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Manual Therapy 12 (2007) 29–33

Original article

Myofascial trigger points in subjects presenting with mechanical neck

pain: A blinded, controlled study
C. Fernández-de-las-Peñas, C. Alonso-Blanco, J.C. Miangolarra
Department of Physical Therapy, Occupational Therapy, Physical Medicine and Rehabilitation, Universidad Rey Juan Carlos (URJC), Alcorcón, Spain
Received 12 November 2004; received in revised form 4 January 2006; accepted 3 February 2006


The aim of this study was to describe the differences in the presence of myofascial trigger points (TrPs) in the upper trapezius,
sternocleidomastoid, levator scapulae and suboccipital muscles between patients presenting with mechanical neck pain and control
healthy subjects. Twenty subjects with mechanical neck pain and 20 matched healthy controls participated in this study. TrPs were
identified, by an assessor blinded to the subjects’ condition, when there was a hypersensible tender spot in a palpable taut band, local
twitch response elicited by the snapping palpation of the taut band, and reproduction of the referred pain typical of each TrP. The
mean number of TrPs present on each neck pain patient was 4.3 (SD: 0.9), of which 2.5 (SD: 1.3) were latent and 1.8 (SD: 0.8) were
active TrPs. Control subjects also exhibited TrPs (mean: 2; SD: 0.8). All were latent TrPs. Differences in the number of TrPs between
both study groups were significant for active TrPs (Po0.001), but not for latent TrPs (P40.5). Moreover, differences in the
distribution of TrPs within the analysed cervical muscles were also significant (Po0.01) for all muscles except for both levator
scapulae. All the examined muscles evoked referred pain patterns contributing to patients’ symptoms. Active TrPs were more
frequent in patients presenting with mechanical neck pain than in healthy subjects.
r 2006 Elsevier Ltd. All rights reserved.

Keywords: Mechanical neck pain; Myofascial trigger points; Myofascial pain; Blinded controlled study

1. Background and neural impairments (Simons et al., 1999; Maitland

et al., 2000). Soft tissue therapies and spinal manipula-
Mechanical neck pain affects 45–54% of the general tion/mobilization are manual therapies commonly used
population at some time during their lives and can result in the management of mechanical neck pain and
in severe disability (Côté et al., 1998). The exact associated impairments (Gross et al., 2002).
pathology of mechanical neck pain is not clearly Simons et al. (1999) have claimed that myofascial
understood and has been purported to be related to trigger points (TrPs) from neck and shoulder muscles
various anatomical structures including, uncovertebral might play an important role in the genesis of
or intervertebral joints, neural tissues, discs, muscular mechanical neck pain. There are epidemiological studies
disorders and ligaments (Simons et al., 1999; Maitland suggesting that TrPs represent an important source of
et al., 2000). Different authors often assume that musculoskeletal disorder (Chaiamnuay et al., 1998). A
mechanical neck pain is associated with muscular, joint TrP is a hyperirritable spot within a palpable taut band
of a skeletal muscle that is painful on compression,
Corresponding author. César Fernández de las Peñas, Facultad de
stretch or overload of the affected tissues and that can
Ciencias de la Salud, Universidad Rey Juan Carlos, Avenida de Atenas give rise to a typical referred pain pattern (Simons et al.,
s/n, 28922 Alcorcón Madrid, Spain. Tel.: + 34 91 488 88 84;
fax: +34 91 488 89 57.
1999). TrPs are typically located by the following
E-mail addresses:, physical examination findings: presence of a palpable
(C. Fernández-de-las-Peñas). taut band in a skeletal muscle, tender spot within the

1356-689X/$ - see front matter r 2006 Elsevier Ltd. All rights reserved.
30 C. Fernández-de-las-Peñas et al. / Manual Therapy 12 (2007) 29–33

