Why does my rotator cuff hurt at night?

Why Rotator Cuff Pain Worsens at Night

Rotator cuff pain typically worsens at night due to increased pressure on the injured tendon when lying down, decreased distraction from pain while at rest, and inflammatory processes that naturally intensify during nighttime hours. 1

Mechanisms of Nighttime Pain

Anatomical and Positional Factors

• When lying down, particularly on the affected shoulder, direct pressure increases on the already inflamed or damaged rotator cuff tendons
• Horizontal positioning eliminates the gravity-assisted decompression that occurs when upright
• Blood flow increases to the horizontal shoulder, potentially exacerbating inflammation in the injured area

Physiological Factors

• Inflammatory mediators follow circadian rhythms with increased activity at night
• Cortisol (natural anti-inflammatory) levels decrease during nighttime hours
• Pain perception increases with fewer distractions and sensory inputs while trying to sleep

Understanding Your Rotator Cuff Condition

The rotator cuff consists of four muscles and their tendons that stabilize the shoulder joint:

• Supraspinatus (most commonly affected)
• Infraspinatus
• Teres minor
• Subscapularis

Rotator cuff problems typically present as:

1. Tendinopathy/tendinosis (degeneration)
2. Partial-thickness tears
3. Full-thickness tears

These conditions are common, affecting approximately 4.5 million patients annually in the US, with prevalence increasing with age - 13% of people in their 40s, 20% in their 50s, and 31% in their 60s have rotator cuff tears 2.

Management Strategies for Nighttime Pain

Immediate Relief Measures

• Sleep position modifications:

  • Avoid sleeping on the affected shoulder
  • Use a pillow to support the affected arm when side-sleeping on the unaffected side
  • Try sleeping semi-reclined in a recliner or with pillows propping you up

• Pain management before bed:

  • NSAIDs (like ibuprofen) are recommended as first-line treatment 1
  • Apply ice for 15-20 minutes before sleep to reduce inflammation
  • Consider heat therapy if it provides better relief for your specific condition

Longer-Term Treatment Approach

For persistent rotator cuff pain, a structured approach is recommended:

1. First-line conservative management:

   • NSAIDs for pain and inflammation control 2, 1
   • Structured exercise program focusing on rotator cuff strengthening 2
   • Activity modification to avoid painful movements

2. Second-line interventions:

   • Physical therapy with supervised exercises
   • Corticosteroid injections (limited to 2-3 injections with 4-6 weeks between) 1

3. Advanced imaging and specialist referral:

   • If symptoms persist beyond 4-6 weeks, plain radiographs (X-rays) are recommended 1
   • MRI or ultrasound if symptoms continue despite conservative management 2
   • Orthopedic referral if pain persists despite 3-6 months of well-managed conservative treatment 1

When to Consider Surgical Intervention

Surgery may be indicated in specific circumstances:

• Acute traumatic tears, especially in younger patients 3
• Persistent pain despite 3-6 months of appropriate conservative management 1
• Significant functional limitations affecting quality of life 1
• Progressive joint degeneration evident on imaging 1

Important Considerations

• Workers' compensation status correlates with less favorable outcomes after rotator cuff repair 2
• Early surgical repair after acute injury is an option but not mandatory for all rotator cuff tears 2
• Degenerative tears most commonly originate approximately 9-10mm posterior to the biceps tendon 4
• Full-thickness tears in younger patients with acute trauma should be managed with surgical repair as soon as possible, ideally within 4 months of injury 3

By understanding the mechanisms behind nighttime rotator cuff pain and following appropriate management strategies, you can significantly improve your sleep quality and overall shoulder function.