Why the shoulder hurts at night
Many patients begin the conversation with the same sentence: during the day it is bearable, at night the shoulder wakes me up. Night pain in the shoulder is not a condition of its own but a pointer — usually to the tendons, the bursa or the joint capsule. This article sets out where it comes from and when an examination becomes sensible.
In short
The shoulder often hurts more at night because lying down removes the relieving pull of the arm's own weight, because the humeral head presses against tendons and bursa when you lie on your side, and because at rest nothing distracts from the pain any more. Behind it there is usually a disorder of the rotator cuff, a calcium deposit in the tendon, an inflamed and shrinking joint capsule or wear of the joint. Until the assessment, a changed sleeping position and an adjusted load help; whether heat or cold feels better depends on how you experience it. If the night pain persists, or if loss of strength, numbness or a fall are added, the shoulder should be examined. Which cause is present is clarified by the conversation, the clinical examination and the ultrasound in the practice.
Why the pain increases when you lie down
That the shoulder acts up at night, of all times, has mechanical and biological reasons. They usually apply together.
- The relief falls away — while standing, the weight of the arm pulls the humeral head slightly downwards and space remains under the acromion. When you lie down this pull is missing, the space becomes tighter and irritated tendons come under pressure.
- The position presses directly — lying on the affected side loads tendons and bursa immediately; an arm placed above the head narrows the space as well.
- Circulation and inflammation — at night the circulation is turned down and the warmth of the bed acts on tissue that is irritated anyway. Inflammatory processes then make themselves felt more clearly.
- The distraction is missing — during the day movement covers the irritation, at night the pain is left on its own. Many people therefore experience it as stronger at night, although nothing has changed about the findings.
Common causes and how to recognise them
Night pain is a pointer to be taken seriously. Which structure is affected is usually revealed by the accompanying complaint:
- Rotator cuff — irritation or a tear of the tendon cap. Typical are night pain on the affected side and loss of strength when working overhead. More on the rotator cuff tear and its repair.
- Calcific tendinitis (tendinitis calcarea) — a calcium deposit in the tendon that hurts severely in certain phases and barely lets the arm move. More on calcific tendinitis and shockwave therapy.
- Subacromial bursitis (formerly called impingement) — the bursa beneath the acromion is irritated. Lying on that side raises the pressure on it, and a certain arc hurts when lifting overhead. More on subacromial bursitis of the shoulder.
- Frozen shoulder (shoulder stiffness) — the joint capsule becomes inflamed and shrinks. Night pain stands at the beginning; later, turning the arm outwards becomes difficult, for instance when putting on a jacket. More on the course of a frozen shoulder.
- Osteoarthritis of the shoulder (omarthrosis) — cartilage wear with pain on starting to move and grinding in the joint; night pain is added as it goes on. More on shoulder osteoarthritis and its treatment.
These pictures overlap: an irritated tendon can inflame the bursa, and a protective posture can let the capsule become stiff. Assigning a cause from the description alone is therefore not possible — that needs the examination. An overview sorted by leading symptom can be found on the page about shoulder pain and its assessment.
What you can do yourself until the appointment
The following points do not replace a diagnosis. They are what can be said responsibly without knowing the findings.
- Adjust the sleeping position — lie on the other side or on your back. On your back a flat pillow under the elbow supports the arm; on your side a pillow in front of the body carries the upper arm. Placing the arm above the head is unfavourable.
- Adjust the load, do not immobilise — set aside overhead work, heavy lifting with a straight arm and jerky movements for now. Complete rest is the wrong way: a shoulder that is not moved becomes stiff.
- Heat or cold as it feels right — with a freshly irritated shoulder that feels warm, many people find cold more pleasant; with a tense, stiff shoulder, heat tends to feel better. Both are allowed; what matters is what does you good.
- Set aside exercise programmes from the internet — what helps an irritated tendon can do the opposite with a shrinking capsule. Which movement makes sense follows from the findings.
I deliberately say nothing here about painkillers: that depends on the cause, on pre-existing conditions and on other medication, and belongs in the personal conversation.
When an assessment makes sense
A single restless night is no reason to worry. You should have the shoulder examined if one of these points applies:
- The night pain persists and regularly disturbs your sleep.
- The arm can no longer be lifted with force or held against resistance.
- The complaints began after a fall, a dislocation or a sudden jolt.
- Mobility is decreasing, especially turning outwards.
- Numbness or tingling radiates into the arm.
- Redness, warmth or fever appear as well — in that case promptly.
An appointment is usually available within a week; if the matter is acute, I also find a slot outside the regular practice hours. You do not need a referral; please bring everything you have — e-card, previous reports, doctors' letters and X-ray, CT or MRI images.
How I examine the shoulder
It begins with the conversation: how long the complaints have existed, which movement triggers them, how you sleep, what you do at work and in sport. The clinical examination follows, with functional tests that separate tendons, bursa and joint capsule from one another. Ultrasound is available to me in the practice; with it I assess the tendons in movement and in comparison with the other side, and recognise calcium deposits, fluid and tendon defects. Where needed I arrange an X-ray or an MRI — both take place outside the building.
The findings determine the route. With calcific tendinitis or an irritated bursa, treatment usually begins conservatively, depending on the cause with physiotherapy, an ultrasound-guided injection, focused or radial shockwave therapy or PRP therapy. With a recent or larger tear of the rotator cuff, on the other hand, I discuss surgery early. Whether a procedure makes sense for the other causes depends on the findings and on your everyday life — we make that decision together once all the results are in.
Frequently asked
Frequently asked questions about shoulder pain at night
When you lie down, the gentle pull that the weight of the arm exerts on the joint while standing falls away. The space under the acromion becomes tighter, and irritated tendons and an inflamed bursa come under pressure. Added to this are the warmth of the bed, a reduced circulation and the missing distraction of movement and everyday activity. The pain is therefore often more noticeable at night, without anything having changed about the findings themselves.
Lying on the painful side usually increases the pressure, which is why many people move to the other side or onto their back. On your back a pillow under the elbow helps, so that the arm does not sink backwards; on your side a pillow in front of the body, on which the upper arm can rest. Placing the arm above the head is unfavourable. Which position feels comfortable remains individual.
Both are possible, and there is no rule that applies to everyone. With a freshly irritated shoulder that feels warm, many people find cold more pleasant; with a tense and stiff shoulder, heat tends to feel better. Go by what does you good, and protect the skin while doing so. If the night pain persists, neither heat nor cold replaces finding out the cause.
If the night pain persists and regularly disturbs your sleep, the shoulder should be examined. An assessment is sensible sooner after a fall or a dislocation, with loss of strength when lifting, with decreasing mobility, with numbness or tingling in the arm and with redness, warmth and fever. You do not need a referral; please bring all existing reports and images with you.
Dr. med. Martin Eigenschink
Specialist in Orthopaedics and Traumatology · Specialist in elbow, shoulder and hand surgery
Surgical and conservative treatment of the elbow, shoulder and hand, preferably minimally invasive. Practice at the Orthozentrum Döbling, 1190 Vienna. More about my background
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Medical notice: The contents of this page serve as general information. They do not replace a medical examination, diagnosis or individual advice. Medicine is a constantly evolving field — despite careful research, no guarantee can be given that the content is fully up to date.