What types of shoulder pain most commonly affect sleep quality? A scoping systematic review
Jakie przyczyny bólu barku najczęściej wpływają na jakość snu? Przegląd systematyczny
2 Faculty of Medicine, Medical University of Łódź, Poland
3 Department of Orthopaedics and Traumatology, Veterans’ Memorial Teaching Hospital in Łódź, Medical University of Łódź, Poland
Introduction. Shoulder pain is a common symptom of multiple pathologies, which may impair sleep quality.
Aim. To analyze the most common reasons for shoulder pain, which decreases sleep quality.
Materials and methods. From September to December 2022, two independent researchers searched the following databases: PubMed, Scopus, Science Direct, and Google Scholar according to PRISMA Extension for Scoping Reviews guidelines. Terms: “shoulder pain”; “sleep deprivation”; “sleep initiation maintenance disorders”, and “sleep quality” were used. All English-language articles pertaining to the topic were included, regardless of the year of publication. Non-peer-reviewed publications and reviews were excluded from the search.
Results. The initial search identified 1561 articles. After removing duplicates, 401 articles were screened by the title and abstract. 1124 articles were excluded because they did not fulfill the inclusion criteria. In the end, 78 articles were included in the review. Each of the included articles was sorted into one of the following groups: injuries and pathologies (34 articles), postoperative pain (16 articles), head and neck related pain (11 articles), rare conditions and diseases (7 articles), psychological factors (6 articles), or neoplasms (4 articles).
Conclusions. Shoulder pain may have a highly diverse etiology. Proper diagnosis of its origin and problem-specific therapy may effectively increase sleep quality.
Wstęp. Ból barku jest częstym objawem wielu patologii, który może zaburzać jakość snu.
Cel. Analiza najczęstszych przyczyn bólu barku, które obniżają jakość snu.
Materiał i metody. Od września do grudnia 2022 roku, dwóch niezależnych badaczy przeszukało następujące bazy danych: PubMed, Scopus, Science Direct i Google Scholar zgodnie z wytycznymi PRISMA dla przeglądów badawczych. W tym celu wykorzystano terminy „shoulder pain”; „sleep deprivation”; „sleep initiation maintenance disorders” i „sleep quality”. Uwzględniono wszystkie anglojęzyczne artykuły dotyczące tematu, niezależnie od roku ich publikacji. Publikacje nierecenzowane i prace przeglądowe zostały wykluczone z wyszukiwania.
Wyniki. Wstępne wyszukiwanie zidentyfikowało 1561 artykułów. Po usunięciu duplikatów, 401 artykułów sprawdzono pod kątem tytułu i streszczenia. 1124 artykuły zostały wykluczone, ponieważ nie spełniały kryteriów włączenia. Ostatecznie do przeglądu włączono 78 artykułów. Każdy z włączonych artykułów został przydzielony do jednej z następujących grup: urazy i patologie (34 artykuły), ból pooperacyjny (16 artykułów), ból związany z głową i szyją (11 artykułów), rzadkie stany i choroby (7 artykułów), czynniki psychologiczne (6 artykułów) lub nowotwory (4 artykuły).
Wnioski. Ból barku może mieć bardzo zróżnicowaną etiologię. Prawidłowa diagnoza jego pochodzenia i terapia dostosowana do problemu może skutecznie poprawić jakość snu.
Shoulder pain is a non-specific symptom of multiple pathologies, both rare and common. What is more, this pathology significantly decreases the quality of life of our patients. It mainly presents as an upper extremity impairment but may also result in psychiatric disorders when the pain becomes chronic [1–3]. Rotator cuff disease is responsible for most shoulder pain cases [4–6], but little is been known about the etiology of shoulder pain at night. Therefore, this scoping systematic review aimed to analyze the most common reasons for shoulder pain.
Materials and methods
From September to December 2022, two independent researchers (N.P. and Z.G.) searched the following databases: PubMed, Scopus, Science Direct, and Google Scholar according to PRISMA Extension for Scoping Reviews guidelines. The following terms were used: “shoulder pain”; “sleep deprivation”; “sleep initiation maintenance disorders,” and “sleep quality”. All full-text English-language articles on the topic were included (except reviews), regardless of the year of publication. Articles were excluded if they lacked correlation between shoulder pain and its etiology or sleep quality. Non-peer reviewed publications and articles that did not specify the etiology of shoulder pain were also excluded from the search. Two researchers screened the records by titles and abstracts and independently decided if a record met the inclusion criteria. In the event of any disagreement, the opinion of the senior researcher (M.D.) was sought, and his decision was final. References of the included studies were checked for additional data. Data extraction was performed by two researchers (N.P. and Z.G.), while the third researcher (M.K.) supervised the process to ensure accuracy. The data was then sorted into subtopics based on the etiology of shoulder pain. Due to the scoping nature of the review and the heterogenous designs of the included studies, the meta-analysis could not be performed. The study selection is visualized in the flow diagram (Fig. 1).
The initial search identified 1561 articles. After removal of duplicates, 401 articles were screened by the title and abstract. 1124 articles were excluded because they did not fulfill the inclusion criteria. Finally, 78 articles were included in the review, sorted into groups and presented in Table 1.
1. Injuries and pathologies
1.1. Rotator cuff disease
Rotator cuff disease (RCD) was the most prevalent in the “pathologies and injuries” group. RCD related shoulder pain is the most common cause of shoulder pain and accounts for 70% of shoulder pain cases. . Nocturnal pain is reported by up to 91% of RCD patients [5, 6]. RCD related pain is a multidimensional disorder, and the role of sleep disorders in the chronification of this pain is well known [7, 8]. Sleep disturbances are the primary reason patients with RCD contact their doctor [5, 9]. However, the mechanisms of this nocturnal pain have not yet been fully established. One hypothesis describes it as a result of impingement and bursitis in the subacromial space. A higher level of proinflammatory cytokine – TNF-α was observed among patients with RCD who suffer from pain-related sleep disturbances . Two studies pointed out that synovitis causes increased blood flow in the synovial membrane, which results in increased blood flow in the artery supplying the capsule – anterior humeral circumflex (AHCA). The conclusion is that night pain among RCD patients may be related to the hemodynamics, and it diminishes when the blood flow velocity decreases. [11,12]. A study by Mengi et al. showed that the presence of subscapularis tendinosis appears to be an independent predictor of nocturnal pain. In addition, patients with a positive Neer’s test may experience more nocturnal pain .