taut band, local twitch response provoked by snapping neck pain intensity was less than four points on a 10-cm
palpation of the TrP, and referred pain pattern (Simons horizontal visual analogue scale. This study was
et al., 1999). The formation of TrPs may result from a supervised by the Department of Physical Therapy,
variety of factors, such as severe trauma, overuse, Occupational Therapy, Physical Medicine and Rehabi-
mechanical overload or psychological stress (Simons litation of the Universidad Rey Juan Carlos. The
et al., 1999). Recent studies have hypothesized that the research project was approved by the local human
pathogenesis of TrPs results from injured or overloaded research committee of the Universidad Rey Juan Carlos.
muscle fibres. This leads to involuntary shortening, loss All subjects signed an informed consent prior to their
of oxygen supply, loss of nutrient supply and increased inclusion.
metabolic demand on local tissues (Mense et al., 2000).
Although previous studies have investigated the
prevalence of TrPs in benign chronic headaches (Jaeger, 2.2. Procedure
1989; Marcus et al., 1999), we were unable to locate any
study in the peer-reviewed literature analysing the Subjects were examined for TrPs by an assessor who
prevalence of TrPs in the cervical musculature (levator had more than 4 years experience in TrPs diagnosis, and
scapulae, sternocleidomastoid, upper trapezius muscle). who was blinded to the subjects’ condition. The
These TrPs have the potential to refer pain contributing diagnosis of the TrP was performed following the latter
to neck and shoulder symptoms in patients presenting five diagnostic criteria described by Simons et al. (1999)
with mechanical neck pain. Our aim was to describe the and by Gerwin et al. (1997): (1) presence of a palpable
differences in the presence of TrPs in the upper taut band in a skeletal muscle; (2) presence of a
trapezius, sternocleidomastoid, levator scapulae and hypersensible tender spot in the taut band; (3) local
suboccipital muscles between subjects with mechanical twitch response elicited by the snapping palpation of the
neck pain and healthy controls. In addition, we taut band; (4) reproduction of the typical referred pain
examined the possible correlation in the presence of pattern of the TrP in response to compression; and (5)
TrPs among the aforementioned muscles. spontaneous presence of the typical referred pain
pattern and/or patient recognition of the referred pain
as familiar. If the first four criteria were satisfied the TrP
2. Material and methods was considered to be latent. If all of the aforementioned
criteria were present the TrP was considered to be active
2.1. Subjects (Gerwin et al., 1997; Simons et al., 1999). Tender points
were also diagnosed when subjects reported local
Twenty subjects presenting with mechanical neck pain tenderness but they did not report referred pain to
for at least 4 months and 20 healthy age- and sex- compression and/or overload of the affected tissues, so
matched controls without neck pain during the prior 6 minimum criteria for TrP diagnosis were not fulfilled
months participated in this study from January to (Gerwin et al., 1997; Simons et al., 1999).
September of 2004. For the purpose of this study, In criteria four and five, pressure on the TrP was
mechanical neck pain was defined as generalized neck assessed using a Pressure Threshold Meter (PTM). The
and/or shoulder pain with mechanical characteristics assessor applied continuous pressure approximately at a
including: symptoms provoked by maintained neck rate of 1 kg/cm2/seg until 2.5 kg/cm2. A PTM distributed
postures or by movement, or by palpation of the by ‘‘Pain Diagnosis and Rehabilitation’’ commercial
cervical muscles. Patients were excluded if they exhibited home (233 East Shore Road, Suite 108, Great Neck,
any of the following: (1) diagnosis of fibromyalgia New York 11023) was used in this study. The PTM
syndrome according to the American College of consists on a rubber disk with 1 cm2 surface The rubber
Rheumatology (Wolfe et al., 1990); (2) previous history disk is connected to a pressure pole inserting into a
of a whiplash injury; (3) history of cervical spine gauge which records pressure in kilograms (kg). Pressure
surgery; (4) diagnosis of cervical radiculopathy or measurements are expressed in kg/cm2. The range of
myelopathy determined by their primary care physician; pressure is between 0 and 10 kg/cm2 recording values
or (5) therapeutic intervention for myofascial each 0.1 kg. Previous papers reported an intra-examiner
pain within the past month before the study. The (I.C.C.) reliability of the PTM ranging from 0.6 to 0.97,
health status of all patients was clinically stable, and an inter-examiner reliability (I.C.C.) ranging from
without current symptoms of any other concomitant 0.4 to 0.98 (Takala, 1990; Levoska, 1993). Pressure
chronic disease. The clinical history for each patient thresholds lower than 3 kg, are considered abnormal
was solicited from their primary care physician to (Fischer, 1996). Fig. 1 details the location and the
assess the exclusion criteria and to check the presence referred pain patterns evoked by TrPs in the examined
of ‘‘red flags’’, i.e. infection, malignancy. Subjects cervical muscles based on the comprehensive research
with neck pain were examined on days in which the performed by Simons et al. (1999).
C. Fernández-de-las-Peñas et al. / Manual Therapy 12 (2007) 29–33 31

