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Shoulder Pain at Night

Night after night, your shoulder pain awakens you.   The pain is hot and searing and getting worse.  Why does your shoulder hurt at night?  Why does your shoulder pain occur at night?  What are the treatment options for shoulder pain at night?  Are there non-surgical treatment options?  Let’s dig in.

Why Does My Shoulder Hurt at Night?

There are many causes of shoulder pain at night. The major causes include:

Tendonitis

Tendons are thick bands of connective tissue that connect muscle to bone. The rotator cuff is compromised of 4 tendons which are the supraspinatus, infraspinatus, subscapularis, and teres minor. They are susceptible to injury and can become inflamed, degenerated, or torn (1).  Common causes of shoulder tendonitis include overuse, repetitive motion, trauma, poor blood flow, and prior surgery (2).  Pain is the most frequent symptom which is aggravated by overhead activity.  Shoulder pain at night is common with shoulder tendonitis.

Bursitis

A bursa is a fluid-filled sac that allows tendons, ligaments, and muscles to slide smoothly over boney surfaces.  There are 6 bursae in the shoulder which can become inflamed and a source of shoulder pain at night (3). Pain is typically aching in character and made worse with movement.  Some patients complain of a reduced range of motion.  Bursitis is a common source of shoulder pain at night as pressure is applied to the bursae when lying on the affected side.

Osteoarthritis

The shoulder is a ball-socket joint.  The joint is lined with cartilage which allows the two bones to easily move together.  This in turn allows you all the remarkable movements of the shoulder such as throwing, grabbing, and lifting overhead.  Unfortunately, the cartilage can be damaged or eroded leading to shoulder arthritis.  Pain, stiffness, and grinding or clicking sounds are common (4).  As arthritis advances most patients complain of reduced range of motion and shoulder pain at night.

Shoulder Impingement Syndrome

Shoulder impingement syndrome involves Inflammation of the rotator cuff tendons as they pass through the narrow boney passageway in the shoulder called the subacromial space (5).  Pain, weakness, and restriction in range of motion are the most common symptoms (6).  Pain typically develops over time and typically is localized on the top of the shoulder with radiations to the side of the arm (7). Shoulder pain at night is common in patients with shoulder impingement syndrome.

Neck Injury

Referred pain is pain that is perceived or felt in an area different than the location of the actual injury.  For example, disc protrusion or herniations in the neck can cause pain that is referred into the shoulder.  Small joints in the neck called facet joints can also refer pain into the shoulder.  Facet joints can be injured in motor vehicle accidents or other types of trauma.  Finally, nerves in the neck such as the C6 nerve can be compressed or irritated resulting in pain that is referred to the shoulder.  Changes in the neck position can cause or aggravate shoulder pain at night.

AC Joint Impingement

AC joint Impingement is a painful condition that occurs when the space beneath the acromion bone is narrowed.   This narrowing can result in irritation of the rotator cuff tendons and bursa.  A bursa is a fluid-filled sac that reduces the friction on tendons and muscles as they cross bony surfaces.  A tendon is thick collagen tissue that connects muscles to bones.  The rotator cuff tendons provide important support and enable movement in the shoulder.   If severe,  impingement can cause tears in the rotator cuff tendons.  Patients with AC joint impingement typically have pain with elevation of the arm and or while lying on the shoulder.

Read More About AC Joint Impingement

Arthritis in Shoulder

The shoulder is a truly remarkable joint.  It allows you to reach out into virtually all directions: overhead, forward, and backwards. Unfortunately, like other joints in the body the shoulder is susceptible to irritation and injury. Osteoarthritis is the most common cause of disability in the United States, affecting up to 32.8% of patients over sixty years of age (1). Shoulder arthritis is a common condition estimated to be as high as 16-20% in the middle aged and elderly population (2).  Shoulder arthritis can compromise range of motion, strength and be a source of debilitating pain. This blog will review the shoulder. 

Read More About Arthritis in Shoulder

Avascular Necrosis of the Shoulder

Avascular Necrosis is essentially a lack of blood flow, eventually resulting in necrosis, or dying of the bone. This happens in multiple joints. And today we’re talking specifically about the shoulder. So talking about AVN in the shoulder, patients typically come up with two main questions. Number one, can this heal on its own? And if not, how long or how fast will this progress? Now we classify AVN in multiple different stages: Number one: we have stage one, where it’s very normal X-ray  — usually, typically, someone just has pain with activity. Is the bone itself continues to deteriorate, then we start getting some changes on your X-ray..

