ORIGINAL ARTICLE
Referred Pain From Myofascial Trigger Points in Head, Neck,
Shoulder, and Arm Muscles Reproduces Pain Symptoms in
Blue-collar (Manual) and White-collar (Office) Workers
Ce´sar Fernández-de-las-Peñas, PT, MSc, PhD,*w Christian Gröbli, PT,w
Ricardo Ortega-Santiago, PT, PhD,* Christine Stebler Fischer, PT,w Daniel Boesch, PT,w
Philippe Froidevaux, PT,w Lilian Stocker, PT,w Richard Weissmann, PT,w and
Javier González-Iglesias, PT, PhDw
Objective: To describe the prevalence and referred pain area of
trigger points (TrPs) in blue-collar (manual) and white-collar (office)
workers, and to analyze if the referred pain pattern elicited from TrPs
completely reproduces the overall spontaneous pain pattern.
Methods: Sixteen (62% women) blue-collar and 19 (75% women)
white-collar workers were included in this study. TrPs in the
temporalis, masseter, upper trapezius, sternocleidomastoid, splenius
capitis, oblique capitis inferior, levator scapulae, scalene, pectoralis
major, deltoid, infraspinatus, extensor carpi radialis brevis and
longus, extensor digitorum communis, and supinator muscles were
examined bilaterally (hyper-sensible tender spot within a palpable
taut band, local twitch response with snapping palpation, and elicited
referred pain pattern with palpation) by experienced assessors
blinded to the participants’ condition. TrPs were considered active
when the local and referred pain reproduced any symptom and the
patient recognized the pain as familiar. The referred pain areas were
drawn on anatomic maps, digitized, and measured.
Results: Blue-collar workers had a mean of 6 (SD: 3) active and 10
(SD: 5) latent TrPs, whereas white-collar workers had a mean of 6
(SD: 4) active and 11 (SD: 6) latent TrPs (P>0.548). No significant
differences in the distribution of active and latent TrPs in the
analyzed muscles between groups were found. Active TrPs in the
upper trapezius, infraspinatus, levator scapulae, and extensor carpi
radialis brevis muscles were the most prevalent in both groups.
Significant differences in referred pain areas between muscles
(P<0.001) were found; pectoralis major, infraspinatus, upper
trapezius, and scalene muscles showed the largest referred pain
areas (P<0.01), whereas the temporalis, masseter, and splenius
capitis muscles showed the smallest (P<0.05). The combination of
the referred pain from TrPs reproduced the overall clinical pain
area in all participants.
Conclusions: Blue-collar and white-collar workers exhibited a
similar number of TrPs in the upper quadrant musculature. The
referred pain elicited by active TrPs reproduced the overall pain
Received for publication June 20, 2011; revised September 15,
2011; accepted September 24, 2011.
From the *Department of Physical Therapy, Occupational Therapy,
Rehabilitation and Physical Medicine, Universidad Rey Juan
Carlos, Alcorcón, Madrid, Spain; and wDavid G. Simons Academy,
Winterthur, Switzerland.
Financial disclosure statements have been obtained, and no conflicts of
interest have been reported by the authors or by any individuals in
control of the content of this article. No funds were received for this
study. No financial benefits are derived to the authors from this
study. Data from this study have not been presented in any
other form.
Reprints: César Fernández-de-las-Peñas, PT, MSc, PhD, Facultad de
Ciencias de la Salud, Universidad Rey Juan Carlos, Avenida de
Atenas s/n, 28922 Alcorcón, Madrid, Spain (e-mail: cesar.fernandez
@urjc.es).
Copyright r 2012 by Lippincott Williams & Wilkins
Clin J Pain  Volume 28, Number 6, July/August 2012
pattern. The distribution of TrPs was not significantly different
between groups. Clinicians should examine for the presence of
muscle TrPs in blue-collar and white-collar workers.
Key Words: trigger points, referred pain, blue-collar workers,
white-collar workers
(Clin J Pain 2012;28:511–518)
I t is estimated that 70% of the adult population in the
western world experience arm pain symptoms at some
time during their life.1,2 The point prevalence estimate
ranges between 7% and 26%.3 In modern societies,
musculoskeletal disorders represent the majority of occupa-
tional illnesses and arm pain is second only to back pain as
a cause of work-related illness.4 In general, prevalence rates
are higher in individuals who are workers than among
the nonworking general population with rates varying
