Elsevier

Medical Hypotheses

Volume 74, Issue 4, April 2010, Pages 639-643
Medical Hypotheses

Sleep position and shoulder pain

https://doi.org/10.1016/j.mehy.2009.11.013Get rights and content

Abstract

The overuse theory for musculoskeletal joint pain cannot explain adequately the occurrence of shoulder pain in those who do not engage in activities that involve repeated and stressful use of the shoulder since the percentage of the painful right shoulders usually does not match the percentage of dominant right arms in such individuals. An alternative hypothesis is presented to propose that shoulder pain is caused by postural immobility in the decubitus or side position during sleep. Prolonged pressure on the shoulder caused by the weight of the thorax can produce enough damage to cause subsequent shoulder pain. In order to test this hypothesis, a preliminary study was carried out to compare the laterality of shoulder pain with the laterality of sleep position. The calculated laterality ratios for sleep position and shoulder pain were found to be strikingly similar, suggesting a causal relationship between the two phenomena. However, the prevalence of shoulder pain in the general population was found to be smaller than the percentage of the time people would spend sleeping in the decubitus position. This discrepancy could be explained by the idea that in order for shoulder pain to develop subjects may have to spend longer times in the same decubitus position before changing to another position than the average person would. Additional evidence from published clinical studies also supports the postural theory of shoulder pain. More studies can be done to test this hypothesis by focusing on the sleep habits of patients with shoulder pain. According to the present hypothesis shoulder pain should for the most part occur on the side that the patient preferred to sleep on before the onset of shoulder pain. The postural theory of shoulder pain provides the possibility for a new and noninvasive method to treat shoulder pain by the modification of posture during sleep.

Introduction

Shoulder pain is a common musculoskeletal disorder [1], [2], [3], [4]. It is particularly prevalent among people of advanced age [5], [6], [7] and those who suffer from rheumatoid arthritis [8], [9], spinal cord injury [10], [11], stroke [12], [13] and Parkinson’s disease [14], [15] (Table 1). An important aspect that distinguishes shoulder pain from other forms of musculoskeletal pain is the prevalence of sleep related symptoms [16]. A plethora of clinical studies have shown that nocturnal pain [5], [17], [18], [19], insomnia [7], [10], [13], [20] and inability to sleep on the affected side [1], [2], [21] are prominent features of shoulder pain. Furthermore, patients sometimes report that they experience shoulder pain for the first time when they wake up at night or in the morning, without prior warning or a specific inciting event [4], [22].

The etiology of shoulder pain has remained the subject of speculation [23], [24]. In those patients who experience repetitive trauma due to athletic activity, a causal relationship between such trauma and the ensuing shoulder pain can be inferred from the occurrence of the shoulder pain in the dominant side [25], [26]. However, the cause of shoulder pain in the general population is less clear [2], [27].

In general, unilateral shoulder pain affects the right shoulder more often than the left shoulder [20], [28]. This has been taken as an indication to suggest that shoulder pain is a consequence of overuse of the arm [20], [23], since the right arm is typically the dominant and thus the overused arm. However, in those studies that tested this idea, the discrepancy between the laterality of shoulder pain and arm dominance was found to be too great to suggest a relationship between the two phenomena [29], [30].

The purpose of this communication is to propose an alternative theory which suggests that shoulder pain develops during sleep when the subject assumes the decubitus or the side position. Such a position causes the upper body to inflict pressure on the shoulder which in the long run can cause shoulder pain. The observation that many patients report feeling shoulder pain for the first time when they wake up suggests that there is a temporal relationship between sleep and shoulder pain. Furthermore, the pain resulting from lying on the affected side is so intense that it suggests that lying on the side may be a repetition of the original event that caused the shoulder pain.

The postural theory of shoulder pain can be tested by comparing the laterality of shoulder pain with the laterality of sleep position. If the theory is relevant then the laterality of shoulder pain should match the laterality of sleep position and the prevalence of shoulder pain should equal the percentage of the time people spend sleeping in the decubitus position.

Section snippets

Inclusion criteria (shoulder pain)

Samples of shoulder pain patients were included only if they were diagnosed with shoulder impingement, including rotator cuff, supraspinatus or bicipital tendinitis. Only samples with their laterality defined in terms of right or left and using exact numbers or percentages were included. Studies which defined laterality in terms of dominant/non-dominant terms were not included unless they provided additional information about right or left involvement. Samples were included only if they came

Laterality of sleep position

All studies of sleep position showed that subjects spent more time in the right than in the left decubitus position. The aggregate sample for the interviewed group yielded a laterality ratio of 63.2% while the aggregate sample for the monitored group yielded a laterality ratio of 61.3%. This shows that the laterality ratios obtained by the two different methods were essentially similar (Table 2).

Laterality of shoulder pain

The shoulder pain group showed a preponderance for the involvement of the right side with an overall

Discussion

The purpose of this study was to explore the relationship between sleep position and shoulder pain. The rationale for sample collection and utilization was to gather enough numerical data to be able to make a statistical comparison between the lateralities of shoulder pain and sleep position and to find out whether there is any similarity between the two. Sample selection was carried out using the same principles that are relevant to meta-analysis [46], even though the present study does not

Conflicts of interest statement

None declared

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