Background: Cotton textile industry employees use their neck, shoulder and upper limbs extensively in their work. However, there is no adequate documentation of the type of musculoskeletal morbidity among these workers. Objectives: To study the prevalence, patterns and disability due to musculoskeletal disorders among cotton textile industry workers in Tamil Nadu. Methods: The study was conducted in a cotton textile factory in Coimbatore. The factory was selected randomly from a list of medium scale factories. Stratified random sampling among supervisors, labourers and housekeeping staff in the factory was performed. The Nordic Musculoskeletal Questionnaire (NMQ) was used to collect information on pain in different areas of the body. Exploratory factor analysis was performed to group the pain, its severity and disability into syndromes. Based on the factor scores, the participants were grouped into clusters of pain patterns using K means cluster analysis. Results: A total of 100 participants responded to the study. The main syndromic patterns of musculoskeletal morbidity included - Acute upper limb pain, Chronic and acute pain in knee, ankles and feet, Acute and Activity limiting pain of back, hip and thighs, Chronic and Activity limiting pain in the back and shoulders, Activity limiting upper limb pain. Based on these syndromes, the participants were classified into three main clusters – cluster 1 - Acute, activity limiting pain of upper limb, low back, hips and thigh (13%), cluster 2 – Acute pain of knees, ankle and feet (12%) and cluster 3 – Activity limiting pain of upper back, shoulder and upper limb (75%). Conclusion: The cotton textile industry workers had predominantly upper limb, upper back and shoulder musculoskeletal morbidity and disability, which needs to be addressed by appropriate ergonomic measures in the factories.