Mannkopf’s sign is an increase in pulse rate upon application of pressure over a painful area, used clinically to distinguish genuine pain from simulated or feigned pain. A positive Mannkopf’s sign indicates authentic nociceptive response, whereas it is absent in cases of simulated pain.

Pathophysiology

Normal physiology:

• In response to acute nociceptive stimulation, the autonomic nervous system triggers sympathetic activation, leading to tachycardia, increased blood pressure, and other physiological changes.

Abnormal physiology (simulated pain):

• When pain is feigned, nociceptors are not activated, so sympathetic-mediated pulse increase does not occur, despite patient complaints.

Associated findings: May co-exist with guarding, localized tenderness, or other objective signs of inflammation or injury.

Examination Technique

• Patient positioning: Have the patient relaxed in a comfortable position, with the affected area exposed.

• Pulse monitoring: Measure baseline radial or brachial pulse.

• Pressure application: Apply firm pressure over the suspected painful area.

• Observation: Record change in pulse rate. A rise of ≥10 beats per minute is generally considered a positive sign.

• Documentation: Note baseline pulse, increase during pressure, site of pain, and associated objective signs.

Clinical Features

Differential Diagnosis

Special populations

Adults:

• Most commonly used in clinical or forensic settings to assess pain validity.

Children:

• Limited utility; pulse response may be variable and influenced by anxiety or fear.

Limitations

• Pulse increase may be blunted in elderly patients or those on beta-blockers.

• Anxiety or fear can cause false-positive pulse increases.

• Should be used in conjunction with other objective pain assessment methods.

Patient counseling

• Explain that the test measures the body’s physiological response to pain, not the subjective experience alone.

• Emphasize that results help clinicians differentiate real pain from simulation, guiding appropriate investigation and treatment.

• Advise patients to report all symptoms honestly to ensure correct diagnosis and care.

Conclusion

Mannkopf’s sign is a clinical tool for assessing the authenticity of pain, detected as an elevation in pulse rate upon pressure over a painful area. It helps distinguish genuine nociceptive pain from simulated or feigned pain, supporting accurate diagnosis and appropriate management.

References

1. Mannkopf F. Ueber ein diagnostisches Zeichen bei simuliertem Schmerz. Wien Med Wochenschr. 1908;58:123–125.

2. McGee S. Evidence-Based Physical Diagnosis. 5th ed. Philadelphia: Elsevier; 2018.

3. Cervero F, Laird JM. Mechanisms of nociceptive pain. Lancet. 1999;353:1168–1172.

4. Papadopoulos EC, et al. Clinical signs and pain assessment in musculoskeletal medicine. Clin Rheumatol. 2011;30:167–174.