Read More About Avascular Necrosis of the Shoulder

Ehlers-Danlos Syndrome (EDS)

isorders that affect and weaken the connective tissues such as tendons and ligaments. It is a hereditary disorder which means you are born with it.  EDS has many different signs and symptoms which can vary significantly depending upon the type of EDS and its severity.   It most commonly affects the skin, joints, and blood vessels.  Joints are typically hypermobile with excessive joint range of motion because of a defect in collagen formation. In most cases Ehlers-Danlos syndrome is inherited. That is to say that you are born with it. The two main ways EDS is inherited are: autosomal dominant inheritance and autosomal recessive inheritance…

Read More About Ehlers-Danlos Syndrome (EDS)

Frozen Shoulder

Frozen shoulder, also known as adhesive capsulitis, is a painful loss of shoulder movement and range in motion.  The incidence of frozen shoulder is 3-5% in the general population and up to 20% in those with diabetes.  The peak incidence is between 40-60 years of age.  The exact mechanism is poorly understood.  In general, the capsule becomes inflamed, thickened, and contracted with pain and significant restriction in range of motion. causes are poorly understood but risk factors include trauma, prolonged immobility, systematic diseases such as diabetes, stroke, connective tissue disease, and heart disease.  Other causes include post-surgery, chronic inflammation causing stimulation of myofibroblasts

Read More About Frozen Shoulder

Rotator Cuff Tear

Are you plagued by shoulder pain that has now transitioned from intermittent to constant and keeps you up at night? Are daily shoulder movements, such as dressing and reaching for objects in the kitchen cabinets, painful? Is your range of motion decreasing as your pain is increasing? You may have a full- or partial-thickness rotator cuff tear. Has conservative therapy in the form of heat, ice, stretching, rest, and acupuncture failed to provide significant relief? Has an MRI demonstrated a full-thickness or partial-thickness tear of the rotator cuff? What to do? If left untreated, full-thickness and 26% of partial-thickness tears will progress.

Read More About Rotator Cuff Tear

Shoulder Impingement Syndrome

Pain is the most common symptom.  It typically occurs with the elevation of the arm, forced movement overhead, and when lying on the shoulder.  Impingement can also cause shoulder pain when reaching across the body. Narrowing of the subacromial space is the most common cause of shoulder impingement syndrome (6).  The subacromial space is the area between the top of the arm bone (humerus) and the AC joint.   This narrowing compresses or pinches the rotator cuff tendons and bursa.  If left untreated the rotator cuff tendons can become inflamed, damaged, and or torn.Bursa and tendons can not be seen on x-ray.  An x-ray may demonstrate…

Read More About Shoulder Impingement Syndrome

Shoulder Labral Tears

The labrum is a cartilaginous cup that circles the shallow shoulder socket (the glenoid) to make the socket deeper. The labrum supports and stabilizes the shoulder joint. Causes of Shoulder Labral Tears Injury to the labrum typically occurs from repetitive trauma in overhead throwers, such as in baseball. It can also occur from a traction injury to the arm, such as lifting a heavy object off the ground or getting your arm jerked. Symptoms of Shoulder Labral Tears. Typical symptoms include pain in the front of the shoulder or deep inside the joint. Treatment options initially include physical therapy which is designed to restore range of motion and strength to the shoulder.

Read More About Shoulder Labral Tears

Thoracic Outlet Syndrome

The thoracic outlet is an area around the collar bone where the nerves that come from your neck meet up with the blood vessels from your heart and together supply the entire upper extremity (shoulder and arm). These blood vessels (subclavian artery and vein) and nerves (brachial plexus) travel from the base of your neck to your armpit (axilla) and are considered the “thoracic outlet”. Now that you know what the thoracic outlet is, what is thoracic outlet syndrome? Simply listening to a patient’s history and completing a physical examination is all that is needed to diagnose TOS. But more involved imaging such as X-rays…

Read More About Thoracic Outlet Syndrome
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Why Does This Occur at Night?

There are several reasons why shoulder pain at night occurs or is aggravated.  The common explanations include:

  1. Sleep typically involves a static position lasting hours at a time with little or no movement.
  2. Sleeping on your side places additional pressure on the tendons and bursa of the shoulder
  3. Sleep can cause muscles and tendons to settle in a slightly different position resulting in additional pressure and reduced blood flow.

Treatment Options for Shoulder Pain at Night?

Identifying the underlying problem is important!  This allows therapy to focus exclusively on the exact problem or problems.  When appropriate conservative care is always the first line of treatment.  Focus is typically on strengthening and improving range of motion.  Please remember that range of motion is KEY!.  A stiff joint is a painful joint.  When conservative care fails to provide significant improvement many patients are referred for steroid injections.  Steroids are very powerful anti-inflammatory agents that are toxic to cartilage and should be avoided (8).  Repeated steroid injections can weaken the tendons and ligaments and accelerate arthritis.  Each of the outlined causes of shoulder pain at night discussed above has a specific treatment.  These treatments are discussed in previous blogs.   MRI is useful when conservative treatment fails to provide benefit,

Changing your sleeping position may reduce your shoulder pain.  Avoid sleeping on the affected shoulder.  Placing a pillow underneath your chest wall can also help reduce the pressure on the shoulder.   Placing a firm pillow behind your shoulder to eliminate additional movement and elevation of the head of the bed has been successful for many patients.