Vergili et al. tried to compare sleep quality in patients with RCTs (rotator cuff tears) of different sizes. The study showed no significant difference between patients with small and large RCTs . Similar conclusions were reached by Reyes et al. , Serbest et al. , and Khazzam et al. . Only tendon retraction showed a significant correlation with pain . On the other hand, a study by Gumina et al. showed that patients with small tears have poorer sleep quality compared to patients with more severe tears. It was shown that they needed more time to fall asleep and had more disturbed sleep than patients with large and massive tears. . As presented, this problem is still under debate; however, Ansok et al. described that patients even tend to overreport their time spent asleep when compared to objective time asleep measured by validated monitors .
The literature search showed two studies in which RCD was treated non-surgically with an evaluation of pain and sleep disturbances. The first was physiotherapy. Passive mobilization, manual ischemic trigger point therapy, and passive traction were performed. After 12 weeks of follow-up, the patient had decreased pain levels and improved sleep quality and quantity . In the second study, the authors evaluated the therapeutic effect of subacromial platelet-rich plasma (PRP) injections in RCD. After 12 months of follow-up VAS, ASES, and Constant-Murley Score indicated improvement after the injection. Sleep disorders were resolved in 86% of the patients .
A review of the literature revealed 7 studies pertaining to rotator cuff repair (RCR) with evaluation of pain and sleep disturbances. One of the main goals of RCR is to restore normal sleep patterns. Dolan et al. indicated that 77% and 81% of patients reported resolution of sleep disturbances by 6 months and 2 years postoperatively, respectively . In agreement with these results, Longo et al. proved that sleep disturbances improved three to six months after RCR , and Cho et al. reported that after RCR, sleep disturbances decreased among their patients from 6.6 ± 3.6 PSQI score before surgery to 4.2 ± 3.3 at 12 months after surgery. . In a study by Horneff et al., sleep quality achieved in the sixth month post-surgery was maintained over a follow-up period of more than 24 months (5.4 vs 5.5 PSQI score). The interesting addition to their study is that the prolonged use of narcotic medication negatively affected sleep, with a greater effect seen over time. . In all of the aforementioned studies, RCR resulted in a significant decrease in pain intensity.
According to Wu et al., preoperative sleep disturbances of patients are independently associated with the occurrence of moderate or above pain 1 month after surgery (OR = 3.794, 95% CI: 1.261–11.409, p = 0.018). Preoperative sleep disturbances should be given more attention and actively improved to effectively promote postoperative pain management in patients with rotator cuff tears. . On the contrary, Cho et al. demonstrated that preoperative sleep disturbances did not predict poor outcomes (pain intensity or sleep quality) after RCR . Bingöl&Biçici presented interesting results about rotator cuff re-ruptures. Sleep disturbances may indicate rotator cuff retear. Patients with re-rupture after 1 year follow-up had significantly higher postoperative PSQI scores and lower CSS and OSS scores compared to those without re-rupture (p < 0.001) .
1.2 Frozen shoulder
Patients with adhesive capsulitis, also known as frozen shoulder (FS) are particularly vulnerable to reduced sleep quality. The incidence of sleep disturbance was reported to be around 85% in FS patients . It is generally characterized by a three-phased evolution of the disease – freezing, frozen, and thawing. Stage 1 is the painful phase where sleep disturbances are common due to nocturnal shoulder pain [24,25]. In a cross-sectional study by Mulligan et al., it appeared that FS, in comparison to subacromial impingement syndrome (SIS,) led to poorer sleep quality (PSQI score 12.07 ± 5.7 vs 8.59 ± 4.73; p = 0.008) and function (SANE score 34% vs 53%, p= 0.007; ASES score 38 vs 51, p = 0.007) .
Pain in FS may lead to depression or anxiety and impairs patients’ quality of life (QoL) [24,25]. FS patients with depression or anxiety have significantly lower PROMs values and significantly higher prevalence of sleep disturbances compared with FS patients with normal psychological status . Besides the excruciating pain, patients with FS struggle to reestablish a sense of normalcy as they cope and adapt to a profound emotional change. A sociological approach to FS was extensively described in a study by King et al. and referred to as “no-man’s land.” . Considering all the aforementioned symptoms, it is critical not to delay surgical intervention. Arthroscopic capsular release significantly decreases nocturnal pain and sleep disturbances regardless of the timing of surgery .
1.3 Subacromial impingement syndrome
Subacromial impingement syndrome (SIS) causes sleep disturbances due to pain mediated by the free nerve endings in the subacromial bursa. The majority of included studies focused on a conservative treatment approach. Patients with shoulder pain due to SIS may benefit from painkillers and cognitive-behavioral interventions that specifically target sleep disturbances. . Response to subacromial corticosteroid injections and lidocaine/tetracaine patches in patients with SIS can be predicted from pretreatment pain quality. Patients with the most to gain (i.e., those reporting the highest levels of various pain qualities) can expect the best response to effective treatments . Joint mobilizations with supervised exercises in patients with SIS reduce pain, improve sleep quality, and increase conditioned pain modulation after 8 weeks of exercise . Therapeutic ultrasound does not have any benefits on SIS. However, transcutaneous electrical nerve stimulation (TENS) combined with exercise programs are effective in pain, disability, and sleep disturbances in patients with SIS . Low-level laser treatment (LLLT) and extracorporeal shock wave therapy (ESWT) treatments were reported to be effective in the treatment of SIS at 3 months extended follow-up .
Myofascial pain syndrome (MPS) is characterized by regional or widespread myalgia with trigger points (TrP). The TrP is a painful, physical sign that occurs in various myalgic conditions. Latent TrPs are very common and have been identified in the shoulder girdle muscles in 45-55% of healthy young adults. The upper part of the trapezius muscle is one the most common sites affected by this condition. The relationship between the presence of active TrPs, pain intensity, disability, and sleep quality is significantly associated with MPS . During the literature search, the authors found one study on dry needling, considered one of the most effective MPS treatment methods. It is widely used by physiotherapists and leads to improved sleep quality and decreased pain intensity .
