Why does my shoulder hurt at night?

You experience pain at night for three physiological reasons: your cortisol levels (a natural pain-relieving hormone) decrease during sleep, lying down increases pressure on inflamed structures, and slowed blood circulation promotes the accumulation of inflammatory substances in the joint.

Nighttime shoulder pain is one of the most disruptive symptoms. It wakes you up, disturbs your sleep, and creates a vicious cycle: pain prevents sleep, and lack of sleep increases sensitivity to pain.

Cortisol plays a central role. This hormone has powerful anti-inflammatory and analgesic properties. Your body produces the most cortisol in the morning. During the night, levels drop to their lowest. This decrease reduces your protection against pain. Pain signals that are tolerable during the day become intense at night.

Lying down makes the mechanical problem worse. When you lie on your painful shoulder, your weight compresses the inflamed structures. The bursa and tendons are crushed. This compression increases pressure and stimulates pain receptors.

Blood circulation slows down during sleep. In an inflamed shoulder, this slowdown allows inflammatory substances to accumulate. During the day, movement promotes circulation. At night, immobility creates stagnation. The accumulation of inflammatory mediators sensitizes the nerves and increases pain.

What sleeping position should you adopt to reduce shoulder pain?

To reduce nighttime pain, sleep on the opposite side with a pillow under the affected arm, or on your back with a small pillow under your elbow. Avoid sleeping directly on the painful shoulder or with your arm above your head.

Sleeping on the opposite side eliminates direct compression. Place a pillow in front of you and rest your affected arm on it. This position keeps the shoulder neutral and reduces tension.

Sleeping on your back can be comfortable. Place a small pillow under the elbow on the affected side. This position reduces tension on the anterior capsule.

Avoid sleeping directly on the painful shoulder at all costs. Also avoid sleeping with your arm above your head—this position creates subacromial impingement.

If nighttime pain persists despite these adjustments, it may indicate active inflammation requiring treatment. Anti-inflammatory drugs taken in the evening may help. A cortisone injection may be considered in cases of refractory bursitis.

How to diagnose shoulder pain?

The diagnosis is based primarily on a clinical examination, during which the physical therapist or doctor assesses mobility and strength and reproduces the pain using specific tests. Imaging (ultrasound, MRI) is not routine and is reserved for complex or pre-surgical cases.

Clinical examination is the cornerstone of diagnosis. A competent physical therapist or physician can identify most conditions without imaging.

The mobility assessment follows the detailed history. The professional observes elevation, rotation, and range of motion behind the back. They compare active mobility (you move) and passive mobility (they move your arm). This comparison reveals a lot. A restriction in active mobility alone suggests weakness or painful inhibition. A restriction in passive mobility as well indicates capsular stiffness (capsulitis).

Strength tests evaluate each muscle of the rotator cuff. Significant weakness may indicate a partial or complete tear.

Provocation tests reproduce pain to identify the problematic structure. The Neer test (maximum passive elevation) causes pain in cases of subacromial impingement.

What tests are needed for shoulder pain?

A clinical examination is sufficient in most cases. Ultrasound can confirm tendinopathy or a tear. MRI is reserved for complex cases or in preparation for surgery. The French National Authority for Health recommends that imaging should not be used systematically.

The modern trend is toward less routine imaging. Why? Because imaging often reveals "abnormalities" that are unrelated to your symptoms. Many people without pain have abnormalities on MRI. Among people aged 40 to 60 without symptoms, about 20% have a partial tear of the rotator cuff that is detectable on MRI.

X-rays are of limited use for soft tissues. They show bones—fractures, osteoarthritis, or calcifications. They do not show tendons, muscles, or bursae.

Ultrasound is the preferred examination for visualizing the rotator cuff tendons. It is less expensive than MRI. It allows for dynamic assessment. It is effective at detecting tears, calcifications, and inflammation of the bursa.