Regenerative Treatment Options

PRP and bone marrow concentrate (BMC) are effective, nonsurgical treatment options for shoulder arthritis, bursitis, tendonitis, and partial thickness tears in the rotator cuff.  Our randomized controlled study examined the use of BMC and demonstrated significant clinical and radiographic improvement in comparison to patients who underwent exercise therapy (9).  Disc herniations and bulges that cause referred pain into the shoulder can be treated with PRP and BMC.  This allows patients to avoid the side effects of steroid injection and pain management procedures that burn the nerves in the neck.  It also enables patients to avoid shoulder surgery. To learn more about shoulder pain and how you can avoid shoulder surgery click here.  This is a free downloadable book written by Dr, Centeno:  Shoulder 2.0

At the Centeno-Schultz Clinic, we are experts in the treatment of shoulder injuries. Every new patient examination includes an ultrasound examination of the shoulder.  These examinations can identify instability and small defects in the tendons and ligaments not appreciated on MRI or CT.  The PRP and BMC injections are performed under ultrasound guidance to ensure the accurate placement of the platelets and bone marrow concentrate (containing stem cells).  This will ensure the best clinical outcome.  The injections are very demanding and can not be performed by your PCP or orthopedic surgeon.  To watch one of my shoulder injections please clinic on the video below.

Related: Snapping Scapula

 

In Conclusion

Shoulder pain at night can be debilitating.  Common causes include tendonitis, bursitis, osteoarthritis, shoulder impingement syndrome, and referred pain from the neck.  Possible explanations why this occurs or is aggravated at night include prolonged periods in a static position with additional pressure applied to the shoulder tendons and bursae. The best treatment for shoulder pain at night involves identifying the underlying problem.  Then therapy can be focused on correcting the area of damage or irritation.  Conservative therapy when appropriate is the first-line therapy.  Steroids injections should be avoided as they are toxic.  PRP and BMC are effective, non-surgical options in the treatment of shoulder pain at night.  Most importantly shoulder pain at night is an indication that something is wrong and action is required.  If left untreated most small problems tend to get larger.

If your shoulder keeps talking to you at night, and or if you are awakened regularly when you roll over at night, please schedule a telemedicine consultation from the comfort of your home or backyard.  Speak with a board-certified, fellowship-trained physician who will provide you with a diagnosis and the appropriate regenerative treatment options.  Stop suffering and start living by calling today!

 
 
 
References

1.Factor D, Dale B. Current concepts of rotator cuff tendinopathy. Int J Sports Phys Ther. 2014;9(2):274-288.

2.Spargoli G. TREATMENT OF ROTATOR CUFF TENDINOPATHY AS A CONTRACTILE DYSFUNCTION. A CLINICAL COMMENTARY. Int J Sports Phys Ther. 2019;14(1):148-158.

3.Draghi F, Scudeller L, Draghi AG, Bortolotto C. Prevalence of subacromial-subdeltoid bursitis in shoulder pain: an ultrasonographic study. J Ultrasound. 2015;18(2):151-158. Published 2015 Apr 2. doi:10.1007/s40477-015-0167-0

4.Chillemi C, Franceschini V. Shoulder osteoarthritis. Arthritis. 2013;2013:370231. doi:10.1155/2013/370231

5. Singh B, Bakti N, Gulihar A. Current Concepts in the Diagnosis and Treatment of Shoulder Impingement. Indian J Orthop. 2017;51(5):516-523. doi:10.4103/ortho.IJOrtho_187_17.

6.. Koester MC, George MS, Kuhn JE. Shoulder impingement syndrome. Am J Med. 2005;118(5):452-455. doi:10.1016/j.amjmed.2005.01.040.

7.Consigliere P, Haddo O, Levy O, Sforza G. Subacromial impingement syndrome: management challenges. Orthop Res Rev. 2018;10:83-91. Published 2018 Oct 23. doi:10.2147/ORR.S157864

8. Wernecke C, Braun HJ, Dragoo JL. The Effect of Intra-articular Corticosteroids on Articular Cartilage: A Systematic Review. Orthop J Sports Med. 2015;3(5):2325967115581163. Published 2015 Apr 27. doi:10.1177/2325967115581163

9.Centeno C, Fausel Z, Stemper I, Azuike U, Dodson E. A Randomized Controlled Trial of the Treatment of Rotator Cuff Tears with Bone Marrow Concentrate and Platelet Products Compared to Exercise Therapy: A Midterm Analysis. Stem Cells Int. 2020;2020:5962354. Published 2020 Jan 30. doi:10.1155/2020/5962354

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