William Woltman (1889-1964), publishes a detailed, objective study of the delayed relaxation phase of the Achilles tendon reflex in myxoedema using a mechanical apparatus and graphical tracings. While not naming Woltman, he credits the Mayo Clinic Section of Medicine for observing the finding “for a number of years”.

He collected his data by building a device that connected to the foot. When the Achilles tendon was struck, the device would transmit changes in air pressure caused by the plantar flexion and subsequent relaxation of the foot to a tambour and marker, resulting in a graphical representation of the reflex. Chaney’s work demonstrated a consistent delay in muscle relaxation post-reflex in myxedema patients, correlated with reduced basal metabolic rate.

1. In cases of myxedema, the tendon reflexes produce such slow movement of the parts affected that the quality can be recognized without the aid of mechanical devices and is a valuable sign in the diagnosis of the disease.

2. In cases of myxedema, a greater stimulation is necessary to elicit a tendon reflex than in a normal person.

5. When a patient with myxedema is treated and brought back to normal so that he loses the usual characteristics of this disease, his tendon reflexes also seem to return to normal, and the approach of the reflexes to normal seems to keep pace with the basal metabolic rate

The results obtained show graphically, what has been observed for a number of years in the routine examination of these patients in the Section on Neurology of the Mayo Clinic, that myxedema is apparently the only condition in which the tendon reflexes are much slower than normal.

Chaney 1924

1953 – Mayo Clinic physicians Millikan and Haines wrote that this finding was first observed by Woltman

Dr. Henry Woltman was, to our knowledge, the first to make this observation and following his suggestion Chaney in 1924 made graphic records which demonstrated the “delayed reaction” of the stretch reflexes in myxedema.

Millikan CH, Haines SF 1953

1956 – Woltman retired from the Mayo Clinic, the term “Woltman’s sign of myxedema” was formally coined, honoring his indirect but influential role in defining this clinical phenomenon.

In addition to the advantages, already mentioned, of eliciting reflexes by percussion of the examiner’s finger, it should be pointed out that this method is the best available for estimating and comparing the speed of contraction and relaxation of the muscle which has been stimulated reflexly. By no other method is one as likely to recognize the presence of Woltman’s sign of myxedema.

Recognition depends on observing the marked slowing of relaxation, particularly easily observed in the biceps, quadriceps, gastrocnemius, and soleus reflexes. This sign is invaluable as a clinical test for confirming the diagnosis in a case of suspected myxedema; or, as often happens in practice, the recognition of slow relaxation of reflexes may initiate the suspicion of myxedema in the first place

Bastron et al 1956: 188

A series of studies in the 1960s evaluated the ankle/Achilles reflex time as a test of thyroid function. The Achilles reflex time was measured with the patient kneeling on a cushioned chair; the Burdick photomotogram and ECG paper running at 50mm/s.

1969 – Studies found that half-relaxation time (HRT) in euthyroid patients is approximately 240-320 ms. Cheah et al found 91% of patients with hyperthyroidism and 100% of hypothyroid patients had a half-relaxation time outside the normal range.

1973 – Gupta et al calculated the mean HRT in 129 patients to be statistically different in hyperthyroid (210ms); euthyroid (300ms); and hypothyroid (430ms) patients, but concluded that the test was not useful in determining requirement for thyroid replacement.

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Associated Persons

• Sir William Withey Gull (1816–1890)
• Henry William Woltman (1889-1964)
• William Calvert Chaney (1889-1965)

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Controversies

Woltman did not publish any original research or descriptions regarding the delayed relaxation phases of the muscle stretch reflexes in patients with myxoedema, and he was not named in Chaney’s 1924 publication. Chaney clearly stated that the finding had been used in the Mayo Clinic Section of Neurology for years prior to his publication and although Woltman’s name did not appear on the publication, it was not uncommon for him to mentor projects…

…without personal identification in the printed reports, so that the resulting honors came to adorn other shoulders

Moersch 1965

The eponym Woltman sign first appeared in the 1956 Mayo Clinic publication of Clinical Examinations in Neurology. A tome dedicated to Henry Woltman and Frederick Moersch, and was presented to Woltman at the time of his retirement. It is most likely that the eponym of Woltman sign of myxoedema is an homage to an esteemed colleague entering retirement, rather than the definitive designation of priority in discovery.

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References

Original articles

• Gull WW. On a cretinoid state supervening in adult life in women. Trans Clin Soc Lond, 1874; 7: 180–185.
• Ord WM. On Myxœdema, a term proposed to be applied to an essential condition in the “Cretinoid” Affection occasionally observed in Middle-aged Women. Med Chir Trans. 1878; 61: 57-78
• Ord WM. Report of a committee of the Clinical Society of London nominated December 14, 1883, to investigate the subject of myxoedema. Trans Clin Soc Lond 1888; 21: 298-301
• Gull W. Sur le Myxœdème. Archives générales de médecine 1879; 677-685
• 685, 1879.
• Chaney WC. Tendon Reflexes in Myxedema: A Valuable Aid in Diagnosis. JAMA. 1924; 82(25): 2013-2016 [Woltman sign]
• Millikan CH, Haines SF. The thyroid gland in relation to neuromuscular disease. Arch Intern Med 1953; 92: 5–39
• Bastron et al. Clinical studies in neurology. 1956: 188 [First use of the term Woltman sign]

Review articles

• Houston CS. The diagnostic importance of the myxoedema reflex (Woltman’s sign). Can Med Assoc J. 1958 Jan 15;78(2):108-12.
• Moersch FP. Henry William Woltman MD. 1889 – 1964. Arch Neurol 1965; 13: 101–3.
• Reinfrank RF, Kaufman RP, Wetstone HJ, Glennon JA. Observations of the Achilles reflex test. JAMA. 1967 Jan 2;199(1):1-4.
• Cheah JS, Tan BY. The Achilles tendon reflex time as a parameter of thyroid function. Singapore Med J. 1969 Dec;10(4):272-9.
• Gupta SP, Kumar V, Ahuja MMS. Evaluation of Achilles reflex time as a test of thyroid function. South Med J 1973 ;66(7): 754–8.
• Larner AJ. Normalisation of Slow-Relaxing Tendon Reflexes (Woltman’s Sign) After Cardiac Pacing for Complete Heart Block. Br J Clin Pract. 1995; 49 (6): 331-2
• Pearce JM. Myxoedema and Sir William Withey Gull (1816-1890). J Neurol Neurosurg Psychiatry. 2006 May;77(5):639.
• Burkholder DB, Klaas JP, Kumar N, Boes CJ. The origin of Woltman’s sign of myxoedema. J Clin Neurosci. 2013; 20(9): 1204-6
• Iwasaki Y, Fukaya K. Woltman’s Sign of Hypothyroidism. N Engl J Med. 2018 Oct 4;379(14):e23.