In a case study by Scibek&Carcia, the authors presented a patient with calcific tendinitis with severe sleeping disturbances forcing the patient to sleep in an upward position. Pain control was achieved with codeine combined with ice massage after exercise and at the end of the day. By completing a physiotherapeutic regimen focusing on decreasing pain, improving range of motion and strength over an 18-day period, pain levels at rest and with activity decreased from 8-9/10 to 0/10, and scores for SST progressively increased from 0/12 to 12/12 with no recurrence of symptoms in 22 months follow-up .
Additionally, shoulder pain is a common and significant problem in world-class badminton players. It was correlated with consequences such as sleep disturbances, changes in training, and competition habits. Previous shoulder pain was reported by 37% of players, and ongoing shoulder pain by 20% of players .
2. Postoperative pain
Surgical interventions generally improve self-reported sleep quality and PROMs from before to after surgery (e.g., RCR, total shoulder arthroplasty, arthroscopic capsular release, comprehensive arthroscopic management, and sternoclavicular joint procedures) [15,38]. It was also reported that arthroscopic shoulder surgery performed in outpatient care also improves sleep quality and alleviates pain in 88% of patients . Similar problems are also common after laparoscopic cholecystectomy (LC). Pain after laparoscopic procedure is complex with multifactorial etiology, but the most common theory is carbon dioxide persistence between the right diaphragm and the hepatic dome . Pain was reported in 35-60% of patients after LC. Intravenous administration of lidocaine and magnesium reduced intraoperative and postoperative opioid requirement and pain scores while improving postoperative analgesia. Lidocaine was also associated with the earlier return of bowel function, and magnesium – with improved sleep quality. . Nakhli et al. also demonstrated that premedication with gabapentinoids can enhance postoperative rehabilitation quality after LC by reducing postoperative shoulder pain and improving sleep quality during the first postoperative night .
2.1 Postoperative pain: total shoulder arthroplasty
During a 3-month follow-up, Total Shoulder Arthroplasty (TSA) has been shown to reduce patients’ pain and improve their sleep quality. These benefits are particularly noticeable during activities of daily living that involve forward elevation and waist-level movements, in that specific chronological order . Sleep disturbances have the strongest associations with post-operative outcomes of physical functions and pain interference (p < 0.01) . After surgery, sleep quality significantly improves within 6 weeks and returns to normal levels in 1 year. The negative correlation of PSQI with ASES score suggests that improved functional outcomes are related to enhanced sleep quality . Postoperative pain control after TSA may be augmented by continuous cryotherapy or plain ice because they were proven to be similarly effective with no differences in pain control, quality of sleep, or narcotic usage . A multimodal sleep pathway after TSA, including non-pharmacologic sleep hygiene interventions and the use of zolpidem and melatonin, improves patient analgesia and sleep. It also reduces opioid usage, increases sleep duration, and improves reported sleep quality during the postoperative recovery period .
2.2 Postoperative pain: drugs
Effective postoperative pain management after arthroscopic shoulder surgery enables patients to leave the hospital earlier, lowers the chance of hospital readmission, and speeds up recovery time. Preoperative, intraoperative, and postoperative measures should all be considered as a comprehensive approach to pain control as they also improve patients’ sleep quality [48–52]. Painless sleep after surgery may be achieved with oral analgesics, sleep medications, or continuous cold-flow therapy . Other drugs that help in the induction of painless sleep are: local anesthetics injections (ropivacaine [48,50] or bupivacaine  blocks), steroid injections (betamethasone), and, if necessary, opioids like oxycodone .
If possible, pain management should be multimodal. Elkassabany et al. presented the Multimodal Perioperative Pain Protocol (MP3), which consisted of preoperative oral acetaminophen and gabapentin, intraoperative intravenous ketorolac, and postoperative oral acetaminophen, gabapentin, and ketorolac with oxycodone as needed for breakthrough. Implementation of the MP3 after shoulder arthroscopy improved pain management and sleep quality two days after ambulatory shoulder surgery. Additionally, this protocol significantly reduced opioid consumption up to three days after surgery .
3. Head and neck-related pain
Neck and shoulder pain (NSP) is a common work-related musculoskeletal disorder with unclear mechanisms [54,55]. High strain, active jobs and sleep disturbances are prognostic factors that increase the risk of NSP. Furthermore, sleep disturbances may modify the association between high strain and troublesome NSP . Autonomic regulation is involved in the pathogenesis of chronic NSP. NSP patients have elevated heart rates, reduced heart rate variability during sleep, higher levels of stress and fatigue, and reduced sleep quality .
Significant correlations exist between aerobic exercise, uninterrupted sleep, and the absence of NSP . Moreover, individuals with poor sleep quality are less likely to recover from NSP, and the severity of NSP is directly proportional to the decline in sleep quality . Conversely, sleep problems are associated with an increased risk of chronic NSP. Regular exercise and maintenance of normal body weight may break this vicious cycle [56,58]. The NSP patients with the most pronounced sleep problems have significantly higher OR (OR 2.00; CI 1.09-3.67) for long-term sickness absence from work (> 90 days) . The literature search revealed several pathologies coexisting with NSP, including temporomandibular disorders , concussions or cervical spine injuries , common headaches , and thoracic outlet syndrome .
The authors found several methods alleviating the NSP-related sleep disturbances. People who regularly exercise (≥1 hour per week) have a lower risk of chronic NSP (OR: 0.8) [56,58]. Furthermore, people with BMI <25 kg/cm(2) and sleep problems have a lower risk of chronic NSP than people with BMI ≥25 kg/cm . He et al., in their randomized controlled trial, proved that intensive acupuncture may also improve the quality of sleep among NSP patients. The effect lasted for at least three years during the follow-up period .
4. Rare conditions and diseases
Joint hypermobility in Ehlers-Danlos syndrome (EDS) was correlated with poor sleep quality. According to questionnaires, 90% of patients reported having pain most frequently localized in the neck, shoulders, hips, forearms, and legs (>40% of all patients). 50% of the patients suffering from pain were awakened during the night due to pain .