according to particular occupations. For instance, 50% of
computer workers in the United States experience musculo-
skeletal arm pain.5 In addition, arm pain results in high
costs as 58% of patients use healthcare at least once per
year: 81% consulted their general practitioner, 59% a
medical specialist, and 54% a physical therapist.6
Walker-Bone et al7 found that pain experienced by
workers is frequently perceived within the dominant arm
and the neck. This study also revealed that being female
and a blue-collar worker were independent risk factors for
generalized arm pain.7 Arm pain can be caused by many
different conditions. Pain within the arm, neck or shoulder,
which are not based on acute trauma or underlying
systemic diseases, have been defined as “complaints of the
arm, neck and/or shoulder region” (CANS).1,8 Simons
et al9 suggested that myofascial trigger points (TrPs) can
play a relevant role in the genesis of musculoskeletal arm
pain. TrPs are usually defined as hypersensitive spots in a
taut band of a skeletal muscle that are painful on
contraction, stretching, or stimulation, and give rise to a
referred distant pain.9 Active TrPs are the ones in which
local and referred pain reproduced symptoms as reported
by patients. Latent TrPs have the same clinical findings as
active TrPs, but they do not cause pain.9 Clinical distinction
between active and latent TrPs is substantiated by bio-
chemical findings because higher levels of chemical
mediators, such as bradykinin, substance P, or serotonin,
have been found in active TrPs as compared with latent
TrPs and non-TrPs.10
It has been demonstrated that active TrPs reproduced
symptoms in patients with chronic tension-type headache,11,12
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Fernández-de-las-Peñas et al
neck pain,13 lateral epicondylalgia,14 shoulder impingement,15
and shoulder pain.16 However, scientific evidence for non-
specific arm pain and TrPs in workers is scarce. To the best of
the authors’ knowledge, no studies have investigated the
presence of referred pain elicited by active TrPs in blue-collar
or white-collar workers. Therefore, the aims of the current
study were: (1) to analyze the differences in the prevalence of
active TrPs in head, neck, shoulder, and arm muscles between
blue-collar (manual) and white-collar (office) workers; (2) to
analyze if the referred pain pattern elicited by these TrPs
reproduces the pain symptoms experienced by blue-collar and
white-collar workers; and (3) to compare the referred pain
patterns and size of the areas in relation to clinical features of
pain in blue-collar and white-collar workers.
METHODS
Participants
Consecutive blue-collar or white-collar workers with
pain in the upper quadrant were potential eligible participants.
A blue-collar worker (manual) typically performs manual
labor and earns an hourly wage. Blue-collar work may be
skilled or unskilled, and may involve manufacturing, mining,
building or construction trades, mechanical work, mainte-
nance, repair, operations maintenance, or technical installa-
tions. A white-collar worker (office) performs nonmanual
labor in an office. Blue-collar workers are distinguished from
those in the service sector and from white-collar workers
whose jobs are not considered manual labor. Participants
should report symptoms within the upper quadrant (neck,
shoulder, arm, forearm, or hand) not attributed to a specific
medical diagnosis, for example, lateral epicondylalgia. Partic-
ipants are examined by their medical doctor to exclude any
specific medical condition.
Participants were excluded if they presented with any of
the following: (1) history of surgery in the upper quadrant; (2)
whiplash injury; (3) comorbid medical diagnosis that can
influence pain development, that is, osteoarthritis, fibromyal-
gia, or, hypothyroidism; (4) previous diagnosis of fibromyal-
gia; (5) psychiatric illness (eg, schizophrenia or substance
abuse); (6) medication usage (antidepressant, narcotics) other
than as-needed analgesics; or (7) presence of a score >9
points in the Beck Depression Inventory (BDI)-II suggesting a
state of depression.
The study protocol was approved by local Ethics
Committee (URJC 10 to 35) and conducted after the
Helsinki Declaration. Participants signed an informed
consent before inclusion.
Muscle TrP Examination
Muscle TrPs were examined in 15 pairs of muscles:
temporalis, masseter, upper trapezius, sternocleidomastoid,
