Sleeping With Shoulder Pain: A Shoulder Surgeon's Guide

The number one reason that people end up in my office as a shoulder surgeon is not their inability to raise their arm. It's not shoulder instability or strength loss or stiffness. It's sleep. And this has a huge impact on your quality of life. Most people will tolerate a little strength loss, but if you can't sleep, it affects your general mood. It affects your energy levels. So they can push through the day, but But once they lie down, their pain becomes miserable and it even impacts their partners in many situations. In fact, many people come to my clinic and their loved one is with them who's really encouraging them to do something because it's affecting their sleep as well. So let's treat it like it's the actual problem it is. I'm going to give you the full ladder, everything from things that cost nothing to the operation I do in order to actually show you what can work. And not all of these have evidence, and I'll call those out when we go over those, but many of these are low cost. There are simple interventions you can do to improve your quality of sleep. And I've had personal experience myself because I've had shoulder pain that's kept me up at night. I've had shoulder surgery and I know personally what this involves. It's a big headache on your life. I'm Dr. Patrick Denard. I'm an orthopedic surgeon who specializes in the shoulder. 100% of my practice is dedicated to shoulder surgery and I've done over 10,000 surgeries over my career and published over 300 articles on outcomes after So first I want to validate something because patients often say it's not a big deal. They feel sheepish about it. They say, I know it's just sleep, or that's really the thing that's bringing them in, but it's not just sleep. If we look at the numbers, 90% of people who have a rotator cuff problem have sleep disturbance and it impacts your quality of life. In fact, it's been shown that your mood decreases when you're not sleeping well, and of course it impacts physical endurance as well. What's interesting about this is when you look at studies, it's not just that people aren't sleeping well. Average scores in studies, when you look at what's called a Pittsburgh Sleep Score, it actually doubles the cutoff for poor sleep. So people are getting really bad sleep due to their shoulder problems. And here's what I want you to sit with. It's really interesting. If you look at a study of 130 patients who had shoulder pain for 3 months or longer, and compared them to healthy controls. In the shoulder pain group, about 82% had sleep disturbance. 22% screened positive for depression. So shoulder pain impacting your mental state is real. In fact, in this study, when they ran the analysis, having shoulder pain for 3 months was the strongest single predictor of sleep disturbance in the entire dataset. So you really have 3 things locked in this triangle of pain, sleep, and mood. Pain wrecks your sleep, poor sleep lowers your pain threshold, tomorrow it hurts more than it did the other day, and then you have in that loop mood, which gets worse. Mood gets worse, pain gets worse. It's a vicious cycle. And I'm not being dramatic here, I'm just trying to say that it's not in your head. So we got to do things to find ways to help you sleep better because sleep is so critical for our overall function. And much of that involves some simple tricks you can do, but then in other cases, addressing an underlying problem. Another interesting finding is that if people are having prolonged sleep disturbance and they go into surgery, that persists. So the earlier you can intervene to improve that sleep, the better chance you're going to have in your recovery. Because if you're going to go through shoulder surgery, you need to recover. That means eating well, but it also means sleeping well because your body needs that time to heal. So why is pain worse at night? Well, you feel fine during the day, you go to sleep, and all of a sudden it gets worse. Now, I want to be upfront here because the evidence on this is not clear. A lot of it comes from just what we can put together, but I'll give you really what I think contributes because there's no real consensus in what drives shoulder pain at night. So the first thing is that gravity stops helping. When you're in an upright position, your arm is coming down to the side. Simply put, when you're laying down, you have your shoulders sag more. That can be laying on your back. And then of course, if you're laying on your side, it's direct pressure. That puts increased stress on your shoulder compared to a standing or a seated position. And this isn't proven, but it lines up certainly with the experience I see in my patients. A second mechanism that's kind of interesting is blood flow. So there was a study in Japan where they did Doppler ultrasounds. They measured blood flow in people And they measured the anterior humeral circumflex vessel in 47 patients with rotator cuff tears, plus 20 healthy controls. In the healthy individuals, there was no side-to-side difference in blood flow. But in patients who had tears without night pain, there was no difference either. But those with pain actually had a difference in blood flow. The affected side was elevated. So somehow the blood flow was driving more, perhaps contributing to inflammation in the form of syndesmosis or bursitis. in the shoulder, which is really an interesting phenomenon. That's kind of consistent with what I see because those people really have a painful shoulder. Their synovium, or the inside of their shoulder, will often be more irritated than somebody who just simply has weakness in their shoulder. In other words, you'll see that with an arthroscope or looking inside the shoulder with a camera. The other thing that kind of goes along with this was a follow-up study where it was shown that if people laid down The blood flow to their shoulder actually increases. So that kind of goes hand in hand. So it speaks to the idea of elevating the shoulder slightly as you're going to sleep to perhaps have less of this phenomenon. The third thing that makes a lot of sense but is not necessarily proven is that cortisol drops at night. So your own anti-inflammatory production goes down. Cortisol is a steroid, essentially naturally occurring in your body, and it's an anti-inflammatory. Your levels naturally drop At night. So your body goes through a daily rhythm where you have the lowest levels at night and it's highest in the morning. So it's therefore a setup that your inflammatory or your