MRI provides the best visualization of soft tissue. It is particularly useful before potential surgery. However, MRI is expensive and often unnecessary. The French National Authority for Health recommends that MRI should not be used routinely.

The key: imaging does not dictate treatment. Your clinical response dictates treatment. If you respond well to physical therapy, a partial tear visible on MRI is irrelevant.

What are effective treatments for shoulder pain?

Effective treatments include physical therapy (specific exercises and manual therapy) as a first line of treatment, anti-inflammatory drugs to relieve acute pain, corticosteroid injections in certain cases, and surgery reserved for cases that fail to respond after 6 to 12 months of conservative treatment.

Physical therapy is the first line of treatment. Meta-analyses from 2024 show that specific exercises are effective for up to 52 weeks in reducing chronic pain and restoring function.

Targeted exercises are at the heart of treatment. They have several objectives: to strengthen the rotator cuff muscles, improve scapular control, increase range of motion, and correct muscle imbalances.

Manual therapy complements the exercise program. Joint mobilization can improve capsular mobility. These passive interventions are never sufficient on their own. They prepare the ground for the exercises.

Anti-inflammatory drugs (NSAIDs) relieve pain in the acute phase. They do not cure the condition. They allow you to participate more comfortably in your rehabilitation. Use them for as short a time as possible.

How can you quickly relieve shoulder pain at home?

To quickly relieve shoulder pain, apply ice for 15-20 minutes several times a day during the acute phase, avoid painful movements without completely immobilizing the shoulder, and do gentle mobility exercises. Heat can help with chronic muscle tension.

Ice remains the treatment of choice during the acute phase (the first few days). It reduces inflammation and numbs the pain. Apply an ice pack wrapped in a towel for 15 to 20 minutes. Repeat 3 to 4 times a day.

Relative rest means avoiding activities that cause pain, without completely immobilizing yourself. Complete immobilization can lead to stiffness. Continue to move within comfortable ranges of motion.

Heat helps in cases of chronic muscle tension or capsular stiffness. Use a hot water bottle for 15 to 20 minutes. Never use heat during the acute phase—it can aggravate inflammation.

Over-the-counter anti-inflammatory drugs (ibuprofen, naproxen) can help in the short term. Follow the recommended doses.

Gentle exercises are important even in the acute phase. Codman's pendulum exercise maintains mobility without aggravating inflammation.

When are injections or surgery necessary?

Corticosteroid injections are considered after 6 to 8 weeks of physiotherapy have failed in cases of refractory bursitis or tendinopathy. Surgery is reserved for symptomatic complete tears or failure of conservative treatment after 6 to 12 months.

Corticosteroid injections can be very effective. Refractory subacromial bursitis responds particularly well. Relief can be dramatic and last for several months. However, the effect is temporary. The injection does not correct the underlying factors.

Current recommendations suggest trying physical therapy for 6 to 8 weeks before undergoing an injection. If pain persists despite a well-conducted program, an injection may resolve the situation.

Injections carry risks. They can temporarily weaken the tendon. Repeated injections increase the risk of rupture. They are generally limited to 2-3 injections per year.

Surgery is rarely the first option. The main indications are: complete tear in an active person, acute traumatic tear in a young patient, or failure of conservative treatment carried out correctly for 6 to 12 months. Even in these situations, it is important to note that 60% of patients with rotator cuff pathology improve with conservative treatment within 2 years.

Recent studies question the effectiveness of acromioplasty. Several randomized trials show that it is no more effective than placebo surgery. If your doctor suggests surgery, ask them for scientific evidence of its effectiveness for your specific condition.

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How can physical therapy treat my shoulder pain?

Physical therapy treats shoulder pain through a combination of targeted therapeutic exercises, manual therapy, and education. Meta-analyses from 2024 show that specific exercises reduce chronic pain and restore function for up to 52 weeks after treatment.

The modern approach is based on three pillars: exercises, manual therapy, and education. Exercises are the central pillar. They create the lasting adaptations necessary for recovery.

