Shoulder Pain at Night

Shoulder pain after sleeping is one of the most common symptoms for patients with shoulder conditions such as shoulder impingement, bursitis, tendinitis, rotator cuff tears, frozen shoulder, and arthritis.

Other shoulder pain conditions at night may also include poor posture, overexertion, ageing, or repetitive work injuries.

Read on to learn more about what may be causing your shoulder pain at night as well as the best ways to find relief.

Here is everything you’ll learn from this post about shoulder pain and relief at night:

1. What are the causes of shoulder pain at night?
2. Why does my shoulder pain get worse at night?
3. How should you sleep if your shoulder hurts?
4. 5 simple exercises to help shoulder pain at night
5. When to seek treatment for shoulder pain?

What are the causes of shoulder pain at night?

There are many of causes of shoulder pain that result from a variety of shoulder conditions. The most common causes include shoulder impingement, bursitis, tendon damage (tendinopathy or tendinitis) or rotator cuff tears and arthritis (which can affect a few areas of the shoulder).

Unfortunately several of these common sources of shoulder problems cause increased pain at night or during periods of rest. It certainly makes it difficult to get a good night’s sleep when your shoulder is in pain.

Shoulder impingement

Shoulder impingement is when there is a reduced space in the shoulder between the rotator cuff tendons and a bone above these tendons. This bone is called the acromion and it is a part of the scapula or shoulder blade.

There are a few causes for this condition.

Most commonly, it is due to an altered shape of the acromion or a spur (extra bone) forming under the acromion. This extra bone reduces the space for the tendons to move and can cause direct injury to the tendons. There is a normal fluid filled sac called a bursa which sits between the acromion and rotator cuff tendons. The bursa helps buffer the tendons and forms a lubricating pillow to assist in making smooth movement, protecting the tendons from damage.

Some people are born or develop an abnormal shaped acromion as they age. Acromions that are flat create more room for the tendons and bursa to move. Unfortunately, some people have a curved or hooked acromion that reduces that space, causing shoulder problems.

When the space is reduced due to a spur or an abnormal shaped acromion, the bursa becomes compressed, aggravated and irritated. This angry and inflamed tissue causes the majority of the shoulder pain.

Movement of the shoulder further aggravates the bursa and tendons. Eventually the extra bone rubs on the tendon potentially causing a tear. This invariably causes further shoulder pain and dysfunction.

Gravity and your arm’s weight can pull the space apart when upright which can alleviate the pain temporarily. Unfortunately, this space compresses once you lie down and try to sleep which can lead to a restless night grappling with pain.

Bursitis

The bursa is a normal structure within the shoulder that helps lubricate the joint and buffers the tendon from damage from the overlying bone.

Once irritated the bursa becomes inflamed. Inflammation causes the bursa to over react and develop cells (cytokines) that incite pain. It’s your body’s way of telling you that something is wrong.

Shoulder bursitis commonly presents with the following symptoms:

• Gradual onset of your shoulder symptoms over weeks or months
• Pain on the outside of your shoulder
• Pain may spread down your arm towards the elbow or wrist
• Pain made worse when lying on your affected shoulder
• Pain made worse when using your arm above your head
• Painful arc of movement – shoulder pain felt between 60–90 degrees of the arm moving up and outwards
• When your arm is by your side there is minimal pain and above 90 degrees relief of pain
• Shoulder pain with activities such as washing hair, reaching up to a high shelf in the cupboard

Often the problem causes a vicious cycle of further pain and shoulder problems; the more the bursa gets inflamed and tightens up the space, the more irritated it gets and hence enlarges even more, leading to even more pain and discomfort.

While sleeping or lying directly on the side of shoulder, the bursa can be compressed without the help of gravity.

Tendon damage (tendinopathy or tendinitis) or tear (rotator cuff tears)

Rotator cuff tendons that surround the shoulder joint help stabilise the joint and gives it the ability to move and have power. Their integrity and form is vital to maintain movement, strength and power.

