Detrimental positions, postures, and activities are obstacles to healing. Today, we will discuss ONE significant variable that, when corrected, allows patients to heal more quickly—sleep posture. This blog will identify six condition-specific sleep faults, and recommend clear-cut solutions through modifications of the sleeping routine. Patients requesting help with a sleep position for neck pain is a common request.. 

The frequently overlooked problem—SLEEP Posture.

Musculoskeletal symptoms frequently surface at night. As sleep comprises one-third of our lives, this correlation deserves significant attention and patient education. When you sleep is typically also when you heal.  Why not give tissue the best chance to recover during sleep?  Improper sleeping postures may impede blood flow, directly compress tissue, or stretch injured structures, all of which affect the inflammatory process. 

This is most problematic to those conditions that are caused by ischemia, i.e., tendinopathies and neuropathies. However, all healing and recovery require an inflammatory process to build new tissue while simultaneously removing unwanted debris. Unfortunately, some sleep positions negatively affect the healing process, resulting in delayed healing, poor sleep, and prolonged symptoms. 

How Does Sleep Position Affect Six Common Orthopedic Diagnoses?

1. Rotator Cuff Syndrome

Problem: “Many of us sleep with the arm in the overhead position of shoulder impingement, and this is a lifelong habit. Over time, this may be considered a “pathological sleep position.” The long-term result of chronically impinging the rotator cuff while asleep is to fall within the continuum of chronic tendinopathy. This could hypothetically be the chronic pain generator of nocturnal pain, the seemingly “asymptomatic shoulder” and may even explain “spontaneous” rotator cuff rupture.” (1)

Solution: Avoid sleeping on the affected side. Consider sleeping supine, or with the affected side up, placing a pillow between the arm and body for support and to minimize the effects of traction ischemia.

2. Neck Pain

Problem: Pathologic sleep positions may create or perpetuate cervical dysfunction. Neck pain is commonly associated with shoulder impingement from the side-lying sleeping posture. Similarly, pillow height can force static compression or stretch to the cervical structures, resulting in pain. Thin pillows aggravate degenerative conditions by allowing excessive extension or lateral flexion of the spine. Static cervical flexion from thicker pillows can negatively affect disc lesions.

Solution: Choose a pillow that allows the neck to remain in a neutral position. Avoid excessively thick or thin pillows. Generally, feather or fiberfill pillows allow greater conformity than rigid foam.

3. Tennis Elbow

Problem: Sleep position is a possible aggravating factor that delays the healing of an acute injury and may result in chronic pain with lateral epicondylosis. (2) In particular, sleeping with the affected elbow beneath a pillow results in sustained compression to the wrist extensors. 

Solution: Keeping the arm at the side results in a reduction of lateral elbow pain. 

4. Carpal Tunnel Syndrome

Problem: Sleeping in a fetal position with sustained wrist flexion results in compressive ischemia to the median nerve.

Solution: A night splint can help prevent hyper-flexion of the wrist by reducing nerve compression. (3) Cock-up splints can prevent static flexion/compression during sleep, but patients who are susceptible to traction ischemia should avoid excessive extension.  Also, avoid wearing an excessively tight brace, as this may be counterproductive to a compressive neuropathy.

5. Cubital Tunnel Syndrome

Problem: Sleeping in a fetal position with sustained elbow flexion results in traction ischemia to the ulnar nerve.

Solution: Limiting sustained elbow flexion will reduce ulnar nerve stretch. (4) Utilizing a brace that prevents elbow flexion beyond 45 degrees will limit stretch to the ulnar nerve. 

Pro Tip: consider the ulnar nerve floss for self-care to desensitize the nerve throughout the day.

6. Gluteal Tendinopathy

Problem: Gluteal tendon pain increases with positions, activities, and exercises that involve sustained or repetitive compressive loading—including sleeping. (5) Side-lying sleeping directly compresses the lateral hip resulting in ischemia and reduced ability to heal.  Similarly, sleeping on the opposite side without a pillow under the knee will traction the TFL/ITB against the greater trochanter resulting in static compression. 

Solution: Try to sleep on your back. If side lying is unavoidable, place a pillow between the knees to reduce torque on the upper hip. An eggshell mattress topper can limit compression of the underside hip. Avoid weighted blankets.

Author: Dr. Brandon Steele, DC, DACO

Dr. Steele began his career at The Central Institute for Human Performance. Dr. Steele has trained with experts including Pavel Kolar, Stuart McGill, Brett Winchester, and Clayton Skaggs. He has been certified in Motion Palpation, DNS, ART, and McKenzie Therapy. Dr. Steele lectures extensively on clinical excellence and evidence-based musculoskeletal management. He currently practices in Swansea, IL and serves on the executive board of the ICS.

  1. Gorski, J. (2018). Letter to the Editor. Journal of the American Academy of Orthopaedic Surgeons, 1. Link
  2. Gorski JM. Evaluation of Sleep Position for Possible Nightly Aggravation and Delay of Healing in Tennis Elbow. JAAOS Global Research & Reviews. 2019 Aug;3(8). Link
  3. McCabe SJ, Uebele AL, Pihur V, Rosales RS, Atroshi I: Epidemiologic associations of carpal tunnel syndrome and sleep position: Is there a case for causation? Hand 2007;2:127-134. Link
  4. Seror P: Treatment of ulnar nerve palsy at the elbow with a night splint. J Bone Joint Surg Br 1993;75:322-327. Link
  5. Cook JL, Purdam CR. The challenge of managing tendinopathy in competing athletes. Br J Sports Med. 2014 Apr 1;48(7):506-9. Link
  6. Rompe JD, Segal NA, Cacchio A, Furia JP, Morral A, Maffulli N. Home training, local corticosteroid injection, or radial shock wave therapy for greater trochanter pain syndrome. The American journal of sports medicine. 2009 Oct;37(10):1981-90. Link