Two articles were found on spinal cord injury (SCI). Adults who experienced it before the age of eighteen, individuals with shoulder pain, and people with tetraplegia are more likely to report poor sleep . Paired associative stimulation (PAS) and motor rehabilitation were reported to improve patients’ functioning after SCI . The literature search also indicated two studies about shoulder pain in fibromyalgia (FM) affecting sleep quality. FM patients have shorter total sleep time, longer sleep latency, and reduced sleep efficiency in polysomnography. The associations between heart rate variability, sleep quality and shoulder pain were found to be the most pronounced during non-REM stage 3 of sleep . The use of high-intensity laser therapy (HILT) as an alternative therapy for pain management in FM was reported to effectively decrease pain, improve ROM, mood, activity level, and sleep quality, lasting for 1 week. After 1 week, only 50% of the initial pain intensity returned .
Patients suffering from postherpetic neuralgia (HSP) localized in cervical/upper extremity dermatomes may additionally suffer from insomnia . The same phenomenon was reported among patients with neuronal amyotrophy. It is a relatively uncommon inflammatory brachial plexopathy that often manifests as severe pain followed by weakness in the shoulder girdle muscles. A 45-degree angle and noninvasive ventilation may be required for better sleep .
5. Psychological factors
A decrease in the amount and quality of sleep affects the relaxation and recovery of shoulder girdle muscles. An increase in muscle tension and activity may also result from psychological factors such as depression, anxiety, or stress, all of which may create a vicious cycle. Shoulder pain can reduce the quality of sleep and cause psychological disorders, and poor sleep quality and psychological disorders can further affect shoulder dysfunction and pain .
Stressful factors in the work environment among health-care and hospital workers are correlated with a lack of adequate sleep and pain in the shoulder [2,3]. Results of a study by Sigursteinsdóttir et al. revealed a positive correlation between mental and physical exhaustion at the end of the workday and musculoskeletal pain. Adequate sleep had a significant negative correlation with all stressful factors in the work environment and shoulder pain . Almost one in four healthcare professionals surveyed reported a severe or very severe musculoskeletal disorder (MSD), and nearly one in seven reported a severe sleep disorder (SD). General stress, work stress, physical effort at work, and particularly a painful or tiring posture at work were found to be clear and strong risk factors for MSDs, whereas only general and work-related stress were found to be significantly associated with SDs . Also, academic pressure in students who experience a heavy learning burden and high level of stress is closely related to chronic shoulder pain, which results in sleep disturbances .
During the COVID-19 pandemic, social isolation potentiated painful symptoms in various parts of the body. Working and learning from home, along with using portable devices that require flexing the neck and repetitive movements, have led to a significant rise in the prevalence of shoulder pain, which is further correlated with sleep latency. In addition, compelling evidence suggests that reduced physical activity during the pandemic has been linked to a decline in sleep quality. This, in turn, has been associated with depression and musculoskeletal pain [73,74].
Four articles about neoplasms impairing sleep quality due to shoulder pain are characterized in Table 3.
Rotator cuff disease
The most important result of this systematic review was that the most frequent cause of nocturnal shoulder pain mentioned in the literature was RCD. Results of systematic review performed by Castro-Contreras and Valdez-Pardo show that 100% of patients with rotator cuff injury suffer from sleep disturbances, and up to 93% feel pain at night . Both of these findings are in accord with the results reported in studies included in this review [5,6]. The resolution of sleep disturbances and pain reduction among RCD patients may be achieved by both conservative [18,19] or surgical treatment [5,9,20–23]. However, Longo et al. presented in their meta-analysis that surgical management is more effective in terms of pain alleviation in comparison to the conservative treatment group at 12 months follow-up (VAS score = − 1.08, 95% CI − 1.58 to − 0.58; p < 0.001) . Unfortunately, there was no possibility of assessment and comparison of sleep quality among the groups due to the heterogeneity of the included studies.
According to our results, psychological factors were associated with shoulder pain at night [1–3,72–74]. This topic may seem difficult for an orthopedic surgeon or a physiotherapist to cope with as it is not in the field of these specialties. However, a deeper understanding of our patients’ minds would help guide them through the treatment process and break the vicious cycle created by psychological factors . Maxwell et al. performed a qualitative synthesis exploring the experiences of individuals living with shoulder pain . In the study, the authors describe 3 main types of patients. The first group comprises individuals who experience shoulder pain that has a negative impact on their emotional and social lives, as well as their daily activities. These individuals are fully focused on their negative emotional state, experiencing feelings of frustration and depression. It may be beneficial to include a psychiatrist or psychologist on the medical team to provide appropriate care for them. The second group are patients with a desperate need of a definite diagnosis, with a feeling of “structural fault,” which rapidly needs permanent treatment. The surgical approach may be the most beneficial to them. Finally, the third group consists of patients who manifest apprehension of movement because they anticipate shoulder pain. A rehabilitation program under the supervision of a physiotherapy specialist with consistent psychological support may be the most adequate for such people. Knowledge of our patients’ minds, their emotions and empathy from the medical team is known to have
a significant therapeutic impact, far beyond the effects
of prescribed drugs, surgeries and other treatment
Environmental and socioeconomic factors
When considering the causes of sleep disorders, one should not forget environmental factors comprising sound insulation, temperature and room humidity . Also, socioeconomic factors like night clothes, bedding quality, and mattress rigidity or elasticity have significant impacts on sleep quality . While searching the literature, our attention was drawn to studies that noted the effect of mattress and pillow type on sleep quality; however, they were excluded due to the lack of a specified shoulder pain etiology [84–86]. Jacobson et al. reckon that most healthcare practitioners have patients who complain about sleep disturbances and shoulder pain probably caused by the type of mattress they sleep on. To investigate this issue, they designed a study, which proved that using a prescribed bedding system more efficiently reduces shoulder pain and stiffness and improves sleep quality than a personal (patient’s own) bedding system. Significant improvement was observed in shoulder pain (by 60.83%) and sleep quality (by 60.73%) .