Tendon damage occurs from a few causes ranging from trauma or an injury, to slower processes involved in increasing age and wear and tear. The most common cause is repeated microtrauma to the rotator cuff tendons rather than a specific one of trauma. Rotator cuff surgery and recovery may be required to alleviate pain and get back a full range of motion.

Shoulder tendonitis (or tendinitis) is an inflammation injury to the tendons. Because inflammation is not always present in injuries to the shoulder tendons, this group of injuries are medically known as a rotator cuff tendinopathy or tendinopathies. Once this progresses, the tendon will fail and cause a tear.

Shoulder tendonitis commonly has the following symptoms:

• Shoulder popping or clicking and/or an arc of shoulder pain when your arm is about shoulder height
• Pain when lying on the sore shoulder or lifting with a straight arm
• Shoulder pain or clicking when moving your hand behind your back or head
• Anterior shoulder pain and upper arm pain (potentially as far as your elbow)
• As your shoulder tendonitis deteriorates, your shoulder pain may even be present when resting and often worsens at night after using the shoulder all day.

Shoulder arthritis

Wear and tear of the shoulder that affects the cartilage lining of the shoulder joint is called arthritis. This progressive condition causes shoulder pain and is often worse at night after a day of use. The chances of you suffering shoulder arthritis are increased if your shoulder has been overworked or injured. It can be a result of years of sports that involve heavy use of the shoulder including AFL football, cricket, and tennis.

Arthritis can affect the main joint of the shoulder (gleno-humeral joint) or the AC joint (acromio-clavicular joint).

The acromio-clavicular joint (AC joint) is the intersection between the end of the collar bone and the end of the shoulder blade. The joint often gets earlier wear and tear from ageing and can suffer an AC joint injury and arthritis due to an injury from a fall or as result of playing sports that involve arm elevation. Arthritis from this area presents with pain on top of the shoulder and is often worsened by sleep when your arm is crossed over your chest or when lying directly onto your shoulder.

Other shoulder pain conditions that lead to discomfort at night include poor posture, sports & work injuries, ageing, overuse, and overexertion.

Why does my shoulder pain get worse at night?

Shoulder pain at night is a very common problem and can be both disruptive and frustrating. The most common cause of night pain in your shoulder is due to a process we call rotator cuff tendinosis and shoulder bursitis.

While there is no exact science as to why your shoulder pain is worse at night, some factors may be sleeping on your side, direct pressure on your shoulder, and/or your mattress. Certainly, using your shoulder during the day means that the bursa is more inflamed and the rotator cuff tendon is over worked by the end of the day, hence the symptoms worsening by night time. Other factors may be unrelieved tension of pressure and stress.

During the day, the weight of the arm and gravity help to increase the space in your shoulder to reduce pressure and compression on the bursa and rotator cuff tendons. However, at night and during sleep, this is no longer the case as gravity is eliminated while lying flat. The muscles are also relaxed while sleeping and aren’t activated to centre the ball within the socket so this also reduces the space.

Direct pressure when sleeping directly on the painful side exacerbates the problem, especially when this occurs for an extended period of time while in deep sleep. Pressure for prolonged periods throughout the night puts direct compression on the subacromial joint space and compresses this inflamed tissue and bursa.

Uncontrolled movements of the arm or sleeping with your arm across your chest or above your head for extended periods (abnormal positions) are other factors that may contribute to more pain at night and after sleeping.

How should you sleep if your shoulder hurts?

Going to sleep with shoulder pain is difficult and certainly if you wake due to shoulder pain, falling back asleep can be very troublesome.

Resting your shoulder during day may reduce the inflammation, reducing the pain enough that you can sleep.

Taking tablets that help reduce pain and inflammation (analgesics and anti-inflammatories) can also assist in reducing pain during the night. Taking the tablets well before night time is advisable to allow enough time for them to work.

If you wake up with a shoulder that hurts after directly lying on the shoulder, try sleeping on the opposite side. It might sound obvious but it isn’t as easy as it sounds given you often don’t control your movements when in deep sleep. Try placing a pillow behind you to stop you rolling over while sleeping on your affected shoulder and changing sides with your bed partner depending on which shoulder is involved. Sleeping propped up on a few pillows or on a special bed that has you a bit upright might also stop you rolling over onto the painful shoulder.