2.3. Analysis of data The w2 of association was used to assess the differences
in the distribution of TrPs within each muscle between
Descriptive data was collected on all patients. The both study groups and the presence of TrPs among the
number of active and latent TrPs was recorded for each analysed cervical muscles. The statistical analysis was
patient and then the group mean was calculated. The conducted at a 95% confidence level. A P-value less
inter-group comparison between the number of TrPs than 0.05 were considered as statistically significant.
(active or latent) was analysed with the unpaired t-test.

3. Results

A total of 20 neck pain subjects, 7 men and 13

women, 20–44 years old (mean age: 2877 years), were
studied. The duration of neck complaints ranged from 7
to 15 months (mean ¼ 9.2573 months). The mean level
of neck pain according to the 10 cm visual analogue
scale on the day of the examination was 2.5 cm (SD 0.7).
Control subjects were 20 healthy volunteers, 10 men and
10 women, aged 20–50 (mean age: 2979 years).
Each of the 20 neck pain patients exhibited at least
three TrPs in the analyzed muscles. The mean number of
TrPs on each patient was 4.3 (SD: 0.9), of which 2.5
(SD: 1.3) were latent and 1.8 (SD: 0.8) were active TrPs.
On the other hand, each control subject also exhibited
TrPs (mean: 2; SD: 0.8). All were latent TrPs.
Differences in the total number of TrPs (active and
latent) and the number of active TrPs between both
study groups reached the statistical significance
(Po0.001). Differences in the number of latent TrPs
were not significant (P40.05).
Moreover, differences in the distribution of active
TrPs within each cervical muscle were also significant
for all muscles except for both levator scapulae (see
Table 1). Within the neck pain group, TrPs in the
suboccipital muscles were the most prevalent (n ¼ 18;
90%), following by TrPs in the right sternocleidomas-
toid muscle (n ¼ 17; 85%), and TrPs in the left upper
Fig. 1. Referred pain pattern from myofascial trigger points in some trapezius muscle (n ¼ 14; 70%). Surprisingly, TrPs in
cervical muscles based on the comprehensive research performed by the suboccipital muscles were the most prevalent in our
Simons et al. (1999).
neck pain patients (90%). As the referred pain evoked

Table 1
Distribution of subjects with myofascial trigger points (active or latent) in both study groups

Suboccipital muscles Upper trapezius muscle Levator scapulae muscle Sternocleidomastoid muscle

Left side Right side Left side Right side Left side Right side

Subjects with mechanical neck pain

Active TrPs (n) 10 7 8 0 3 3 5
Latent TrPs (n) 8 7 5 6 3 10 12
Control healthy subjects
Active TrPs (n) 0 0 0 0 0 0 0
Latent TrPs (n) 5 8 10 6 7 1 4
P-value 0.001 0.01 0.006 NS NS 0.001 0.001

TrP, myofascial trigger point; NS, non-significant; n, number of subjects, P-values express differences between active TrPs. Differences between latent
TrPs were not significant.
32 C. Fernández-de-las-Peñas et al. / Manual Therapy 12 (2007) 29–33