Therapeutic exercises target several objectives. Strengthening the rotator cuff improves dynamic stability. Stronger muscles better maintain the humeral head centered, reducing subacromial impingement. Strengthening the scapular stabilizers (lower trapezius, serratus anterior) corrects the positioning of the scapula.

Capsular and muscle stretches increase range of motion. They are particularly important in capsulitis. Stretches of the posterior capsule reduce the tension that contributes to anterior impingement.

Manual therapy complements the exercises. Joint mobilization improves joint mobility. Myofascial release reduces muscle tension.

Education helps you understand your condition. This understanding reduces anxiety and improves treatment adherence.

What types of exercises will the physical therapist have me do?

The physical therapist will prescribe exercises to gradually strengthen the rotator cuff, stretch the capsule and muscles, stabilize the scapula, and improve posture. The program is tailored to your specific condition and evolves as you progress.

Strengthening exercises start gently. In the initial phase, you will perform isometric contractions (contraction without movement). These contractions activate the muscles without excessive joint compression.

As the pain subsides, you progress to resistance exercises. External and internal rotations with elastic bands strengthen all the muscles of the rotator cuff. The resistance increases gradually.

Scapular stabilization exercises are often overlooked but crucial. They strengthen the lower trapezius and serratus anterior muscles. These muscles control the positioning of the shoulder blade during arm movements.

Stretches target shortened structures. Stretching the posterior capsule (arms crossed in front of the chest) is almost universal. This stiffness forces the head of the humerus forward and creates anterior impingement.

Postural work incorporates all these elements. You learn how to maintain optimal shoulder blade position during your daily activities.

What exercises can I do at home for my shoulder pain?

You can do several simple exercises at home: Codman's pendulum exercise for mobility, posterior capsule stretches, isometric rotator cuff strengthening, and scapular posture exercises. Always consult a physical therapist before starting.

Home exercises complement your treatment. They maintain and amplify the gains. The key is consistency. It is better to do 10 minutes every day than 60 minutes once a week.

Before you begin, consult a physical therapist. Not all exercises are suitable for all conditions. A professional can assess your condition and prescribe the appropriate exercises.

Listen to your body. Mild discomfort is normal. Severe pain that persists for several hours is a sign that you are overdoing it. Progress should be gradual.

Patience is essential. Tendons adapt slowly. The first significant gains appear after 4 to 6 weeks of regular exercise.

How do you perform Codman's pendulum exercise?

To perform Codman's pendulum exercise, lean forward on a table, let your affected arm hang down, and make small, controlled circles in both directions for 30 seconds to 1 minute. Repeat 2-3 times a day.

The pendulum exercise is often the first exercise prescribed in the acute phase. It maintains mobility without creating joint compression. Gravity and momentum do the work.

Stand next to a table. Lean forward and place your healthy hand on the surface. Let your affected arm hang freely. Your back should be almost parallel to the floor.

Initiate small swinging movements by moving your body slightly, not by contracting your shoulder muscles. Start with forward and backward movements (20-30 seconds). Then do side-to-side movements (20-30 seconds). Finally, make small circles in one direction and then the other (20-30 seconds each).

Movements should be small and controlled. The goal is to maintain mobility and stimulate circulation without irritating the tissues.

Repeat 2 to 3 times a day. This is particularly useful in the morning to "wake up" the shoulder after nighttime stiffness.

What stretches help relieve a sore shoulder?

Beneficial stretches include stretching the pectoral muscle (arm against a door frame), stretching the posterior capsule (arms crossed in front of the chest), and stretching the upper back. Hold each stretch for 30 seconds, 2-3 times on each side.

Stretching the posterior capsule is probably the most important. The posterior capsule stiffens in almost everyone. This stiffness forces the head of the humerus forward. For this stretch, bring your affected arm in front of your chest. With your other hand, gently pull your elbow toward you. You should feel a stretch in the back of your shoulder. Hold for 30 seconds, repeat 2-3 times.

