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Manual Therapy 12 (2007) 29–33

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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

Abstract

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

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

1356-689X/$ - see front matter r 2006 Elsevier Ltd. All rights reserved.
doi:10.1016/j.math.2006.02.002
 ARTICLE IN PRESS
30 C. Fernández-de-las-Peñas et al. / Manual Therapy 12 (2007) 29–33
taut band, local twitch response provoked by snapping
palpation of the TrP, and referred pain pattern (Simons
et al., 1999). The formation of TrPs may result from a
variety of factors, such as severe trauma, overuse,
mechanical overload or psychological stress (Simons
et al., 1999). Recent studies have hypothesized that the
pathogenesis of TrPs results from injured or overloaded
muscle fibres. This leads to involuntary shortening, loss
of oxygen supply, loss of nutrient supply and increased
metabolic demand on local tissues (Mense et al., 2000).
Although previous studies have investigated the
prevalence of TrPs in benign chronic headaches (Jaeger,
1989; Marcus et al., 1999), we were unable to locate any
study in the peer-reviewed literature analysing the
prevalence of TrPs in the cervical musculature (levator
scapulae, sternocleidomastoid, upper trapezius muscle).
These TrPs have the potential to refer pain contributing
to neck and shoulder symptoms in patients presenting
with mechanical neck pain. Our aim was to describe the
differences in the presence of TrPs in the upper
trapezius, sternocleidomastoid, levator scapulae and
suboccipital muscles between subjects with mechanical
neck pain and healthy controls. In addition, we
examined the possible correlation in the presence of
TrPs among the aforementioned muscles.
2. Material and methods
2.1. Subjects
Twenty subjects presenting with mechanical neck pain
for at least 4 months and 20 healthy age- and sex-
matched controls without neck pain during the prior 6
months participated in this study from January to
September of 2004. For the purpose of this study,
mechanical neck pain was defined as generalized neck
and/or shoulder pain with mechanical characteristics
including: symptoms provoked by maintained neck
postures or by movement, or by palpation of the
cervical muscles. Patients were excluded if they exhibited
any of the following: (1) diagnosis of fibromyalgia
syndrome according to the American College of
Rheumatology (Wolfe et al., 1990); (2) previous history
of a whiplash injury; (3) history of cervical spine
surgery; (4) diagnosis of cervical radiculopathy or
myelopathy determined by their primary care physician;
or (5) therapeutic intervention for myofascial
pain within the past month before the study. The
health status of all patients was clinically stable,
without current symptoms of any other concomitant
chronic disease. The clinical history for each patient
was solicited from their primary care physician to
assess the exclusion criteria and to check the presence
of ‘‘red flags’’, i.e. infection, malignancy. Subjects
with neck pain were examined on days in which the
neck pain intensity was less than four points on a 10-cm
horizontal visual analogue scale. This study was
supervised by the Department of Physical Therapy,
Occupational Therapy, Physical Medicine and Rehabi-
litation of the Universidad Rey Juan Carlos. The
research project was approved by the local human
research committee of the Universidad Rey Juan Carlos.
All subjects signed an informed consent prior to their
inclusion.
2.2. Procedure
Subjects were examined for TrPs by an assessor who
had more than 4 years experience in TrPs diagnosis, and
who was blinded to the subjects’ condition. The
diagnosis of the TrP was performed following the latter
five diagnostic criteria described by Simons et al. (1999)
and by Gerwin et al. (1997): (1) presence of a palpable
taut band in a skeletal muscle; (2) presence of a
hypersensible tender spot in the taut band; (3) local
twitch response elicited by the snapping palpation of the
taut band; (4) reproduction of the typical referred pain
pattern of the TrP in response to compression; and (5)
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
was considered to be latent. If all of the aforementioned
criteria were present the TrP was considered to be active
(Gerwin et al., 1997; Simons et al., 1999). Tender points
were also diagnosed when subjects reported local
tenderness but they did not report referred pain to
compression and/or overload of the affected tissues, so
minimum criteria for TrP diagnosis were not fulfilled
(Gerwin et al., 1997; Simons et al., 1999).
In criteria four and five, pressure on the TrP was
assessed using a Pressure Threshold Meter (PTM). The
assessor applied continuous pressure approximately at a
rate of 1 kg/cm2/seg until 2.5 kg/cm2. A PTM distributed
by ‘‘Pain Diagnosis and Rehabilitation’’ commercial
home (233 East Shore Road, Suite 108, Great Neck,
New York 11023) was used in this study. The PTM
consists on a rubber disk with 1 cm2 surface The rubber
disk is connected to a pressure pole inserting into a
gauge which records pressure in kilograms (kg). Pressure
measurements are expressed in kg/cm2. The range of
pressure is between 0 and 10 kg/cm2 recording values
each 0.1 kg. Previous papers reported an intra-examiner
(I.C.C.) reliability of the PTM ranging from 0.6 to 0.97,
and an inter-examiner reliability (I.C.C.) ranging from
0.4 to 0.98 (Takala, 1990; Levoska, 1993). Pressure
thresholds lower than 3 kg, are considered abnormal
(Fischer, 1996). Fig. 1 details the location and the
referred pain patterns evoked by TrPs in the examined
cervical muscles based on the comprehensive research
performed by Simons et al. (1999).
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2.3. Analysis of data
Descriptive data was collected on all patients. The
number of active and latent TrPs was recorded for each
patient and then the group mean was calculated. The
inter-group comparison between the number of TrPs
(active or latent) was analysed with the unpaired t-test.
The w2 of association was used to assess the differences
in the distribution of TrPs within each muscle between
both study groups and the presence of TrPs among the
analysed cervical muscles. The statistical analysis was
conducted at a 95% confidence level. A P-value less
than 0.05 were considered as statistically significant.