Doing some light stretching might also help to relieve shoulder pain. It may relax some of the tight muscles around the shoulder and also allowing the space to open up in the shoulder enough so that the pain reduces and you can try to get back to sleep.

5 simple exercises to help shoulder pain at night

1. Standing wall stretchPlace both hands on a wall so they form a 90-degree angle to you body. Walk feet backwards until the arms straighten and then bow, hinging forward at the hips. Do not push on the wall, and do not allow your arms to raise up too high in order to avoid shoulder impingement. Keep shoulder blades set back and avoid scrunching shoulders around the neck.
2. Shoulder rollsFrom a position of proper alignment, roll shoulders up, then back, then down in a fluid motion. Repeat this movement about a dozen times, then reverse it, rolling forward another dozen times.
3. Shoulder rotationWith your back to a wall, allow the shoulder blade (scapula) to rest in a neutral position and bring both elbows out to 90 degrees (so the side of your biceps are in contact with the wall). Without moving the position of your elbows turn right arm upward, so the back of the right hand touches the wall, and left arm downward so the left palm touches the wall (or they come as close as possible). Slowly switch (right arm up, left arm down, then reverse it with left arm up and right arm down) for about 30 seconds, trying to keep arms at 90 degrees throughout.
4. Cow face armsBegin by kneeling on the floor, sitting your hips back onto your heels. Hold a towel in your right hand. Reach you right arm straight up, bend your elbow to let you right hand and towel fall behind your head. Take your left arm behind your back, bending you elbow to reach your left hand up your back. Grab hold of the other side of the towel with your left hand and use the towel to walk your hands towards one another. If you hands come all the way to touch, you can let go of the towel and interlace your fingers. Try to hold this for 30 seconds to one minute and then switch sides.
5. Thread the needleStart on all fours on the floor. Lift the left hand off the ground and thread the left arm through the space between the right arm and right leg, letting the back of the left hand arm slide along the ground. Allow the upper body (thoracic spine) to naturally rotate toward the right but keep hips level. Stop pushing the arm to the right at the point where your hips begin to open to the right. This may mean less of a range of motion than what you could do if continued to open.

When to seek treatment for shoulder pain?

Living with shoulder pain, especially if it wakes you up at night or makes sleep difficult, is challenging. If your shoulder pain persists for a period of a few weeks or worsens it is recommended to seek consultation and treatment.

More worrying signs that may present with pain include weakness, loss of movement or instability. These additional symptoms warrant more expedient investigation.

The first step would be to see your family doctor who will ask you specific questions and examine your shoulder to narrow the diagnosis as well as order specific tests to help work out what is wrong with your shoulder.

Getting plain X-rays are very useful to check that you don’t have arthritis, spurs or other bone issues that may be causing your night pain. Additional investigations to assess the soft tissues, including the rotator cuff tendons and the bursa, might include an ultrasound scan or an MRI (magnetic resonance imaging) scan.

Depending on what is found during these consultations your doctor might suggest an injection into your shoulder with corticosteroid to help reduce inflammation and pain and a period of rest. Seeing your physiotherapist for exercises to help settle the symptoms and then strengthen your shoulder is also a good option. If your symptoms persist despite these treatments, or if they worsen, your family doctor may suggest a review with a specialist shoulder orthopaedic surgeon for further treatment options.

Surgical options to help alleviate the pain and improve your shoulder function depend on the diagnosis. Most of this surgery can be performed using keyhole or arthroscopic methods. They include removing the inflamed bursa, removing bone spurs and reattaching torn rotator cuff tendons. If your shoulder pain is from a condition called adhesive capsulitis (frozen shoulder), your shoulder surgeon can release tight and inflamed structures (ligaments and capsule) in your shoulder that cause the pain and stiffness. Lastly, if your pain is due to severe arthritis, a shoulder replacement might be a good option to treat your pain and improve your shoulder range of motion and power.

Shoulder exercise photos provided by ActiveCare Physical Therapy