Stretching the pectoral muscles opens up the front of the body. Stand in a doorway. Place your forearm against the door frame, with your elbow at a 90-degree angle. Slowly turn your body outward until you feel a stretch in the front of your shoulder and chest. Hold for 30 seconds.

Stretching the upper back helps correct rounded posture. Interlace your fingers in front of you, arms straight. Round your upper back. You should feel a stretch between your shoulder blades. Hold for 20-30 seconds.

How long does it take to recover from shoulder pain?

The healing time varies depending on the condition: 2 to 8 weeks for bursitis, 3 to 6 months for chronic tendinopathy, and 18 to 30 months for adhesive capsulitis. Approximately 50% of patients improve within 6 months with appropriate conservative treatment.

The timeframes vary greatly. Understanding these timeframes helps you to have realistic expectations and to persevere with your program.

Subacromial bursitis usually heals within 2 to 8 weeks with appropriate treatment. Mild cases may resolve within a few weeks with relative rest, ice, and gentle exercises. Refractory cases may require injection.

Rotator cuff tendinopathy varies greatly. Acute episodes can resolve in 2 to 4 weeks. Chronic tendinopathies take much longer. Approximately 50% of cases improve after 8 to 12 weeks of conservative treatment. Chronic tendinopathies with advanced degeneration may require 3 to 6 months of rehabilitation.

Adhesive capsulitis is the condition that takes the longest to heal. The average duration is 18 to 30 months. This duration reflects the natural progression through three phases. Physical therapy can speed up the process. However, it cannot completely bypass the phases. Patience is essential.

After rotator cuff surgery, full recovery takes 3 to 6 months. A full return to demanding activities may take 6 to 12 months.

What factors influence the duration of healing?

The duration of recovery depends on the specific condition, the patient's age, the presence of comorbidities (diabetes, smoking), the speed of treatment, and above all, adherence to the exercise program. Early diagnosis and treatment generally speed up recovery.

Age influences healing. Older people's tissues regenerate more slowly. However, this does not mean that older people do not heal—it means that the process may be slower.

Diabetes significantly slows down healing. Chronic hyperglycemia affects cellular function and circulation. Optimal glycemic control is essential.

Smoking is a major risk factor for poor healing. Tobacco reduces blood flow to the tendons. Smokers take longer to heal and must work hard to recover. Quitting smoking significantly improves the prognosis.

The speed of treatment makes a difference. Early treatment generally yields better results than late treatment. Chronic symptoms are accompanied by secondary changes that complicate treatment.

Sticking to the exercise program is probably the most important factor that you can directly control. Patients who do their exercises regularly recover faster and more completely. Consistency matters more than intensity.

When should I see a professional about my shoulder pain?

You should consult a professional if shoulder pain persists for more than two weeks, regularly disrupts your sleep, limits your daily activities, or is accompanied by significant weakness. Emergency consultation is necessary in the event of chest pain or sudden loss of strength.

Most minor pain resolves within a few days to two weeks. If your pain persists beyond two weeks despite rest and simple measures, it is time to consult a doctor.

Nighttime pain that regularly disrupts your sleep warrants attention. If the pain wakes you up almost every night, consult your doctor. Persistent nighttime pain often suggests bursitis or tendinopathy, which will respond well to treatment.

Limitations in daily activities are another sign. If you have trouble getting dressed, doing your hair, putting away groceries, or performing your job duties, you should not accept these limitations. Even simple tasks such as parking and getting out of your car can become difficult.

Significant weakness in the arm is cause for concern. If you have difficulty raising your arm or cannot hold it up, seek medical attention promptly. Marked weakness may indicate a significant tear.

What are the red flags that require urgent consultation?

Red flags requiring urgent consultation include: chest pain radiating to the left shoulder (possible cardiac origin), sudden loss of arm strength after trauma, fever associated with joint pain, trauma with visible deformity, and complete inability to move the shoulder.

