How to Sleep With Shoulder Pain: A Surgeon's Ladder

Short answer: Start with the free fixes: sleep partly upright on a wedge pillow, support the sore arm with a pillow, and skip alcohol. If that is not enough, an anti-inflammatory taken a couple of hours before bed, ice and magnesium are reasonable next steps. Injections come after that, and surgery is the last rung, for a problem that can be fixed. Avoid narcotics for sleep.

The number one reason people end up in my office is not that they cannot raise their arm. It is sleep. When they lie down the pain becomes miserable, and often their partner is in clinic with them, asking me to do something.

I have had shoulder pain that kept me up at night, and I have had shoulder surgery myself. So here is the full ladder, from things that cost nothing to the operation I do, with an honest note on where the evidence is thin.

Watch: Sleeping With Shoulder Pain: A Shoulder Surgeon's Guide

It is not "just sleep"

Patients often feel sheepish about this. They should not:

• About 90% of people with a rotator cuff problem have sleep disturbance.
• In studies using the Pittsburgh sleep score, average scores in shoulder patients are double the cutoff for poor sleep.
• In one study of 130 people with shoulder pain for three months or longer, compared with healthy controls, about 82% had sleep disturbance and 22% screened positive for depression. Having shoulder pain for three months was the strongest single predictor of poor sleep in the whole data set.

Pain, sleep and mood form a triangle. Pain wrecks your sleep, poor sleep lowers your pain threshold, and your mood drops, which makes the pain worse again. There is another reason to act early: sleep trouble that goes on for a long time tends to persist after surgery, so the sooner you improve it, the better your recovery.

Why shoulder pain is worse at night

To be up front, there is no real consensus on this. These are the four things I think contribute.

1. Gravity stops helping. When you are upright, the arm hangs down at your side. Lying down, the shoulder sags, and lying on your side adds direct pressure. This is not proven, but it matches what I see.
2. Blood flow changes. A study in Japan used Doppler ultrasound to measure blood flow to the shoulder in 47 patients with rotator cuff tears and 20 healthy controls. Healthy people had no difference from side to side, and neither did patients with tears but no night pain. Patients with night pain had higher flow on the painful side. A follow-up study found that lying down increases blood flow to the shoulder. That fits what I see through the arthroscope: painful shoulders often have a more irritated joint lining.
3. Cortisol drops at night. Cortisol is your body's own anti-inflammatory steroid. Levels are lowest at night and highest in the morning. That makes sense as a cause, but it is not proven.
4. Direct compression. Lying on the shoulder pushes it forward and stresses the front, which is where most painful tears in the supraspinatus tendon sit. You may see a study claiming side sleepers get more tears. It had no control group, so I would not conclude that side sleeping causes tears.

The ladder

Rung 1: Free fixes

This is the rung most people skip.

• Sleep partly upright. A simple wedge pillow lets you sleep semi-inclined in your own bed. It helps with gravity and possibly blood flow, and it is a good recovery tool after surgery too.
• Put a pillow under the arm. It gives a little elevation and support.
• If you must sleep on your side, sleep on the other side with the sore shoulder supported so it does not fall forward. If you sleep on the painful side, try what helped me: a pillow under the arm so the shoulder is pushed back, more of a semi-side position.
• Avoid alcohol. You may fall asleep faster, but sleep quality through the night is worse.

Rung 2: Over the counter

• An anti-inflammatory, timed. Take it a couple of hours before bed, with food to protect the stomach, for example ibuprofen or naproxen (Aleve). These are best used for short periods.
• Ice. An ice pack before bed is a pain reliever people overlook. The evidence for plain ice is modest. A cold compression unit costs more, but randomized data show it reduces narcotic use after shoulder surgery. If you are planning surgery and will buy one anyway, start using it now.
• Magnesium. A meta-analysis of randomized trials in adults with insomnia found people fell asleep about 17 minutes faster than with placebo. That pooled only three small trials, and 17 minutes is not huge. It is low risk, so I am in favor of trying it. Take it about two hours before bed. I take mine at 8 for a 10 o'clock bedtime. Too close to bed and I wake up foggy. If you have kidney disease, check with your doctor first.
• Avoid narcotics. If I could tell you one thing about pills, it is this. Using them for sleep is a spiral toward dependency. If you are considering them, you need an evaluation instead.

Rung 3: Injections

I use injections when sleep problems persist despite the steps above, or when pain is stopping someone from doing physical therapy. They should be done by an orthopedic surgeon, ideally a shoulder specialist. They will not heal a rotator cuff or regrow cartilage. The goal is to break the cycle so you can sleep and do your rehab.

Limit them. A good guideline is no more than three in two years if you are staying non-operative. If surgery is planned, avoid a steroid injection within three months before the operation, because it raises the risk of infection. For more, see is a cortisone shot in the shoulder worth it?

Rung 4: Surgery

If you have worked through the ladder and still are not sleeping, you may need an evaluation to see whether the underlying problem can be fixed. Restoring sleep is a stated goal of the operation, not a side benefit.

• In one study of more than 300 rotator cuff repairs, 89% reported sleep disturbance before surgery. It had fully resolved in 77% by six months and in 81% by two years.
• In another study, 46% were sleeping well by three months, another 31% by six months, another 14% by one year and another 8% by two years.

So do not judge your sleep at six weeks. For most people it comes back between three and six months. In my own case, I could sleep after a couple of months, but I could not sleep directly on that shoulder until about a year. For the post-operative side, see how to sleep after shoulder surgery.

The ladder in one line

Recline and support the arm. Use anti-inflammatories as needed, ice and magnesium, and stay away from narcotics. Use injections judiciously. Consider surgery if you are truly not getting better. If your pain comes from a rotator cuff tear, my six-week program for a rotator cuff tear without surgery is the next step.

If you want me to look at your MRI and tell you whether you would benefit from repair, a replacement, or more time on the ladder, send me your MRI for a remote review. If you have already been told you need surgery, read should I get a second opinion before shoulder surgery?

Frequently asked questions

Why is my shoulder pain worse at night?

There is no firm consensus. The four likely reasons are losing the help of gravity when you lie down, higher blood flow to a painful shoulder, the nightly drop in cortisol, and direct pressure on the front of the shoulder.

What is the best sleeping position for shoulder pain?

Partly upright on a wedge pillow, with a pillow supporting the arm. If you have to sleep on your side, use the other side with the sore arm supported, or a semi-side position with a pillow under the arm to keep the shoulder back.

Does magnesium help you sleep with shoulder pain?

Modestly. A meta-analysis of three small trials found people fell asleep about 17 minutes faster than with placebo. It is low risk. Take it about two hours before bed.

How many cortisone shots can I have in my shoulder?

A good guideline is no more than three in two years if you are not having surgery, and none within three months before a planned operation because of infection risk.

Will rotator cuff surgery help me sleep?

For most people, yes. In one study of more than 300 repairs, 89% had sleep disturbance before surgery. It had fully resolved in 77% by six months and in 81% by two years.

This article is for education only and is not medical advice. It does not replace an evaluation of your own shoulder by a qualified clinician.