Sleep Related Injury: part 1

If you’ve ever had a shoulder surgery, you quickly realize that sleeping becomes an impossible endeavor. It’s hard finding a position that doesn’t place the shoulder in a position of torture. Pain limits tolerable positions in the bed and eventually quantity and quality of sleep is lost. Sleep deprivation only compounds how poorly you feel the next day: how much pain you are experiencing and the body’s ability to heal diminishes.

Working in PT, I frequently hear complaints of pain linked to specific pathology in the orthopedic world. As a patient’s therapist, my role quickly moves to troubleshooting for sleep hygiene and educating patients on strategies for comfort management. This post explores some common sleeping habits that easily contribute to everyday pain, and easy solutions to fix the problem.

Calf Tightness & Plantar Fasciitis

Right out of the gate, here is one common theme found in this post. When soft tissue, particularly muscles and fascia are maintained in shortened position for prolonged periods (overnight), people often perceived it to be tighter upon return to normal use.

The reason for this is complicated, the evidence a rabbit hole, but likely points to some short term adaptation in the nervous system. In other situations where healing is taking place, whether after a hard workout, long run, or surgery, the tissue will then heal in a shortened position. This might make things more sore and stiff the next morning.

A classic example of this is the calf muscle. Whether lying on your back or stomach when you sleep, the toes often point straight down, placing the calf in shortened position.  Upon return to standing the next morning, you may notice some increased stiffness and tightness in the calves. This is especially true  if your calves are recovering from a recent increase in activity.

Overtime, if the postural pattern persists, a gradual loss of mobility in the joint may follow. This is more true in those who don’t regularly utilize the full range of the joint or full length of the tissue. The body often follows a “use it or lose it” theme physiologically, as shown in everything from bone density, to muscle mass: from blood volume to tendon density.

There are many injuries correlated with these changes in the research including calf muscle strains, tennis leg, Achilles tendinopathy, and plantar fasciitis.  Regularly engaging in some light stretching, taking time to tell your brain “hey, I still use my full ankle mobility” or “I still use the full length of these tissues” might help prevent mobility loss over time. Think about it: what’s the first thing dogs and cats do after taking a nap?

In severe cases, there are garments designed to limit ankle position overnight while sleeping, These are often helpful for individuals struggling with plantar fasciitis, but have some potential to disturb sleep quality. You must chose your battles wisely.  

Shoulder Pain

Another classic muscle group often maintained in a short position in sleep are the pecs. Side sleepers especially spend lots of time in a ‘fetal position’ with both shoulders migrating forward and inward toward each other. This puts the pec minor muscles in short position, which over time limits the ability of the shoulder blades to move back and drop down for simple overhead movements.

Similarly in fetal position, the arms are typically directly in front of the body in close proximity which will keep the pec major and minor in a short position. Pec major attaches to the front of the shoulder at the upper humerus, so eventually arm movements can be restricted. This is especially true due to the large size of the pec major in contrast to smaller muscles on the back of the shoulder. Tightness in the pec minor will also limited shoulder blade movement, also limiting shoulder mobility.

This common sleeping posture places the pec major and pec minor in the shortest position.

This common sleeping posture places the pec major and pec minor in the shortest position.

These problems are often made worse for those who also spend most of their day sitting at a desk. All of the above also move the thoracic spine into a more rounded posture, which can increase overtime due to ligamentous creep.  The thoracic spine follows the shoulder blades.

This is especially a problem for many who spend time developing chest muscles. If mobility isn’t maintained as strength and muscle bulk advance, postural changes follow. Eventually, shoulder mechanics begin to change and painful injury might not be far behind.

If any of the above apply to you, be sure to spend some time each week exploring movement in the opposite direction. This could include stretching, yoga, or other activities that promote opposite movement like swimming back stroke. Once the shoulder begins to hurt, sleep can easily suffer, so be sure to keep the pecs mobile and loose.

Neck Pain and Head Aches

When humans are young, sleep is deep and bodies are flexible. Pillow decisions are made without abandon, and little attention need be paid to sleeping postures. With age, flexibility can decrease over time, in part due to lifestyle changes, but also due to normal physiology. One’s ability to tolerate poorly fitting pillows decreases with time and eventually you find yourself ordering pillows from infomercials late at night.

In simple cases, the role of a pillow should be supportive of neutral posturing in the neck while sleeping. Similar to soft tissue themes above, joint in the body often do not fare well when taken to one extreme end of the range and are loaded for a prolonged period of time. This is true of any joint in the body: imagine locking your elbow and then adding a load for 3 hours: ouch!

Apply this scenario to the joints of the neck and a poorly matched pillow size, and the result is the same. A night of sleep with the wrong pillow may result in waking with wry neck or neck pain with associated headache. This is why there are different pillow types to correspond with sleeping habits.

When sleeping on one’s side, greater pillow height is needed to keep the head in line with your body. When lying face up, in theory, a thinner pillow is more appropriate. Bear in mind that lying flat on the floor with no pillow brings the head directly in line with the body. Conversely, many people no longer are able to attain neutral alignment of the head, neck and trunk, hence the amount of pillow needed for ‘back sleepers’ could vary drastically between individuals.

Postural tendencies will  determine what is ‘neutral’ for each person. So individuals have significant ‘forward head posture’ sitting and standing (for anatomical reasons) and might not sufficiently be helped with a “back sleeper” pillow while on their back.

Another variable is the combined product of body mass and mattress softness. The amount the torso sinks into the mattress also changes relative head position. Just these few variables alone explains why finding a pillow that works can be so challenging.

Having 6-12 pillows may make a bed look nice, but might not be ideal for sleeping positioning.

Having 6-12 pillows may make a bed look nice, but might not be ideal for sleeping positioning.

Over time, persistent neck posturing abnormality in sleep can lead to exaggeration of postural tendencies. This often leads to shortening of suboccipital muscles in the upper neck and episodic irritation of joints. Any of these can be experienced as episodic neck pain with or without associated headache.

It’s best to find a pillow that helps avoid extreme postures and helps achieve neutral-for-you postures. If you sleep in multiple positions, consider having different height pillows to alternate as needed.

Final Considerations

The title above was chosen a little tongue-in-cheek. I would never imply that sleeping is a major cause of injury. Be that as it may, our chronic posturing habits have ramifications, and under the right circumstances can make an existing problems worse. This applies to time spent awake or asleep.

Good sleep hygiene is important for overall health. As a PT, patient education is a huge part of treatment. For certain problems, avoiding aggravation of symptoms by modifying sleep habits might be enough for a problem to resolve entirely. I could never offer universal truths about positions or habits because each person’s case is unique.

Minor aches and pains experienced overnight can serve as a simple indicator that your body needs some attention. This is especially true in cases that are recurrent, cyclical, or begins to interfere with quality sleep. In going through rehab, it’s important to work hard, but also to rest hard too.

We live in a consumer driven society where patients are more likely to buy a new mattress than to seek out the services of a PT. Before you speed your money on furniture, consider seeing a PT first…to improve your comfort and reduce pain whether on your back or on your feet.

Until next time: don’t stop moving!

-Allan