Pain which is worse at night

As mentioned before, carpal tunnel syndrome usually is worse at night. This may be because of mechanical factors such as "sleeping on one’s hands" with wrists flexed, as well as fluid retention at night. At any rate, patients are often awakened or awaken in the morning with numbness and pain in their hands, often in a median nerve distribution, interestingly, many patients cannot localize the pain in their hands and they even report pain proximally in their forearms or arms and shoulders. Up to 7 percent of patients present with pain in the shoulder region, and only a thorough history and physical examination will detect the nocturnal pattern and association with numbness and tingling in the hands. The trapezius symptoms are presently myofascial and secondary. In terms of mechanical factors in the wrists themselves, prevention of excessive flexion or extension through splinting or better positioning may reduce symptoms.

As mentioned, cervical and lumbar osteoarthritis can be worsened by positioning associated with lying in bed at night. Lumbar facet syndrome in particular is worsened by sustained extension. Unlike patients with discogenic pain, these people are often more comfortable on their side in some degree of lumbar flexion. As mentioned as well, patients with lumbar stenosis are often worsened at night by extension and by fluid retention; this is especially true in the elderly who may have some degree of congestive heart failure or venous insufficiency. Venous pooling at night results in decreased canal diameter with increased symptoms.

Patients with rotator cuff disease or tendinitis often complain of worsening of symptoms at night when they attempt to lie on their sides, especially on the side of their complaints. This is probably due to compression of an already impinged tendon. Although less commonly described by patients with other shoulder problems, patients with instability or acromioclavicular disease may also complain of exacerbation of symptoms by lying on the side of the complaint, probably also due to compression.

Patients with vascular insufficiency may have "night pain" in bed as compared to sitting or standing. Although classical "claudication" symptoms are brought on by walking, arterial pressure to the legs is decreased by lying in bed as compared to sitting and may result in decreased blood flow and precipitation of symptoms as well.

Myofascial pain syndrome and fibromyalgia are worsened by bed rest as well. Whether this is simply the result of relative immobility, whether it is related to hormonal variations at night, what role the non-restorative sleep disorder associated with fibromyalgia might play, or what other rheumatologic factors may be at play -- are unclear at this time.