Codman’s sign is an orthopedic clinical sign indicating rupture of the supraspinatus tendon, a critical component of the rotator cuff. The sign is elicited by passively abducting the patient’s arm and then observing for pain upon withdrawal of examiner support.

A positive Codman’s sign occurs when:

• The patient experiences no pain during passive abduction, but

• Reports sudden pain when support is withdrawn, requiring the deltoid muscle to contract actively.

This pain reflects loss of supraspinatus tendon function, leading to overreliance on the deltoid muscle.

Pathophysiology

• The supraspinatus tendon initiates the first 15° of arm abduction and stabilizes the humeral head in the glenoid.

• Tendon rupture disrupts smooth abduction, leaving the deltoid muscle as the primary abductor.

• When examiner support is withdrawn, the deltoid contracts forcefully, causing:

  • Upward migration of the humeral head,

  • Increased subacromial impingement, and

  • Pain localized to the shoulder.

Examination Technique

Patient Positioning

• Patient seated or standing with the arm relaxed at the side.

Steps

1. Examiner passively abducts the patient’s arm to ~90°.

2. Patient asked to relax completely during passive movement.

3. Examiner suddenly removes support.

4. Observe for:

   • Sudden drop of the arm, and/or

   • Pain reported as the deltoid contracts.

Positive Result

• Pain occurs only after examiner support is removed.

Clinical Utility

• Diagnostic indicator of supraspinatus tendon rupture or severe tear.

• Helps differentiate rotator cuff tears from other causes of shoulder pain.

• Often used in conjunction with:

  • Drop arm test,

  • Neer’s impingement sign,

  • Hawkins-Kennedy test.

Differential Diagnosis

Pediatric cConsiderations

• Rare in children, as rotator cuff tears are uncommon.

• Shoulder pain in pediatrics more often due to trauma, infection, or instability.

Geriatric considerations

• Common in elderly patients due to degenerative changes in the rotator cuff.

• Frequently associated with atraumatic supraspinatus tears and chronic impingement.

Limitations

• Can yield false positives in patients with:

  • Severe shoulder impingement, or

  • Pain hypersensitivity unrelated to tendon rupture.

• Should be interpreted in combination with imaging (MRI, ultrasound) and other shoulder tests.

Patient counseling

• Explain that the test evaluates rotator cuff integrity.

• A positive finding may indicate a tendon tear requiring further imaging and possibly surgery.

• Reassure patients that early detection improves outcomes with appropriate rehabilitation or surgical repair.

Conclusion

Codman’s sign is a valuable orthopedic maneuver for detecting rupture of the supraspinatus tendon. Its diagnostic accuracy improves when combined with other clinical tests and imaging. Recognition of this sign is essential in evaluating patients with shoulder pain and dysfunction, particularly in the context of suspected rotator cuff injury.

References

1. Codman EA. The Shoulder: Rupture of the Supraspinatus Tendon and Other Lesions in or About the Subacromial Bursa. Boston: Thomas Todd Company; 1934.

2. Magee DJ. Orthopedic Physical Assessment. 7th ed. St. Louis: Elsevier; 2021.

3. Hoppenfeld S. Physical Examination of the Spine and Extremities. New York: Appleton-Century-Crofts; 1976.

4. Ropper AH, Samuels MA, Klein JP. Adams and Victor’s Principles of Neurology. 11th ed. New York: McGraw-Hill; 2021.

5. American Academy of Orthopaedic Surgeons. Shoulder Evaluation Guidelines. 2022.