What are the treatment options for shoulder pain that occurs at night during sleep?

Treatment Options for Shoulder Pain During Sleep

For shoulder pain that occurs at night during sleep, first-line treatment should include NSAIDs such as ibuprofen (400mg every 4-6 hours as needed), relative rest, activity modification, and physical therapy with eccentric strengthening exercises for the rotator cuff. 1, 2

First-Line Treatment Options

Medications

• NSAIDs (First-line):

  • Ibuprofen 400mg every 4-6 hours as needed for pain 2
  • Use the lowest effective dose for the shortest duration 2
  • Take with meals or milk if gastrointestinal complaints occur 2

• Acetaminophen:

  • Alternative first-line analgesic if NSAIDs are contraindicated
  • Up to 4g/day 1

• Muscle Relaxants:

  • Methocarbamol for acute muscle spasms
  • Short-term use only (7 days) 1

• Neuropathic Pain Medications:

  • Gabapentin if nerve compression is suspected 1

Non-Pharmacological Approaches

• Sleep Position Modification:

  • Avoid sleeping on the painful shoulder 3, 4
  • Consider using pillows for support to maintain proper positioning

• Physical Therapy:

  • Eccentric strengthening exercises for rotator cuff
  • Deep transverse friction massage to reduce pain 1

• Activity Modification:

  • Reduce activities that exacerbate shoulder pain
  • Avoid overhead movements that stress the supraspinatus tendon 1

Second-Line Treatment Options

Injections

• Corticosteroid Injections:
  • Consider if first-line treatments fail after 4-6 weeks
  • Limited to 2-3 injections with 4-6 weeks between injections 1

Advanced Therapies

• Extracorporeal Shock Wave Therapy (ESWT):
  • Consider before surgical intervention for chronic cases 1

Surgical Options (If Conservative Treatment Fails)

• Consider if pain persists despite 3-6 months of well-managed conservative treatment:
  • Arthroscopic removal of calcification
  • Subacromial decompression
  • Excision of abnormal tendon tissue
  • Longitudinal tenotomies 1

Specific Considerations for Nighttime Pain

Nocturnal shoulder pain is particularly common in patients with adhesive capsulitis, who experience significantly poorer sleep quality 5. Research shows that patients often sleep on the side of their painful shoulder, which may exacerbate symptoms 3. Changing sleep position may provide relief, with evidence suggesting patients should avoid sleeping on the affected side 3, 4.

Treatment Algorithm

1. Start with: NSAIDs + sleep position modification + relative rest
2. If inadequate relief after 2 weeks: Add physical therapy
3. If inadequate relief after 4-6 weeks: Consider corticosteroid injection
4. If inadequate relief after 3-6 months: Consider surgical referral

Follow-up and Monitoring

• Reassess pain and function every 4-6 weeks
• Adjust treatment plan if no improvement after 8-12 weeks of therapy 1
• Be aware that even with optimal management, resolution typically requires 3-6 months 1

Cautions and Pitfalls

• NSAID risks: Increased risk of GI bleeding, cardiovascular events, and renal dysfunction, especially in older adults 2
• Corticosteroid injections: Limit to 2-3 injections to avoid tendon weakening 1
• Diabetic patients: May respond less favorably to conservative measures 1
• AC joint degeneration: May complicate the clinical picture and require separate management 1

Remember that over 90% of cases have a good prognosis with appropriate conservative management 1, but patience is required as resolution typically takes several months.