splenius capitis, oblique capitis inferior, levator scapulae,
scalene, pectoralis major, deltoid, infraspinatus, extensor carpi
radialis brevis, extensor carpi radialis longus, extensor digito-
rum communis, and supinator muscles. TrPs were examined by
an assessor with >15 years’ experience in TrPs diagnosis and
were blinded to the participants’ type of work. The order of
TrP evaluation was randomized between participants. These
muscles were selected based on clinical experience and findings
from previous studies.13–16
TrP diagnosis was performed following the criteria
described by Simons et al9: (1) presence of a palpable taut
band within a skeletal muscle; (2) presence of a hyperirritable
spot in the taut band; (3) local twitch response elicited by the
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Clin J Pain  Volume 28, Number 6, July/August 2012
snapping palpation of the taut band (when possible); and (4)
presence of referred pain in response to compression. TrPs
were considered active when the local and referred pains
evoked by compression reproduced clinical pain symptoms
and also the participant recognized the pain as familiar,
whereas TrPs were considered latent when the local and the
referred pain elicited by digital compression did not reproduce
symptoms familiar to the participant.9 These criteria, when
applied by an experienced assessor, have shown good
interexaminer reliability (k) ranging from 0.84 to 0.88.17
After TrP assessment in each muscle, participants were
asked: “When I pressed this muscle, did you feel any pain
or discomfort locally, and in other areas (referred pain).
Please tell me whether the pain that you feel in the other
area reproduced any symptom that you suffered from.”
Participants had to indicate whether the pain elicited by
palpation reproduced their symptom (familiar pain) or
another nonfamiliar pain. In the current study, only 1 TrP
with referred pain was explored in each muscle examined.
Finally, participants were asked to draw the distribu-
tion of the referred pains on an anatomical map after each
TrP palpation. Referred pain areas were digitized with a
digitizer (ACECAD D9000, Taiwan) to calculate the size of
the referred pain areas and to superimpose the spontaneous
pain pattern and the referred pain areas.18,19
Self-reported Measures
Patients were asked to draw the distribution of their
overall pain symptoms on an anatomical body map. The
overall spontaneous pain symptom area was digitized with
a digitizer (ACECAD D9000, Taiwan). An 11-point
numerical rating scale (0: no pain; 10: maximum pain)
was used to assess the current level of pain, worst, and
lowest level of pain experienced in the preceding week.20
Participants completed the BDI-II, a 21-item self-report
questionnaire assessing affective, cognitive, and somatic
symptoms of depression.21 The BDI-II has shown good
internal consistency (a = 0.90) and adequate divergent
validity.22
Statistical Analysis
Data were analyzed with the SPSS statistical package
(16.0 Version, SPSS Inc., Chicago, IL). Results are
expressed as mean, SD, or 95% confidence interval. The
Kolmogorov-Smirnov test was used to analyze the normal
distribution of the variables (P>0.05). Quantitative data
without a normal distribution (pain history and intensity of
pain) were analyzed with nonparametric tests and those
data with a normal distribution (total number of TrPs and
number of latent/active TrPs) were analyzed with para-
metric tests. Differences in the number of muscle TrPs
(total, active, latent TrPs) between both groups were
assessed with the unpaired student t test. The w2 test was
used to analyze the differences in the distribution of muscle
TrPs (active or latent) for each muscle within groups. The
Spearman rho (rs) test was used to analyze the association
between the number of TrPs with clinical pain variables. A
3-way analysis of variance was used to compare the areas of
the referred pain (arbitrary units) between sides and
muscles as within-participant factors and group as the
between-participant factor. The Bonferroni test was used
for post hoc analyses. The statistical analysis was con-
ducted at 95% confidence level. A P value <0.05 was
considered statistically significant.
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Clin J Pain  Volume 28, Number 6, July/August 2012 Trigger Points in Office and Manual Workers

