A shoulder that wakes you at night almost always points to one of three causes: a problem with the rotator cuff tendons, a calcification, or a frozen shoulder. It is the symptom that brings the most patients in to see me, because it is the one that wears you down.
A shoulder that hurts during the day can be lived with. A shoulder that stops you sleeping ends up affecting everything else. It is a reason to seek advice in its own right, not a detail to mention at the end of an appointment.
It is not in your head, and it is not a question of tiredness. There are precise mechanical reasons for it.
When you lie down, the space beneath the acromion, the bony roof that caps the joint, becomes narrower. The tendon running underneath it is compressed, whereas when you are standing gravity was enough to keep that space open.
Then there is the loss of distraction. During the day your attention is elsewhere, and movement keeps up a circulation that limits swelling. At night, only the pain is left.
Lastly, lying on your side puts the weight of your body directly onto the shoulder. This is why many patients describe pain that appears only when they turn over.
This is the most common cause. The tendon is inflamed but intact. The pain sits over the point of the shoulder and the outer side of the arm, it stops you sleeping on the affected side, and it gets in the way of overhead movements during the day.
The picture is very recognisable: sudden, extremely intense pain, often at night, which makes any movement impossible for a few days, in someone who had almost no symptoms before. A deposit of crystals has formed inside the tendon. The details are on the calcific tendinitis of the shoulder page.
Here the night pain comes with a stiffness that sets in in every direction, including when it is the doctor who moves the arm for you. See the frozen shoulder page.
Night pain occurs here too, but the sign that sets it apart is loss of strength: an arm that drops, difficulty carrying things. See the rotator cuff tear page.
The pain is very localised, on the top of the shoulder, and is set off by sleeping on it or by bringing the arm across the front of the body. Patients point to the painful spot with a single finger.
Night pain appears later here, once the cartilage wear is already advanced. It is deep and mechanical, and comes with a progressive loss of movement.
These measures do not treat the cause, but they will win you a few nights while you wait for your consultation, and they work for most patients.
Sleep semi-upright, with your back raised on two or three pillows. This tilt opens up the subacromial space and takes the pressure off the tendon.
Slide a cushion under the elbow on the painful side, so that the arm is supported and held slightly away from the body rather than hanging loose.
Avoid sleeping on the affected shoulder. If you sleep on the opposite side, wedge a pillow in front of you and rest the painful arm on it, to stop it dropping forwards during the night.
Cold, for around twenty minutes at the end of the day, calms the inflammation in a tendon. Heat relaxes the muscles around the joint instead, and suits stiff shoulders better. Try both and keep whichever relieves you.
If you have been prescribed a painkiller, take it before you go to bed rather than in the middle of the night once the pain has set in.
Avoid repeated overhead movements, which keep up the impingement under the acromion and are paid for the following night. That said, do not rest the arm completely: an immobilised shoulder stiffens up, and a stiff shoulder hurts for longer.
Night shoulder pain that lasts more than two to three weeks deserves a medical opinion, even if it stays bearable during the day.
Do not wait that long if the pain comes with a loss of strength, if the arm no longer lifts, if the shoulder is stiffening in every direction, or if the pain came on suddenly and makes any movement impossible.
Left shoulder pain accompanied by tightness in the chest, breathlessness, sweating or feeling faint must be treated as a cardiac emergency. Call your country's emergency number immediately. This is not shoulder pain, it is pain felt in the shoulder.
The clinical examination already tells us a great deal. How the pain came on, where it sits, and above all the distinction between a stiff shoulder and a supple but weak one, separate the main causes from one another.
An X-ray shows the joint, the wear and any calcifications. Ultrasound examines the tendons. MRI or CT arthrography are kept for situations where surgery is being considered, because they alone show tendon retraction and the quality of the muscle.
The full sequence is described on the shoulder pain page.
In the vast majority of cases, night pain settles without surgery. Treatment combines painkillers, sometimes a short course of anti-inflammatories, and above all physiotherapy, which remains the mainstay of treatment for tendinopathies and frozen shoulders.
An injection may be offered when the pain persists and prevents rehabilitation from being done properly. It is not a treatment in itself, but it opens a window in which to work.
Surgery is only considered if the pain persists despite well-conducted treatment, or if the imaging shows a lesion that will not heal on its own, such as a tendon tear. See the shoulder surgery page.
Because lying down narrows the subacromial space and compresses the tendon, whereas standing up gravity keeps that space open. Add to that the absence of distraction and, if you sleep on your side, the weight of your body pressing directly on the shoulder.
Rotator cuff tendinopathy. Then come calcific tendinitis, frozen shoulder and tendon tears. The way the pain came on, and whether or not there is stiffness, allow them to be told apart.
Semi-upright, propped against two or three pillows, with a cushion under the elbow on the painful side to support the arm. Avoid sleeping on the affected shoulder. If you sleep on the other side, rest the painful arm on a pillow placed in front of you.
Cold suits an inflamed tendon better, for around twenty minutes at the end of the day. Heat relaxes the muscles around the joint and tends to relieve stiff shoulders. Try both and keep whichever relieves you.
Beyond two to three weeks of waking at night, even if the daytime stays bearable. Sooner if there is a loss of strength, an arm that no longer lifts, stiffness in every direction, or sudden pain that makes any movement impossible.
Left shoulder pain associated with tightness in the chest, breathlessness, sweating or feeling faint must be treated as a cardiac emergency: call your country's emergency number immediately. Outside that specific context, isolated left shoulder pain that wakes you at night is ordinary shoulder pain.
No. In the vast majority of cases it settles with painkillers, physiotherapy and sometimes an injection. Surgery is only considered if the pain resists well-conducted treatment, or if the imaging shows a lesion that will not heal on its own.
No. Avoid repeated overhead movements, which keep up the impingement, but carry on using your arm for everyday tasks. An immobilised shoulder stiffens up, and a stiff shoulder hurts for longer.
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