by these TrPs spreads to the head and it is usually have showed different relationships among the presence
perceived as headache (Simons et al., 1999), patients of TrPs in some of the analysed cervical muscles. One
were asked for the presence of headache. Half of these hypothesis to justify these relationships might be that
patients reported tension-type headache concomitant muscles located in the region of the referred pain pattern
with their neck symptoms, especially when their neck of a TrP might also develop secondary TrPs (Hong,
pain were aggravated by stress. Within the control 1994; Simons et al., 1999). This hypothesis might explain
group, the most prevalent TrPs were located in both our results: the presence of TrPs in the sternocleido-
upper trapezius muscles (n ¼ 10; 50% in the right side; mastoid was associated to the presence of TrPs in the
n ¼ 8; 40% in the left side) and in the right levator homo-lateral upper trapezius muscle, or TrPs in the
scapulae muscle (n ¼ 7; 35%). upper trapezius muscle associated to TrPs in the homo-
Finally, w2 analysis by contingency tables showed a lateral levator scapulae. However, our study design did
significant relationship between the presence of TrPs in not enable a cause and effect relationship to be
the left upper trapezius and left sternocleidomastoid established so further studies are required on that topic.
muscles (P ¼ 0.03), between TrPs in the left upper TrPs diagnosis needs adequate innate ability, training,
trapezius and left levator scapulae muscles (P ¼ 0.005) and clinical practice to develop a high degree of
and between TrPs in the right upper trapezius and reliability in the examination (Gerwin et al., 1997;
suboccipital muscles (P ¼ 0.05). Other relationships, i.e. Sciotti et al., 2001). Moreover, some muscles are
TrPs in the right or left sternocleidomastoid and consistently more reliably examined than others. Simons
suboccipital muscles, did not reach a significant level et al. (1999) and Gerwin et al. (1997) recommend that
(P ¼ 0.06). the minimum acceptable criteria for active TrP diagnosis
is the combination of the presence of a spot tenderness
in a palpable taut band in a skeletal muscle and patient
4. Discussion recognition of referred pain that is elicited by pressure
applied to the tender spot. These criteria had obtained a
Our study is the first to provide preliminary evidence good inter-examiner reliability (k) ranging from 0.84 to
suggesting that active myofascial trigger points (TrPs) 0.88 (Gerwin et al., 1997). In the present study, these
are more common in subjects presenting with mechan- two minimum criteria identified active TrPs. Further-
ical neck pain than in healthy controls. Active TrPs of more, the local twitch response, a confirmatory sign of
the examined muscles evoked referred pain patterns TrP diagnosis (Simons et al., 1999), was also an
contributing to neck symptoms seen in our patients. inclusion requirement in the diagnosis of TrPs in all
Simons et al. (1999) claimed that neck pain might be muscles except in the suboccipital muscles, in which it is
usually provoked by TrPs in the upper trapezius and difficult or impossible to elicit a local twitch response by
levator scapulae muscles. Almost all neck pain patients snapping palpation. Suboccipital muscle TrPs were
showed TrPs in the upper fibres of the trapezius muscle, explored bilaterally in order to evoke bilateral referred
in the right and/or left sides. Most of these TrPs were pain (Simons et al., 1999), and also to avoid the
active TrPs, as patients were familiar with the location palpation of TrPs in other cervical posterior muscles.
(posterior-lateral region of the neck) and the quality of The high incidence of suboccipital muscle TrPs in neck
the referred pain (tightening and burning) that was pain patients might be provoked because these muscles
elicited by pressure applied to the TrP. When the could not be explored unilaterally. Tender points were
assessor applied pressure to that TrP, many patients also diagnosed when subjects did not report referred
reported: ‘‘Yes, this is exactly the pain that I usually pain elicited by compression and/or overload of the
feel’’. affected tissues, so minimum criteria for TrP diagnosis
On the other hand, active TrPs in the control healthy were not fulfilled (Gerwin et al., 1997; Simons et al.,
group were scarce (Po0.001). TrPs in this group never 1999).
evoked a familiar ache, and therefore were classified as In the present study the presence of TrPs in subjects
latent TrPs (Gerwin et al., 1997; Simons et al., 1999). with mechanical neck pain has been demonstrated.
Significant differences between neck pain subjects and However, it is possible that other tissues might also
healthy controls were found for active TrPs, but not contribute to symptoms associated with mechanical
for latent TrPs. This is expected, as latent TrPs, have neck pain. Edgar et al. (1994) reported that decreased
been commonly observed in healthy, normal subjects extensibility of the upper quadrant neural structures as
(Chaiamnuay et al., 1998). assessed by the median nerve tension test was associated
Hong (1994) claimed that the treatment of ‘‘key’’ TrPs with decreased length of the upper trapezius muscle.
in some muscles could also relieve the pain arising from Fernández-de-las-Peñas et al. (2005) have recently found
satellite TrPs in other muscles. This was one of the a significant relationship between the presence of TrPs in
reasons for assessing the possible relationship on the the upper trapezius muscle and the presence of inter-
presence of TrPs in the cervical musculature. Our results vertebral joint dysfunctions at C3 and C4 vertebrae.
C. Fernández-de-las-Peñas et al. / Manual Therapy 12 (2007) 29–33 33

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