TABLE 1. Demographic and Clinical Data of White-collar and Blue-collar Workers

White Collar (n = 19) Blue Collar (n = 16) P
Age (y) 44 ± 14 44 ± 13 t = 0.042; P = 0.967
Sex (male/female) 6/13 6/10 w2 = 0.437; P = 0.601
Pain history (mo) 9.1 ± 5.5 13.2 ± 5.3 z = 0.173; P = 0.878
Mean pain (NRS, 0-10) 3.8 ± 2.6 5.0 ± 2.5 z = 1.019: P = 0.317
Worst Pain (NRS, 0-10) 7.3 ± 1.8 7.9 ± 2.3 z = 1.106; P = 0.286
Lowest pain (NRS, 0-10) 1.3 ± 1.4 2.4 ± 2.2 z = 1.761; P = 0.088)
Pain symptoms in the frontal area of the body (au) 5119.5 ± 1606.2 6440.4 ± 1885.2 t = 1.267; P = 0.227
Pain symptoms in the dominant side (au) 7986.3 ± 4171.2 9273.2 ± 5625.2 t = 0.257; P = 0.803
Pain symptoms in the nondominant side (au) 8475.5 ± 2973.4 9083.2 ± 2765.3 t = 0.103; P = 0.992
Pain symptoms in the posterior area of the body (au) 17202.6 ± 6786.2 17611.3 ± 3840.1 t = 0.075; P = 0.941
Unilateral right/left pain (n, %) 16/3 14/2
BDI-II 7.7 ± 4.0 9.7 ± 2.8 t = 0.781; P = 0.440
au indicates arbitrary units; BDI-II, Beck Depression Inventory; NRS, numerical rating scale; t, Student test; z, Mann Whitney U.

RESULTS mechanical work. No significant differences for demographic

Demographic and Clinical Data
of the Participants
Sixteen blue-collar worker, 6 men and 10 women (aged
37 to 52) and 19 white-collar workers, 6 men and 13 women
(aged 36 to 55) were included. All white-collar workers were
office workers, whereas 10 (62.5%) blue-collars worked on
construction and the remaining 6 (38.5%) performed
and clinical data between groups were found. Table 1
summarizes demographic and clinical data of blue-collar
and white-collar workers. The area of pain symptoms
experienced by blue-collar and white-collar workers is
illustrated in Figure 1.
A significant positive linear correlation between mean
intensity of current pain and the worst level of pain
experienced in the preceding week (rs = 0.654; P = 0.006)

FIGURE 1. Overall spontaneous pain pattern in blue-collar and white-collar workers.

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Fernández-de-las-Peñas et al Clin J Pain  Volume 28, Number 6, July/August 2012

TABLE 2. Number (n) of White-collar (Office) Workers With Myofascial TrPs

Temporalis Muscle Masseter Muscle Upper Trapezius Muscle
Right Side Left Side Right Side Left Side Right Side Left Side
Active TrPs (n) 1 1 1 3 12 12
Latent TrPs (n) 4 9 10 11 7 6
No TrPs (n) 14 9 8 5 0 1
Sternocleidomastoid Muscle Splenius Capitis Muscle Oblique Capitis Inferior Muscle
Active TrPs (n) 4 4 4 3 6 6
Latent TrPs (n) 10 10 2 3 6 5
No TrPs (n) 5 5 13 13 7 8
Levator Scapulae Muscle Scalene Muscle Pectoralis Major Muscle
Active TrPs (n) 7 6 3 4 1 1
Latent TrPs (n) 2 5 6 6 12 15
No TrPs (n) 10 8 10 9 6 3
Deltoid Muscle Infraspinatus Extensor Carpi Radialis Brevis Muscle
Active TrPs (n) 2 1 4 6 4 3
Latent TrPs (n) 4 5 10 10 7 9
No TrPs (n) 13 13 5 3 8 7
Extensor Carpi Radialis Longus Muscle Extensor Digitorum Communis Muscle Supinator Muscle
Active TrPs (n) 5 3 4 1 6 3
Latent TrPs (n) 7 7 7 9 6 8
No TrPs (n) 7 9 8 9 7 8
TrP indicates trigger points.