anti-inflammatory levels drop at night and you see more response to pain that occurs at night as a result. A 4th factor is that you compress it directly. I mentioned the lying down in particular in terms of gravity, but if you're lying directly on the shoulder, especially as we push the shoulder forward, we tend to stress more of the anterior or Most rotator cuff tears occur in the supraspinatus tendon, and particularly the symptomatic ones occur in the front of the shoulder. So as we lay down, we push our shoulder forward, we can get more stress on that location with direct compression. Now, you will see one study perhaps out there that mentioned that those who slept on their side had a higher incidence of rotator cuff tears compared to those who slept on their back. I would tell you, however, that that study really did not have a control group. So it may contribute to symptoms, but it's not clearly shown that sleep on your side actually causes rotator cuff tears. So now let's walk through the ladder, some steps you can take to help control pain at night so you can start getting recovery. Everything in the first tier that I'm going to talk about costs nothing. In my experience, it's a tier that a lot of patients just skip and they go right on to the next thing. But there's some simple things that you can do. The first thing is try to sleep partly upright. So you can take a wedge pillow, for instance, and sleep semi-inclined. This affects the gravity phenomenon we talked about earlier. It may affect that blood flow phenomenon I talked about earlier as well. That's suggested based on studies to lead to increased shoulder pain. So I like just a simple wedge pillow. It allows you to sleep semi-upright if you can tolerate sleeping on your back. It also turns out that if you undergo shoulder surgery, it's a really good recovery tool after shoulder surgery as well, because the same phenomenon applies. I see this all the time. A lot of my patients will tell me over time that That they find if they sleep upright after shoulder surgery, they feel much better. They might even prefer a recliner, but I again prefer the wedge pillow because it allows you to sleep in your bed, which is more comfortable, but have that semi-upright position. Going along with that, if you're having shoulder surgery, having some support under your sling can help provide some support to reduce that movement of your shoulder. Another tool that you can use to address this in the non-surgery category is you can place a pillow under your Now that'll just give you a little bit of an upright position and support. Of course, you may have a tendency to move over, over the course of the night, and some people don't like sleeping on their back. They really, really prefer side sleeping. I will have people that are just adamant that they can only sleep on the side. Your options there then are to sleep on the other side with providing some support to the shoulders so it doesn't come forward, or If you're going to sleep on the affected shoulder, one of the things that I found helpful was to put a pillow under my arm so that I was pushing my shoulder back a bit. So it's more of a semi-side position, but rather than sleeping directly on the side, having my shoulder come forward, I could bring my arm under the pillow so that the shoulder is supported and pushed back. You might find that that is effective. The last thing I'll mention in the free category is avoiding alcohol. Actually, I think it's something that really should be considered for people across the board. We all know that alcohol decreases sleep. If you're having trouble sleeping due to shoulder pain, don't make that worse by sleeping with alcohol because you might go to bed quicker, but you're going to have poor quality sleep throughout in general. The next step in the ladder is things you can do over the counter. So these are things like anti-inflammatory. These are things that people ask me about constantly. These are things that can be beneficial, but I think are best used for short term. So the idea of an anti-inflammatory anti-inflammatory is to take it a couple hours before bed. I would advise you take that with meals. You can take things like 600 milligrams of ibuprofen or a couple of Aleve. You want to take that on a full stomach ideally so that you are protecting the stomach lining, which anti-inflammatories tend to affect. I personally prefer not to eat 2 hours before I go to bed because I get better sleep. So if I'm having a problem with my shoulder, I want to take it at that point in time. The idea here is that you're offsetting that inflammation in advance that can occur to that drop in cortisol level and that increased blood supply issue we talked about earlier. So you want to sort of take it upfront a couple hours in advance to help you get through the night. Another one that's really easy to do is ice. You can either do this by icing the shoulder directly before you go to bed with an ice pack. I personally found that the thing that helped me sleep the most easily was using a cold compression unit. That's a dedicated machine that's more costly. Device, but you can place it on the shoulder and provide continuous cooling. But ice is a great pain reliever that people overlook. That helps you really reduce that inflammation prior to going to bed. You may find that this helps you sleep better. When it comes to ice machines, if you just look at ice alone, the evidence for shoulder pain is modest. However, there's randomized controlled data that says that a cold compression unit— so not just ice but actually supplying the compression as well— reduces narcotic usage after shoulder shoulder surgery. Again, this is not always about shoulder surgery, but I think it makes sense if you're going to do it to start doing that in advance. It's really a tool that's easy, it's safe, low-risk intervention. You're not going to lose anything. I tell a lot of my patients who are having shoulder surgery, if they're planning for it in advance and they're going to get a cold compression unit, just start using it now because it can help with sleep. And again, this ties back to that idea that If people have prolonged sleep disturbance, it can keep impacting them for a long period of time because your circadian rhythms get disrupted. So if you know you're going to have surgery, it really makes sense to just start using it in advance to help you get through everything afterwards. Another one that I think is really worth considering is magnesium. It's low-risk thing to do. So magnesium gets recommended everywhere for sleep. So I want to show what the evidence actually says. A meta-analysis of randomized controlled trials in adults with insomnia found that people fell asleep about 17 minutes faster with magnesium than placebo. So that sounds encouraging, but it pooled only 3 small trials. 