People tend to spend about one-third of their lives sleeping. Werner et al. hypothesized that different shoulder positions during sleep could significantly affect nocturnal subacromial pressure. As a result, atrophy and ruptures during sleep may affect tendon healing after RCR . In our opinion, this can also apply to patients with chronic shoulder pain who have not undergone surgery. In the study mentioned above, subacromial pressures were lower among people sleeping supine and higher among people sleeping in prone and lateral decubitus positions . These results seem interesting, especially in relation to the Kempf et al. study, which found that most of their subjects were more likely to sleep on the painful shoulder . A new question arises: Why do people with shoulder pain unconsciously tend to increase their subacromial pressure by lying in the lateral decubitus position? that the answer to this question may be a promising subject for future studies.
Strengths and limitations
This review is of great clinical importance. It does not only summarize the most common etiologies of night shoulder pain, but also highlights the significance of having a broader perspective when patients report sleep disturbances. The presentation of the sleep assessment scales (Tab.2) may also facilitate their introduction into the daily routine of the surgical ward. There are several limitations to this review. Firstly, there is a lack of consistency in the measuring sleep quality. One should bear in mind that sleep quality is impaired in most chronic pain cases but rarely monitored. The six pathology groups are a relatively small number and it may be due to a lack of awareness of the problem among patients and medics. The second limitation is that the study did not have a registered protocol. The third limitation pertains to heterogeneity of scales assessing shoulder pain. This limitation, in conjunction with the first, made it impossible to perform a metanalysis.
This scoping systematic review proves that shoulder pain may have a highly diverse etiology, and may interfere with sleep in many different ways. Sleep quality should be monitored and effectively treated in patients with chronic shoulder pain, because it may significantly impact the effectiveness of the treatment of the primary pathology. And conversely, proper diagnosis of pain etiology and problem-specific therapy may effectively increase sleep quality.
1. Hwang Y, Oh J. The relationship between shoulder pain and shoulder disability in women: The mediating role of sleep quality and psychological disorders. Medicine (Baltimore). 2022;101(41):e31118. doi:10.1097/MD.0000000000031118
2. Sigursteinsdóttir H, Skúladóttir H, Agnarsdóttir T, Halldórsdóttir S. Stressful factors in the working environment, lack of adequate sleep, and musculoskeletal pain among nursing unit managers. Int J Environ Res Public Health. 2020;17(2):673. doi:10.3390/ijerph17020673
3. Hämmig O. Work- and stress-related musculoskeletal and sleep disorders among health professionals: a cross-sectional study in a hospital setting in Switzerland. BMC Musculoskelet Disord. 2020;21(1):319. doi:10.1186/s12891-020-03327-w
4. Mengi A, Akif Guler M. Nocturnal pain in patients with rotator cuff related shoulder pain: A prospective study. Musculoskelet Sci Pract. 2022;59:102536. doi:10.1016/j.msksp.2022.102536
5. Dolan MT, Lowenstein NA, Collins JE, Matzkin EG. Majority of patients find sleep patterns return to normal 6 months following rotator cuff repair. J Shoulder Elbow Surg. 2022;31(8):1687-1695. doi:10.1016/j.jse.2022.01.122
6. Khazzam MS, Mulligan EP, Brunette-Christiansen M, Shirley Z. Sleep quality in patients with rotator cuff disease: J Am Acad Orthop Surg. 2018;26(6):215-222. doi:10.5435/JAAOS-D-16-00547
7. Maestroni L, Marelli M, Gritti M, et al. Is rotator cuff related shoulder pain a multidimensional disorder? An exploratory study. Scand J Pain. 2020;20(2):297-305. doi:10.1515/sjpain-2019-0108
8. Minns Lowe CJ, Moser J, Barker K. Living with a symptomatic rotator cuff tear ‘bad days, bad nights’: a qualitative study. BMC Musculoskelet Disord. 2014;15(1):228. doi:10.1186/1471-2474-15-228
9. Horneff JG, Tjoumakaris F, Wowkanech C, et al. Long-term correction in sleep disturbance is sustained after arthroscopic rotator cuff repair. Am J Sports Med. 2017;45(7):1670-1675. doi:10.1177/0363546517692551
10. Cho CH, Kim DH, Baek EH, Kim DH. Serum levels of TNF-α are increased in patients with rotator cuff tear and sleep disturbance. Diagn Basel Switz. 2021;11(12):2215. doi:10.3390/diagnostics11122215
11. Terabayashi N, Watanabe T, Matsumoto K, et al. Increased blood flow in the anterior humeral circumflex artery correlates with night pain in patients with rotator cuff tear. J Orthop Sci. 2014;19(5):744-749. doi:10.1007/s00776-014-0604-5
12. Watanabe A, Katayama H, Machida T, Hirooka T. Synchronization of blood flow velocity in the anterior humeral circumflex artery and reduction in night pain after arthroscopic rotator cuff repair: A Case Report. Cureus. Published online April 25, 2022. doi:10.7759/cureus.24468
13. Vergili O, Oktas B, Canbeyli IDD, et al. Comparison of sleep quality, shoulder function, and quality of life in patients with different-sized rotator cuff tears. Asian J Med Sci. 2021;12(8):130-136. doi:10.3126/ajms.v12i8.36916