was found within blue-collar, but not white-collar, workers;
the higher the pain intensity, the higher the worst pain
experienced in the preceding week.
TrPs in Blue-collar and White-collar Workers
The mean ± SD number of TrPs for each blue-collar
worker was 16 ± 6 of which 6 ± 3 were active, and the
remaining 10 ± 4 were latent TrPs. The mean ± SD
number of TrPs for each white-collar worker was 17 ± 6
of which 6 ± 4 were active TrPs and the remaining 11 ± 5
were latent TrPs. No significant differences for the total
number (t = 0.676; P = 0.503), the number of active
(t = 0.448; P = 0.657), or the number of latent (t = 0.552;
P = 0.605) TrPs were found between groups. No significant
associations between the number of active TrPs and clinical
pain parameters were found in either blue-collar or white-
collar workers.
The distribution of TrPs between blue-collar and white-
collar workers was not different for both temporalis (right
side: w2 = 0.104, P = 0.950; left side: w2 = 2.961, P = 0.284),
masseter (right side: w2 = 1.037, P = 0.596; left: w2 = 2.903,
P = 0.234), upper trapezius (right: w2 = 3.411, P = 0.182;
left: w2 = 1.583, P = 0.453), sternocleidomastoid (right:
w2 = 2.785, P = 0.248; left: w2 = 0.050, P = 0.975), splenius
capitis (right: w2 = 2.159, P = 0.340; left: w2 = 1.444,
P = 0.486), oblique capitis inferior (right: w2 = 0.235,

TABLE 3. Number (n) of Blue-collar (Manual) Workers With Myofascial TrPs

Temporalis Muscle Masseter Muscle Upper Trapezius Muscle
Right Side Left Side Right Side Left Side Right Side Left Side
Active TrPs (n) 1 1 0 0 11 9
Latent TrPs (n) 4 2 10 10 2 4
No TrPs (n) 11 13 6 6 3 3
Sternocleidomastoid Muscle Splenius Capitis Muscle Oblique Capitis Inferior Muscle
Active TrPs (n) 1 3 6 5 4 2
Latent TrPs (n) 7 9 3 3 5 6
No TrPs (n) 8 4 7 8 7 8
Levator Scapulae Muscle Scalene Muscle Pectoralis Major Muscle
Active TrPs (n) 2 4 1 2 3 3
Latent TrPs (n) 3 3 4 4 7 6
No TrPs (n) 11 9 11 10 6 7
Deltoid Muscle Infraspinatus Extensor Carpi Radialis Brevis Muscle
Active TrPs (n) 2 3 7 6 4 2
Latent TrPs (n) 3 4 8 9 5 7
No TrPs (n) 11 9 1 1 7 7
Extensor Carpi Radialis Longus Muscle Extensor Digitorum Communis Muscle Supinator Muscle
Active TrPs (n) 4 2 1 0 2 1
Latent TrPs (n) 5 4 6 7 8 9
No TrPs (n) 7 9 9 9 6 6
TrP indicates trigger points.

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Clin J Pain  Volume 28, Number 6, July/August 2012 Trigger Points in Office and Manual Workers