17 minutes is not a huge amount. At the same time, there's not really a major downside that I see to taking magnesium. So I'm an advocate of trying it. Because it's a low-risk proposition. It's not a magic bullet, but it can improve your ability to sleep by helping you go to sleep sooner. The thing though that I would qualify about magnesium is it's not something you just wake up and you take in the middle of the night. If you're going to use magnesium, it's in the same category as the anti-inflammatory aspect. You want to take it a couple hours before you go to bed. Personally, what I do, I shoot for bed at 10 o'clock or earlier, so I take it 2 hours in advance. I usually take it at 8 o'clock. I found that that helps me go to sleep just a little bit quicker, and I also avoid drowsiness the next day. If I waited too close to bed, it really doesn't have the onset effect, and then I woke up feeling a bit foggier the next day. One thing I would avoid is narcotics. If I could just tell you one thing that's most important in this section of anything pill-based, avoid narcotics. Going down this pathway is a vicious spiral that will keep taking you closer and closer to having problems. Whether that's addiction or dependency. So do everything you can to avoid narcotics for sleep. If you are at that point where you're considering that, you definitely need to have an evaluation on your shoulder to see if there's other options for you. Step 3 in the ladder to consider is injections. So this is something that needs to be done by an orthopedic surgeon, ideally an orthopedic shoulder specialist. I like to use injections for people who are having trouble sleeping, that's persisting with those other things, or with people who are having a lot of pain that's preventing them from doing physical therapy. Injections are not a cure-all. They're not going to heal your rotator cuff. They're not going to heal your arthritis or regenerate cartilage. But they are reasonable to use on a judicious basis, that is a limited basis, to help you get the sleep that you need to get through your recovery, whether it's conservative Or after surgery. As a general rule, you want to limit the number of times you do this. So good guidelines are no more than 3 in a 2-year period if you're going an absolute conservative approach. If you're having shoulder surgery, the data suggests that you should not have an injection of steroid within 3 months prior to that surgery because it raises the risk of infection. It's not an absolute cutoff. That's just where we can measure it. So it's a good idea to avoid, if possible, taking multiple injections and doing that close to the time of surgery. The real goal here is that you're simply just breaking the cycle so that you can sort of start to get some sleep and start doing rehab and use those other tools. Step 4 in the ladder is surgery. At some point, if you've worked through this ladder and you're not sleeping well, the honest answer is you may need an evaluation. to see if the underlying problem you have can be fixed, because again, sleep is so critical to our overall function and mood. So here's what the data on surgery says. I want to make the point that restoring sleep is one of the stated goals of the operation. It's not a side benefit. In one study of over 300 rotator cuff repairs, 89% of people reported sleep disturbance before surgery. 77% reported it was fully resolved by 6 months and 81% by 2 years. So what does that mean? Not everybody actually gets resolution of their symptoms, but the vast majority get relief. The second thing we see here is that most of the time it's within the first 6 months, but you can continue to get sleep improvement even later. I would tell you a personal story. I could sleep after my shoulder surgery after a couple of months, but it wasn't directly on that shoulder. It wasn't until later that I could directly sleep onto that shoulder, about a year. And that's a pretty common thing that I see in my patients. They'll say, I'm not able to sleep without shoulder pain, but I can't sleep directly on it in those first few months. Another study looked at this, and the portion of people that were sleeping well by 3 months was 46%. You had another 31% by 6 months, another 14% by a year, another 8% by 2 years. So what does this So what I'm just saying, again, it takes time. Don't judge if you're having shoulder surgery what your sleep is by 6 weeks. It's really 3 to 6 months that the vast majority of people regain the ability to sleep after their surgery. Why do those people who don't have the ability to sleep keep having that? Well, that could be a lot of things actually. It could be that some of those people didn't have a good plan to really get a good recovery and they may have an ongoing issue. Another thing can be that sleep disturbance is sort of pervasive across people in the United States in general. So there can be other factors that are playing in here. And then finally, other conditions like back pain, et cetera, that can contribute. But the vast majority of people who have a shoulder surgery will regain the ability to sleep. And I would tell you, among my patients who are motivated, who don't have other underlying problems, They generally return to sleep. And that's usually the thing that people say that gives me the most satisfaction, that 6 months they'll say, I can sleep again on my shoulder. And you can see in their eyes that it really makes a big difference in their lives. So that's the whole ladder there. Recline, support the arm, think about some upright tools, use anti-inflammatories as necessary, ice, magnesium, or other considerations, and stay away from narcotics. Use injections. As needed, and then surgery if you're really not getting better. If you're going to have surgery, think about the postoperative recovery. I'll cover that in another video. If you work on it in that order, I think you have a good chance of getting back your sleep and being able to recover. But there's one thing that I really can't tell you. I really can't tell your specific situation. If you want me to look at your MRI specifically, send it to me and I'll tell you if I think you are somebody who would benefit from repair or replacement. Or if you can keep working up this ladder.