14. Reyes BA, Hull BR, Kurth AB, Kukowski NR, Mulligan EP, Khazzam MS. Do magnetic resonance imaging characteristics of full-thickness rotator cuff tears correlate with sleep disturbance? Orthop J Sports Med. 2017;5(11):232596711773531. doi:10.1177/2325967117735319
15. Serbest S, Tiftikçi U, Askın A, et al. Preoperative and post-operative sleep quality evaluation in rotator cuff tear patients. Knee Surg Sports Traumatol Arthrosc. 2017;25(7):2109-2113. doi:10.1007/s00167-016-4228-5
16. Gumina S, Candela V, Passaretti D, et al. Sleep quality and disturbances in patients with different-sized rotator cuff tear. Musculoskelet Surg. 2016;100(Suppl 1):33-38. doi:10.1007/s12306-016-0405-4
17. Ansok CB, Khalil LS, Muh S. Objective assessment of sleep quality in patients with rotator cuff tears. Orthop Traumatol Surg Res. 2020;106(1):61-66. doi:10.1016/j.otsr.2019.09.033
18. Rachel W, Vaishally T, John S. Association of sleep quality and chronification of musculoskeletal pain in an older adult: A case report. Int J Osteopath Med. 2022;44:36-39. doi:10.1016/j.ijosm.2022.04.003
19. Rossi LA, Piuzzi N, Giunta D, et al. Subacromial platelet-rich plasma injections decrease pain and improve functional outcomes in patients with refractory rotator cuff tendinopathy. Arthrosc J Arthrosc Relat Surg. 2021;37(9):2745-2753. doi:10.1016/j.arthro.2021.03.079
20. Longo UG, Candela V, De Salvatore S, et al. Arthroscopic rotator cuff repair improves sleep disturbance and quality of life: a prospective study. Int J Environ Res Public Health. 2021;18(7):3797. doi:10.3390/ijerph18073797
21. Cho CH, Song KS, Hwang I, Warner JJP. Does rotator cuff repair improve psychologic status and quality of life in patients with rotator cuff tear? Clin Orthop. 2015;473(11):3494-3500. doi:10.1007/s11999-015-4258-1
22. Wu H, Su W, Huang S, et al. Correlation between pre-operative sleep disturbance and post-operative pain in patients with rotator cuff tear. Front Integr Neurosci. 2022;16:942513. doi:10.3389/fnint.2022.942513
23. BÏNgöl İ, BÏÇÏCÏ V. How does rerupture affect sleep and quality of life in patients undergoing arthroscopic rotator cuff repair? Turk J Med Sci. 2021;51(1):181-187. doi:10.3906/sag-2012-169
24. Cho CH, Jung SW, Son ES, Hwang IS. Sleep status and quality of life in patients with frozen shoulder. J Korean Orthop Assoc. 2012;47(3):205. doi:10.4055/jkoa.2012.47.3.205
25. Toprak M, Erden M. Sleep quality, pain, anxiety, depression and quality of life in patients with frozen shoulder1. J Back Musculoskelet Rehabil. 2019;32(2):287-291. doi:10.3233/BMR-171010
26. Mulligan EP, Brunette M, Shirley Z, Khazzam M. Sleep quality and nocturnal pain in patients with shoulder disorders. J Shoulder Elbow Surg. 2015;24(9):1452-1457. doi:10.1016/j.jse.2015.02.013
27. Ding H, Tang Y, Xue Y, et al. A report on the prevalence of depression and anxiety in patients with frozen shoulder and their relations to disease status. Psychol Health Med. 2014;19(6):730-737. doi:10.1080/13548506.2013.873814
28. King WV, Hebron C. Frozen shoulder: living with uncertainty and being in “no-man’s land.” Physiother Theory Pract. 2023;39(5):979-993. doi:10.1080/09593985.2022.2032512
29. Hasegawa A, Mihata T, Fukunishi K, Neo M. Does the timing of surgical intervention impact the clinical outcomes and overall duration of symptoms in frozen shoulder? J Shoulder Elbow Surg. 2021;30(4):836-843. doi:10.1016/j.jse.2020.07.023
30. Tekeoglu I, Ediz L, Hiz O, et al. The relationship between shoulder impingement syndrome and sleep quality. Eur Rev Med Pharmacol Sci. 2013;17(3):370-374.
31. Gammaitoni AR, Trudeau JJ, Radnovich R, et al. Predicting response to subacromial injections and lidocaine tetracaine patch from pretreatment pain quality in patients with shoulder impingement syndrome: predicting treatment response. Pain Med. 2015;16(7):1333-1340. doi:10.1111/pme.12758
32. Lyng KD, Andersen JD, Jensen SL, et al. The influence of exercise on clinical pain and pain mechanisms in patients with subacromial pain syndrome. Eur J Pain. 2022;26(9):1882-1895. doi:10.1002/ejp.2010
33. Yazmalar L, Sarıyıldız MA, Batmaz İ, et al. Efficiency of therapeutic ultrasound on pain, disability, anxiety, depression, sleep and quality of life in patients with subacromial impingement syndrome: A randomized controlled study. J Back Musculoskelet Rehabil. 2016;29(4):801-807. doi:10.3233/BMR-160692
34. Badıl Güloğlu S. Comparison of low-level laser treatment and extracorporeal shock wave therapy in subacromial impingement syndrome: a randomized, prospective clinical study. Lasers Med Sci. 2021;36(4):773-781. doi:10.1007/s10103-020-03093-0
35. Yaghoubi Z, Pardehshenas H, Takamjani IE. The effect of upper trapezius muscle dry needling treatment on sleep quality: A case report. J Bodyw Mov Ther. 2018;22(2):333-336. doi:10.1016/j.jbmt.2017.05.020
36. Scibek JS, Carcia CR. Presentation and Conservative Management of Acute Calcific Tendinopathy: A Case Study and Literature Review. J Sport Rehabil. 2012;21(4):334-342. doi:10.1123/jsr.21.4.334
37. Fahlstrom M, Yeap JS, Alfredson H, Soderman K. Shoulder pain – a common problem in world-class badminton players. Scand J Med Sci Sports. 2006;16(3):168-173. doi:10.1111/j.1600-0838.2004.00427.x