TABLE 4. Referred Pain Areas From Myofascial TrPs in White- TABLE 5. Referred Pain Areas From Myofascial TrPs in Blue-collar
collar (Office) Workers (Manual) Workers
Temporalis Temporalis
Dominant side (n = 5) 1549.0 ± 1216.8 Dominant side (n = 5) 1341.8 ± 751.8
Nondominant (n = 7) 1608.1 ± 580.7 Nondominant (n = 3) 1830.3 ± 385.7
Masseter Masseter
Dominant side (n = 10) 1454.6 ± 940.8 Dominant side (n = 10) 1153.1 ± 515.8
Nondominant (n = 11) 1800.7 ± 918.0 Nondominant (n = 10) 1678.2 ± 1003.4
Upper trapezius Upper trapezius
Dominant side (n = 18) 4421.7 ± 3063.4 Dominant side (n = 14) 4917.9 ± 4034.1
Nondominant (n = 18) 5752.7 ± 4651.6 Nondominant (n = 13) 4228.6 ± 2923.0
Sternocleidomastoid Sternocleidomastoid
Dominant side (n = 13) 3286.7 ± 1953.5 Dominant side (n = 9) 3916.3 ± 3158.5
Nondominant (n = 13) 3064.0 ± 1692.8 Nondominant (n = 11) 3099.4 ± 2079.9
Splenius capitis Splenius capitis
Dominant side (n = 7) 1500.4 ± 968.9 Dominant side (n = 7) 2466.8 ± 1477.9
Nondominant (n = 5) 1230.0 ± 963.0 Nondominant (n = 8) 2582.2 ± 1486.6
Oblique inferior capitis Oblique inferior capitis
Dominant side (n = 12) 2395.7 ± 1637.9 Dominant side (n = 9) 1905.2 ± 1119.6
Nondominant (n = 11) 2860.0 ± 1494.2 Nondominant (n = 7) 1774.1 ± 774.2
Levator scapulae Levator scapulae
Dominant side (n = 8) 2785.8 ± 1296.6 Dominant side (n = 6) 3542.3 ± 1720.5
Nondominant (n = 7) 2095.4 ± 967.3 Nondominant (n = 6) 2669.5 ± 937.4
Scalene Scalene
Dominant side (n = 8) 4808.3 ± 3524.5 Dominant side (n = 5) 4023.6 ± 3770.0
Nondominant (n = 8) 4630.0 ± 2800.1 Nondominant (n = 4) 4485.0 ± 3404.6
Pectoralis major Pectoralis major
Dominant side (n = 13) 6900.4 ± 3925.4 Dominant side (n = 10) 5152.6 ± 2904.9
Nondominant (n = 16) 7885.5 ± 4854.9 Nondominant (n = 9) 880.1 ± 9239.7
Deltoid Deltoid
Dominant side (n = 5) 2514.7 ± 2131.3 Dominant side (n = 5) 1929.8 ± 828.8
Nondominant (n = 6) 2778.5 ± 2152.8 Nondominant (n = 6) 1960.5 ± 618.7
Infraspinatus Infraspinatus
Dominant side (n = 15) 8376.4 ± 7435.4 Dominant side (n = 16) 6121.8 ± 4908.5
Nondominant (n = 17) 7863.4 ± 6476.7 Nondominant (n = 15) 5069.9 ± 1961.2
Extensor carpi radialis brevis Extensor carpi radialis brevis
Dominant side (n = 12) 3380.7 ± 2257.1 Dominant side (n = 8) 3396.5 ± 1791.2
Nondominant (n = 11) 4738.5 ± 3493.0 Nondominant (n = 8) 4878.1 ± 2502.3
Extensor carpi radialis longus Extensor carpi radialis longus
Dominant side (n = 11) 4241.5 ± 1521.4 Dominant side (n = 9) 4980.3 ± 3613.6
Nondominant (n = 10) 4710.5 ± 2656.6 Nondominant (n = 7) 7406.2 ± 4616.5
Extensor digitorum communis Extensor digitorum communis
Dominant side (n = 11) 4407.0 ± 2151.1 Dominant side (n = 6) 3765.3 ± 2250.8
Nondominant (n = 10) 4823.6 ± 2287.6 Nondominant (n = 6) 3150.6 ± 3684.2
Supinator Supinator
Dominant side (n = 13) 4042.8 ± 3437.7 Dominant side (n = 10) 4465.5 ± 2713.8
Nondominant (n = 10) 4110.7 ± 3448.8 Nondominant (n = 10) 5427.2 ± 4008.5
Referred pain areas (arbitrary units) are expressed as means (95% Referred pain areas (arbitrary units) are expressed as means (95%
confidence interval). confidence interval).
TrP indicates trigger points. TrP indicates trigger points.

