Woltman sign

Description

Woltman sign of myxedema: Slowness of both the contraction and the relaxation of muscles in hypothyroid patients, best seen as the “hung-up” ankle jerk and occurring because of mechanical factors and slowness of contraction time, as in myotonia and pseudomyotonia

History

1924 – Chaney published the objectively measured delay of the relaxation phase of the muscle stretch reflex in patients with myxoedema, the first concise and objective description in the medical literature. 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.

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

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

The sign has also been demonstrated in treatment with β-blockers; diabetes mellitus; and complete heart block

Associated Persons

• Henry Woltman (1889 – 1964)
• William Calvert Chaney (1889 – 1965)

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.

Woltman sign has been described as a ‘pseudomyotonia’ because of its superficial resemblance to the slow muscle relaxation of myotonia, however myotonic discharges are not seen on neurophysiological testing.

References

• 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]
• Moersch FP. Henry William Woltman MD. 1889 – 1964. Arch Neurol 1965; 13: 101–3.
• 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
• Burkholder DB, Klaas JP, Kumar N, Boes CJ. The origin of Woltman’s sign of myxoedema. J Clin Neurosci. 2013; 20(9): 1204-6