38. Highland KB, Parry J, Kent M, et al. Lagged effect of patient‐reported outcomes measurement information system (PROMIS) sleep disturbance on subacute postsurgical PROMIS pain behavior. J Orthop Res. 2023;41(4):711-717. doi:10.1002/jor.25412
39. Lakhal W, Chanthany K, Bund L, et al. Outpatient paediatric arthroscopy: A retrospective study in 216 patients. Orthop Traumatol Surg Res. 2018;104(7):1091-1094. doi:10.1016/j.otsr.2018.07.016
40. Nakhli MS, Kahloul M, Jebali C, et al. Effects of gabapentinoids premedication on shoulder pain and rehabilitation quality after laparoscopic cholecystectomy: pregabalin versus gabapentin. Pain Res Manag. 2018;2018:9834059. doi:10.1155/2018/9834059
41. Saadawy IM, Kaki AM, Abd El Latif AA, et al. Lidocaine vs. magnesium: effect on analgesia after a laparoscopic cholecystectomy. Acta Anaesthesiol Scand. 2010;54(5):549-556. doi:10.1111/j.1399-6576.2009.02165.x
42. Morris BJ, Sciascia AD, Jacobs CA, Edwards TB. Sleep disturbance and anatomic shoulder arthroplasty. Orthopedics. 2017;40(3). doi:10.3928/01477447-20170120-02
43. Kolade O, Ghosh N, Buchalter D, et al. Patterns of limitations in activities of daily living, sleep, and pain in the early postoperative period following total shoulder arthroplasty: a prospective study. JSES Int. 2023;7(1):16-20. doi:10.1016/j.jseint.2022.09.017
44. George SZ, Bolognesi MP, Ryan SP, Horn ME. Sleep disturbance, dyspnea, and anxiety following total joint arthroplasty: an observational study. J Orthop Surg. 2022;17(1):396. doi:10.1186/s13018-022-03288-x
45. Elkassabany NM, Wang A, Ochroch J, et al. Improved quality of recovery from ambulatory shoulder surgery after implementation of a multimodal perioperative pain management protocol. Pain Med. 2019;20(5):1012-1019. doi:10.1093/pm/pny152
46. Noyes MP, Denard PJ. Continuous cryotherapy vs ice following total shoulder arthroplasty: a randomized control trial. Am J Orthop Belle Mead NJ. 2018;47(6). doi:10.12788/ajo.2018.0045
47. Cheah JW, Freshman RD, Mah CD, et al. Orthopedic sleep and novel analgesia pathway: a prospective randomized controlled trial to advance recovery after shoulder arthroplasty. J Shoulder Elbow Surg. 2022;31(6):S143-S151. doi:10.1016/j.jse.2022.02.035
48. Woo JH, Lee HJ, Oh HW, et al. Perineural dexamethasone reduces rebound pain after ropivacaine single injection interscalene block for arthroscopic shoulder surgery: a randomized controlled trial. Reg Anesth Pain Med. 2021;46(11):965-970. doi:10.1136/rapm-2021-102795
49. Da H, Song JK, Liu L, Zhou L. Compound betamethasone in the treatment of pain after supraspinatus tendon repair. J Int Med Res. 2022;50(9):030006052211219. doi:10.1177/03000605221121962
50. Mariano ER, Afra R, Loland VJ, et al. Continuous interscalene brachial plexus block via an ultrasound-guided posterior approach: a randomized, triple-masked, placebo-controlled study. Anesth Analg. 2009;108(5):1688-1694. doi:10.1213/ane.0b013e318199dc86
51. Schoenherr JW, Gonzalez M, Serrano R, et al. Quality of recovery after rotator cuff repair with interscalene liposomal bupivacaine versus interscalene nerve catheter. Orthop J Sports Med. 2022;10(11):232596712211348. doi:10.1177/23259671221134819
52. Garnaud B, Mares O, L’hermite J, et al. Multimodal oral analgesia strategy after ambulatory arthroscopic shoulder surgery: case series using adaptive therapeutic approaches by sequential analysis. J Shoulder Elbow Surg. 2021;30(2):250-257. doi:10.1016/j.jse.2020.08.040
53. Ruiz-Suarez M, Barber A. Postoperative pain control after shoulder arthroscopy. Orthopedics. 2008;31(11):01477447-20081101-20081125. doi:10.3928/01477447-20081101-25
54. Hallman DM, Ekman AH, Lyskov E. Changes in physical activity and heart rate variability in chronic neck–shoulder pain: monitoring during work and leisure time. Int Arch Occup Environ Health. 2014;87(7):735-744. doi:10.1007/s00420-013-0917-2
55. Rasmussen-Barr E, Grooten WJA, Hallqvist J, et al. Are job strain and sleep disturbances prognostic factors for neck/shoulder/arm pain? A cohort study of a general population of working age in Sweden. BMJ Open. 2014;4(7):e005103-e005103. doi:10.1136/bmjopen-2014-005103
56. Peterson G, Pihlström N. Factors associated with neck and shoulder pain: a cross-sectional study among 16,000 adults in five county councils in Sweden. BMC Musculoskelet Disord. 2021;22(1):872. doi:10.1186/s12891-021-04753-0
57. Lee MK, Oh J. The relationship between sleep quality, neck pain, shoulder pain and disability, physical activity, and health perception among middle-aged women: a cross-sectional study. BMC Womens Health. 2022;22(1):186. doi:10.1186/s12905-022-01773-3
58. Mork PJ, Vik KL, Moe B, et al. Sleep problems, exercise and obesity and risk of chronic musculoskeletal pain: The Norwegian HUNT study. Eur J Public Health. 2014;24(6):924-929. doi:10.1093/eurpub/ckt198
59. Aili K, Nyman T, Hillert L, Svartengren M. Sleep disturbances predict future sickness absence among individuals with lower back or neck-shoulder pain: A 5-year prospective study. Scand J Public Health. 2015;43(3):315-323. doi:10.1177/1403494814567755
60. Mundt AKG, Helkimo M, Magnusson T. Sleeping position and reported quality of sleep. A comparison between subjects demanding treatment for temporomandibular disorders and controls. Swed Dent J. 2011;35(4):187-193.