P = 0.889; left: w2 = 1.847, P = 0.396), levator scapulae
(right: w2 = 2.789, P = 0.248; left: w2 = 0.707, P = 0.702),
scalene (right: w2 = 1.199, P = 0.549; left: w2 = 0.869,
P = 0.648), pectoralis major (right: w2 = 2.074, P = 0.355;
left: w2 = 4.246, P = 0.144), deltoid (right: w2 = 0.053,
P = 0.974; left: w2 = 1.593, P = 0.451), infraspinatus (right:
w2 = 3.475, P = 0.176; left: w2 = 0.801, P = 0.670), extensor
carpi radialis brevis (right: w2 = 0.144, P = 0.931; left: w2 =
0.194, P = 0.907), extensor carpi radialis longus (right:
w2 = 0.189, P = 0.910; left: w2 = = 1.744, P = 0.621),
extensor digitorum communis (right: w2 = 1.691, P = 0.429;
left: w2 = 1.001, P = 0.606), and supinator (right: w2 = 2.121,
P = 0.346; left: w2 = 1.095, P = 0.578) muscles. Table 2
shows the distribution of TrPs in white-collar worker,
whereas Table 3 details the distribution of TrPs in blue-
collar workers. Active TrPs within the upper trapezius (63%
white collar; 68% blue collar), infraspinatus (32% white
collar; 44% blue collar), levator scapulae (32% white collar;
25% blue collar), and extensor carpi radialis brevis (21%
white collar; 25% blue collar) muscles were the most
prevalent in both groups.
TrPs Local and Referred Pain and Overall
Spontaneous Pain Pattern
No differences in referred pain areas between active
and latent TrPs were found in any muscle in either white-
collar or blue-collar workers; therefore, the mean of the
referred pain area was considered for further analysis. A 3-
way analysis of variance revealed significant differences in
referred pain areas between muscles (F = 11.211, P<0.001),