Chest pain radiating to the left shoulder (especially if accompanied by shortness of breath, nausea, or sweating) requires urgent cardiac evaluation. Call 911 or go to the emergency room immediately.

A sudden and complete loss of strength following trauma may indicate an acute complete rupture of the rotator cuff. If you are completely unable to lift your arm after trauma, seek emergency medical attention.

Fever associated with joint pain may indicate a joint infection (septic arthritis). This condition is rare but serious.

Trauma with visible deformation suggests dislocation or fracture. This condition requires emergency reduction.

Who should you consult for shoulder pain: a physical therapist, doctor, or specialist?

For pain without trauma or red flags, consult a physical therapist directly, who can assess, diagnose, and treat most shoulder conditions. Your family doctor will coordinate complex cases. An orthopedist will be involved if surgery is considered.

In Quebec, you can consult a physical therapist directly, without a doctor's referral. Physical therapists are trained to assess, diagnose, and treat musculoskeletal conditions. In the vast majority of cases, physical therapists are the appropriate first-line professionals.

Your family doctor plays a coordinating role. If your condition requires imaging or infiltration, you will need a medical prescription.

An orthopedist is involved when surgery is being considered. However, most patients never need to see an orthopedist.

Rheumatologists rarely treat simple shoulder pain. However, if your pain is accompanied by systemic symptoms, a rheumatological evaluation may be appropriate.

How can shoulder pain be prevented?

You can prevent shoulder pain by maintaining good posture at work and in front of screens, regularly strengthening the rotator cuff muscles (2-3 times per week), warming up your shoulder before physical activities, and avoiding repetitive movements with your arms above your head.

Posture plays a major role. A forward-rounded posture (head forward, shoulders rounded) compromises shoulder mechanics. It creates stiffness in the posterior capsule and shortening of the pectoral muscles. These changes force the head of the humerus forward and create subacromial impingement.

Correct your working posture. Position your screen at eye level. Keep your shoulders relaxed and slightly pulled back. Take frequent breaks.

Preventive strengthening of the rotator cuff and scapular stabilizers protects the shoulder. Incorporating 2-3 sessions per week of strengthening exercises can prevent problems from developing. Ten minutes of targeted exercises is sufficient.

Warming up before physical activity prepares the shoulder. Before participating in a sport that involves the shoulder, take 5-10 minutes to warm up gradually. Proper warm-up increases circulation, improves mobility, and prepares muscles and tendons for exertion.

Avoid prolonged repetitive movements with your arms above your head without taking breaks. If your work involves such movements, take frequent breaks. Use appropriate tools.

What are the key points to remember about shoulder pain?

Shoulder pain is common and can usually be treated without surgery. Rotator cuff tendinopathy accounts for two out of three cases. Physical therapy with specific exercises is the first line of treatment. Recovery requires patience: from a few weeks to several months, depending on the condition.

Your shoulder has a remarkable ability to heal. Even if the pain is intense, the vast majority of conditions resolve with appropriate conservative treatment. Surgery is rarely necessary.

Rotator cuff tendinopathy causes most shoulder pain (44-65% of cases). Bursitis, capsulitis, and impingement syndrome account for the majority of other cases. Understanding your condition helps you have realistic expectations.

Exercise-based physical therapy is the first line of treatment. The scientific evidence is strong: specific exercises are effective in reducing pain and restoring function. Adherence to the program is the key to success.

Recovery times vary. Bursitis can resolve in a few weeks. Chronic tendinopathy may take several months. Capsulitis often takes 18 to 30 months. This variability is normal.

Consult a professional if your pain persists for more than two weeks, regularly disrupts your sleep, or significantly limits your activities. Early treatment generally yields better results.

You are not alone. Shoulder pain affects up to 70% of adults during their lifetime. With understanding, proper treatment, and your active commitment, you can regain a functional, pain-free shoulder.

Our physical therapists are here to support you in your recovery. Make an appointment today to start your journey to recovery.