3. Results

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

Fig. 1. Referred pain pattern from myofascial trigger points in some
cervical muscles based on the comprehensive research performed by
Simons et al. (1999).
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
trapezius muscle (n ¼ 14; 70%). Surprisingly, TrPs in
the suboccipital muscles were the most prevalent in our
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.
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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
perceived as headache (Simons et al., 1999), patients
were asked for the presence of headache. Half of these
patients reported tension-type headache concomitant
with their neck symptoms, especially when their neck
pain were aggravated by stress. Within the control
group, the most prevalent TrPs were located in both
upper trapezius muscles (n ¼ 10; 50% in the right side;
n ¼ 8; 40% in the left side) and in the right levator
scapulae muscle (n ¼ 7; 35%).
Finally, w2 analysis by contingency tables showed a
significant relationship between the presence of TrPs in
the left upper trapezius and left sternocleidomastoid
muscles (P ¼ 0.03), between TrPs in the left upper
trapezius and left levator scapulae muscles (P ¼ 0.005)
and between TrPs in the right upper trapezius and
suboccipital muscles (P ¼ 0.05). Other relationships, i.e.
TrPs in the right or left sternocleidomastoid and
suboccipital muscles, did not reach a significant level
(P ¼ 0.06).
4. Discussion
Our study is the first to provide preliminary evidence
suggesting that active myofascial trigger points (TrPs)
are more common in subjects presenting with mechan-
ical neck pain than in healthy controls. Active TrPs of
the examined muscles evoked referred pain patterns
contributing to neck symptoms seen in our patients.
Simons et al. (1999) claimed that neck pain might be
usually provoked by TrPs in the upper trapezius and
levator scapulae muscles. Almost all neck pain patients
showed TrPs in the upper fibres of the trapezius muscle,
in the right and/or left sides. Most of these TrPs were
active TrPs, as patients were familiar with the location
(posterior-lateral region of the neck) and the quality of
the referred pain (tightening and burning) that was
elicited by pressure applied to the TrP. When the
assessor applied pressure to that TrP, many patients
reported: ‘‘Yes, this is exactly the pain that I usually
feel’’.
On the other hand, active TrPs in the control healthy
group were scarce (Po0.001). TrPs in this group never
evoked a familiar ache, and therefore were classified as
latent TrPs (Gerwin et al., 1997; Simons et al., 1999).
Significant differences between neck pain subjects and
healthy controls were found for active TrPs, but not
for latent TrPs. This is expected, as latent TrPs, have
been commonly observed in healthy, normal subjects
(Chaiamnuay et al., 1998).
Hong (1994) claimed that the treatment of ‘‘key’’ TrPs
in some muscles could also relieve the pain arising from
satellite TrPs in other muscles. This was one of the
reasons for assessing the possible relationship on the
presence of TrPs in the cervical musculature. Our results
have showed different relationships among the presence
of TrPs in some of the analysed cervical muscles. One
hypothesis to justify these relationships might be that
muscles located in the region of the referred pain pattern
of a TrP might also develop secondary TrPs (Hong,