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Fernández-de-las-Peñas et al
FIGURE 2. Induced-pain pattern from active and latent trigger points (TrPs). Note that the combination of the referred pain patterns
from TrPs fully reproduced the overall spontaneous clinical pain pattern as seen in Figure 1.
but not between groups (F = 0.018, P = 0.894) or sides
(F = 1.855; P = 0.174). No significant interactions between
group muscle (F = 1.011, P = 0.451), groupside (F =
0.268, P = 0.605), side muscle (F = 0.685, P = 0.790), or
group muscleside (F = 0.355, P = 0.986) were found.
Bonferroni post hoc analyses revealed that the largest
referred pain areas were those elicited by the pectoralis
major, infraspinatus, upper trapezius, and scalene muscle
(P<0.01); whereas the smallest referred pain areas were
those elicited by the temporalis, masseter, and splenius capitis
(P<0.05) muscles. Table 4 details the size of the referred pain
areas in all the examined muscles in white-collar workers,
whereas Table 5 summarizes the referred pain areas in blue-
collar workers. No significant correlations between the
intensity of the pain, the length of symptoms, and the size
of the referred pain areas were found in either group
(P>0.240).
The overall spontaneous pain pattern in white-collar
and blue-collar workers is illustrated in Figure 1. The
local and referred pain areas from TrPs are illustrated
in Figure 2. The pain pattern induced from TrPs and the
overall spontaneous pain pattern were extremely similar
and symmetrically distributed throughout the upper quar-
ter. In addition, as shown in Figure 2, local and referred
pain areas induced from TrPs in different muscles over-
lapped. As shown in Figures 1 and 2, the combination of
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Clin J Pain  Volume 28, Number 6, July/August 2012
the referred pain patterns from active TrPs fully reproduced
the overall spontaneous clinical pain area in white-collar or
blue-collar workers.
DISCUSSION
The current study demonstrated that blue-collar and
white-collar workers presented with multiple TrPs in head,
neck, shoulder, and arm muscles from which referred pain
reproduced their overall pain pattern. In fact, pain induced
from active TrPs and the overall spontaneous pain pattern
was similar in pain quality and overall pain area in blue-
collar and white-collar workers. When active TrPs were
explored, workers reported “Yes, this is the pain that I feel
during pain attacks.” The number of active and latent TrPs
and the distribution between muscles was not significantly
different between blue-collar and white-collar workers.
These results suggest that pain symptoms in the upper
quadrant, not related to a specific underlying medical
condition, in blue-collar and white-collar workers may be a
summation of multiple regional pains due to TrPs.
Active TrPs in the upper trapezius, infraspinatus,
levator scapulae, and extensor carpi radialis brevis muscles
were the most prevalent in our sample of blue-collar and
white-collar workers. In addition, referred pain areas
elicited by TrPs in the pectoralis major, infraspinatus,
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Clin J Pain  Volume 28, Number 6, July/August 2012
upper trapezius, and scalene muscles were the largest. This
may be expected as patients mostly reported pain in the
neck, shoulder and forearm areas, places were these TrPs
referred pain. In fact, active TrPs in the same musculature
have also been found in patients with mechanical neck
pain,13 lateral epicondylalgia,14 shoulder impingement,15
and shoulder pain16 diagnosis. Hidalgo-Lozano et al15
reported that the muscles most affected by active TrPs were
the supraspinatus, infraspinatus, and subscapularis in
individuals with shoulder impingement, whereas Bron
et al16 found the infraspinatus, upper trapezius, and deltoid
muscles most affected. In the current study, we showed that
the upper trapezius and infraspinatus muscles were the
most affected, which agree with these two previous studies.
It should be considered that blue-collar and white-collar
workers included in our study did not fulfill the medical
criteria for the diagnosis of specific medical condition, for
example, lateral epicondylalgia. Therefore patients included
in the study can be classified as having CANS.1,8
In addition to active TrP, several latent TrPs were also
found in both blue-collar and white-collar workers. There is
an increasing body of knowledge demonstrating the clinical
and neuro-physiological relevance of latent TrPs. Ge et al23
found pressure pain hypersensitivity at latent TrPs as
compared with non-TrP areas, suggesting nociceptive
activity at latent TrP. Li et al24 demonstrated the presence
of nociceptive (hyperalgesia) and non-nociceptive (allody-
nia) pain sensitivity at latent TrPs. More recent studies
reported that nociceptive stimulation of latent TrP induces
attenuated skin blood flow response25 and induce central
sensitization mechanisms in healthy participants.26 As
latent TrPs may become active under the influence of
several factors, for example, muscle overload, its presence
may be potentially implicated in the development of pain
symptoms, although longitudinal studies are needed to
confirm this hypothesis.
An interesting result of this study was that blue-collar
and white-collar workers exhibited a similar number and
distribution of active and latent TrPs. In addition, the
referred pain areas from TrPs were not significantly
different between groups. Current results were unexpected
as we hypothesized that different types of work demands
may be related to activation of TrPs in different muscles.
Macfarlane et al27 found that mechanical load, repetitive
work, and abnormal working postures are associated with
development of arm pain symptoms. Further, evidence
suggests that neck pain is associated with sustained and
abnormal posture, for example prolonged sitting with the
neck or trunk held in flexion or rotation or a combination
of both.28 Our results suggest that both manual and office
workers overuse the same shoulder muscles and have the
same referred pain patterns even though their work is
different.
The results from the current study have potential
clinical implications. As TrPs represent a nociceptive
source, management of nonspecific CANS should focus
first on inactivating active TrPs and then eliminate risk
factors to create the conditions to allow overloaded
structures the opportunity to recover from the overload
situation. Interventions such as taking microbreaks during
working time, increasing muscle awareness, stress manage-
ment may have a preventive and corrective influence on the
development or inactivation of TrPs. Clinicians should be
aware of the possible presence of TrPs in blue-collar and
white-collar workers.
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Trigger Points in Office and Manual Workers
We should recognize that this was an observational
study. Therefore future longitudinal studies are needed to
further confirm the relevance of TrP referred pain in the
evolution of symptoms in blue-collar and white-collar
workers. Second, the main purpose of the study was to
reproduce the overall pain pattern of each individual; if
stimulation of 1 active TrP in a muscle can reproduce
patient’s pain pattern, no further TrP examination was
allowed in that muscle. It is possible that some muscles
present with multiple TrPs at the same time. Finally, the
results from the current study should be considered with
caution at this stage since the sample size was small. It
would be necessary to repeat the same procedure with
greater sample sizes to further confirm these assumptions.
CONCLUSIONS
We found that blue-collar and white-collar workers
present multiple TrPs in head, neck, shoulder, and arm
muscles from which referred pain reproduce the overall
pain pattern. The number of TrPs and the distribution
between muscles was not significantly different between
blue-collar and white-collar workers. These results suggest
that pain symptoms in the upper quadrant, not related to a
specific underlying medical condition, in blue-collar and
white-collar workers may be a summation of multiple
regional pains due to TrPs. Clinicians should be aware of
the potential presence of muscle TrPs in blue-collar and
white-collar workers.
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