61. Provance AJ, Howell DR, Potter MN, et al. Presence of Neck or Shoulder Pain Following Sport-Related Concussion Negatively Influences Recovery. J Child Neurol. 2020;35(7):456-462. doi:10.1177/0883073820909046
62. Axon DR, Dawid A. Student pharmacist characteristics and management of headache. Curr Pharm Teach Learn. 2022;14(9):1169-1176. doi:10.1016/j.cptl.2022.07.040
63. Milenovic N, Klasnja A, Skrbic R, et al. Sleep problems and disabilities of the arm, shoulder, and hand in persons with thoracic outlet syndrome—a cross-sectional study. Int J Environ Res Public Health. 2022;19(19):12486. doi:10.3390/ijerph191912486
64. He D, Høstmark AT, Veiersted KB, Medbø JI. Effect of intensive acupuncture on pain-related social and psychological variables for women with chronic neck and shoulder pain – an RCT with six month and three year follow up. Acupunct Med. 2005;23(2):52-61. doi:10.1136/aim.23.2.52
65. Voermans NC, Knoop H, Bleijenberg G, Van Engelen BG. Pain in Ehlers-Danlos syndrome is common, severe, and associated with functional impairment. J Pain Symptom Manage. 2010;40(3):370-378. doi:10.1016/j.jpainsymman.2009.12.026
66. January AM, Zebracki K, Chlan KM, Vogel LC. Poor sleep in adults with pediatric-onset spinal cord injury: associations with pain, health, and activity. J Spinal Cord Med. 2017;40(5):560-566. doi:10.1080/10790268.2017.1308109
67. Vaalto S, Nyman AL, Shulga A. Analgesic effect of paired associative stimulation in a tetraplegic patient with severe drug-resistant neuropathic pain: a case report. Scand J Pain. 2021;21(4):831-838. doi:10.1515/sjpain-2021-0012
68. Mork P, Nilsson J, Lorås H, et al. Heart rate variability in fibromyalgia patients and healthy controls during non-REM and REM sleep: a case–control study. Scand J Rheumatol. 2013;42(6):505-508. doi:10.3109/03009742.2012.755564
69. White PF, Zafereo J, Elvir-Lazo OL, Hernandez H. Treatment of drug-resistant fibromyalgia symptoms using high-intensity laser therapy: a case-based review. Rheumatol Int. 2018;38(3):517-523. doi:10.1007/s00296-017-3856-5
70. Lee DH, Park JE, Yoon DM, et al. Factors associated with increased risk for clinical insomnia in patients with postherpetic neuralgia: a retrospective cross-sectional study. Pain Med. 2016;17(10):1917-1922. doi:10.1093/pm/pnw066
71. Diaz-Abad M, Porter N, Zilliox L, Todd N. Use of noninvasive ventilation with volume-assured pressure support in neuralgic amyotrophy with bilateral diaphragmatic paralysis. Open Respir Med J. 2019;13(1):45-47. doi:10.2174/1874306401913010045
72. Zhang Y, Deng G, Zhang Z, et al. A cross sectional study between the prevalence of chronic pain and academic pressure in adolescents in China (Shanghai). BMC Musculoskelet Disord. 2015;16(1):219. doi:10.1186/s12891-015-0625-z
73. Karatel M, Bulut ZI, Sari EO, et al. The profile of musculoskeletal pain and its associations with sleep quality and depression during the COVID-19 in Turkey. Korean J Pain. 2022;35(1):78-85. doi:10.3344/kjp.2022.35.1.78
74. Pedrosa Luna Oliveira J, Zangirolami-Raimundo J, Evaristo De Andrade P, et al. Relationship between musculoskeletal pain, sleep quality and migraine with level of physical activity in college students during the COVID-19 pandemic. Heliyon. 2022;8(10):e10821. doi:10.1016/j.heliyon.2022.e10821
75. Gofeld M, Bhatia A. Alleviation of pancoast’s tumor pain by ultrasound-guided percutaneous ablation of cervical nerve roots. Pain Pract. 2008;8(4):314-319. doi:10.1111/j.1533-2500.2008.00210.x
76. Dahl AA, Nesvold IL, Reinertsen KV, Fosså SD. Arm/shoulder problems and insomnia symptoms in breast cancer survivors: Cross-sectional, controlled and longitudinal observations. Sleep Med. 2011;12(6):584-590. doi:10.1016/j.sleep.2011.01.011
77. Jerath NU, Reddy CG, Moritani T, et al. Clinical reasoning: A 47-year-old woman with left shoulder pain after a fall. Neurology. 2014;83(11):e112-e116. doi:10.1212/WNL.0000000000000776
78. Fong SSM, Ng SSM, Lee HW, et al. The Effects of a 6-month Tai Chi Qigong training program on temporomandibular, Cervical, and Shoulder Joint Mobility and Sleep Problems in Nasopharyngeal Cancer Survivors. Integr Cancer Ther. 2015;14(1):16-25. doi:10.1177/1534735414556508
79. Castro-Contreras E, Valdez-Pardo ME. [Rotator cuff injuries with nighttime pain and sleep quality before and after treatment]. Acta Ortop Mex. 2022;36(1):33-38.
80. Longo UG, Risi Ambrogioni L, Candela V, et al. Conservative versus surgical management for patients with rotator cuff tears: a systematic review and META-analysis. BMC Musculoskelet Disord. 2021;22(1):50. doi:10.1186/s12891-020-03872-4
81. Maxwell C, Robinson K, McCreesh K. Understanding shoulder pain: a qualitative evidence synthesis exploring the patient experience. Phys Ther. 2021;101(3):pzaa229. doi:10.1093/ptj/pzaa229
82. Decety J. Empathy in medicine: what it is, and how much we really need it. Am J Med. 2020;133(5):561-566. doi:10.1016/j.amjmed.2019.12.012
83. Okamoto K, Iizuka S, Okudaira N. The effects of air mattress upon sleep and bed climate. Appl Hum Sci J Physiol Anthropol. 1997;16(3):97-102. doi:10.2114/jpa.16.97
84. Jacobson BH, Gemmell HA, Hayes BM, Altena TS. Effectiveness of a selected bedding system on quality of sleep, low back pain, shoulder pain, and spine stiffness. J Manipulative Physiol Ther. 2002;25(2):88-92. doi:10.1067/mmt.2002.121410
85. Yonei Y, Takahashi Y, Shionoiri A, Inada S. Evaluation of the Effect of α Gel embedded Mattresses as Bedding on the Mind and Body. ANTI-AGING Med. 2007;4(1):11-18. doi:10.3793/jaam.4.11
86. Jacobson BH, Boolani A, Dunklee G, et al. Effect of prescribed sleep surfaces on back pain and sleep quality in patients diagnosed with low back and shoulder pain. Appl Ergon. 2010;42(1):91-97. doi:10.1016/j.apergo.2010.05.004
87. Werner CML, Ossendorf C, Meyer DC, Blumenthal S, Gerber C. Subacromial pressures vary with simulated sleep positions. J Shoulder Elbow Surg. 2010;19(7):989-993. doi:10.1016/j.jse.2010.04.039
88. Kempf B, Kongsted A. Association between the side of unilateral shoulder pain and preferred sleeping position: a cross-sectional study of 83 Danish patients. J Manipulative Physiol Ther. 2012;35(5):407-412. doi:10.1016/j.jmpt.2012.04.015