1994; Simons et al., 1999). This hypothesis might explain
our results: the presence of TrPs in the sternocleido-
mastoid was associated to the presence of TrPs in the
homo-lateral upper trapezius muscle, or TrPs in the
upper trapezius muscle associated to TrPs in the homo-
lateral levator scapulae. However, our study design did
not enable a cause and effect relationship to be
established so further studies are required on that topic.
TrPs diagnosis needs adequate innate ability, training,
and clinical practice to develop a high degree of
reliability in the examination (Gerwin et al., 1997;
Sciotti et al., 2001). Moreover, some muscles are
consistently more reliably examined than others. Simons
et al. (1999) and Gerwin et al. (1997) recommend that
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
recognition of referred pain that is elicited by pressure
applied to the tender spot. These criteria had obtained a
good inter-examiner reliability (k) ranging from 0.84 to
0.88 (Gerwin et al., 1997). In the present study, these
two minimum criteria identified active TrPs. Further-
more, the local twitch response, a confirmatory sign of
TrP diagnosis (Simons et al., 1999), was also an
inclusion requirement in the diagnosis of TrPs in all
muscles except in the suboccipital muscles, in which it is
difficult or impossible to elicit a local twitch response by
snapping palpation. Suboccipital muscle TrPs were
explored bilaterally in order to evoke bilateral referred
pain (Simons et al., 1999), and also to avoid the
palpation of TrPs in other cervical posterior muscles.
The high incidence of suboccipital muscle TrPs in neck
pain patients might be provoked because these muscles
could not be explored unilaterally. Tender points were
also diagnosed when subjects did not report referred
pain elicited by compression and/or overload of the
affected tissues, so minimum criteria for TrP diagnosis
were not fulfilled (Gerwin et al., 1997; Simons et al.,
1999).
In the present study the presence of TrPs in subjects
with mechanical neck pain has been demonstrated.
However, it is possible that other tissues might also
contribute to symptoms associated with mechanical
neck pain. Edgar et al. (1994) reported that decreased
extensibility of the upper quadrant neural structures as
assessed by the median nerve tension test was associated
with decreased length of the upper trapezius muscle.
Fernández-de-las-Peñas et al. (2005) have recently found
a significant relationship between the presence of TrPs in
the upper trapezius muscle and the presence of inter-
vertebral joint dysfunctions at C3 and C4 vertebrae.
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Since the relationship of TrPs to impairments in the
articular or neural systems has not been well established,
further research is required.
5. Conclusion
Active TrPs are more frequent in neck pain patients
than in healthy subjects. The prevalence of latent TrPs is
similar in neck pain patients and healthy subjects. From
a clinical standpoint, the results from the study supports
the clinical practice of assessing TrPs in the cervical
musculature as one important element of the clinical
reasoning process performed by physical therapists in
patients with mechanical neck pain.
Acknowledgements
We would like to acknowledge Dr. David Simons for
his kind encouragement and support. We would also
like to thank to each patients who participated in the
study.
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