Ghosts and ghouls aren’t real, but some things that go bump in the night can be really painful. That’s especially true with knee pain caused by conditions like osteoarthritis, the most common form of arthritis.
Even minimal contact of the joint with, say, the other knee or the bed can be uncomfortable. “Arthritis can cause limitations with range of motion,” notes Dr. P. Maxwell Courtney, an assistant professor of orthopedic surgery at the Thomas Jefferson University Sidney Kimmel Medical College and an orthopedic surgeon at Rothman Orthopaedic Institute at Jefferson Health in Philadelphia. “It can cause their knee to be bent a few degrees — that’s called a flexion contracture — and oftentimes if patients are restless during their sleep,” certain movements can exacerbate pain, he says.
Even if you don’t make contact with anything in your sleep, knee pain at night can be arresting. It’s not that knee pain is relegated to only the evening hours. Certainly many report it to be bad at other times of the day. For many, morning joint pain is also pronounced. But patients and doctors say in the still of the night, when a person’s trying to get comfortable and fall asleep, knee pain can be especially bothersome.
Research indicates that between 60% to 80% of patients with osteoarthritis of the knee will feel knee pain at night, says Dr. Dominic King, a sports medicine physician at Cleveland Clinic Sports Health in Cleveland. Nighttime knee pain is also common with other conditions that can affect the joint like bursitis, which involves inflammation of fluid-filled sacs around joints called bursae, and tendonitis, where the tendon becomes inflamed.
Swelling at Night
The experience of knee pain is both a function of what’s happening physiologically and how that pain is perceived when one is attempting to quiet the body and mind in preparation for sleep, orthopedic experts say. “If people are trying to go to bed and trying to get comfortable, it tends to be a time when knee pain is very annoying,” says Dr. Thomas Bowen, chief of orthopedic oncology for the Geisinger Musculoskeletal Institute and an orthopedic surgeon at Geisinger Medical Center in Danville, Pennsylvania. “They’re trying to relax, and things hurt more.”
The day’s stresses on the knee can add up as well. In addition, inflammation in the knee can cause pain at any time without warning or activity.
Generally speaking, the synovial fluid inside our knee is circulated around the joint as we bend it to stand up, walk or be active in other ways — so when we’re moving, we don’t have as much swelling. Engaging in 150 minutes of “at least moderate physical activity” on a weekly basis can help manage the symptoms of osteoarthritis, according to the Centers for Disease Control and Prevention. Regular physical activity can also reduce the risk of developing other chronic diseases, according to the CDC.
Those disease include:
— Heart disease.
Exercising for at least 150 minutes a week is a factor associated with low osteoarthritis knee pain, according to research published in 2015 in the journal Pain Research and Management.
Many people tend to be more sedentary in the evening before bed, which can make knee pain worse at night.
Once we go to bed, “the tendons start to get a little bit tight, the muscles get a little bit tight, that fluid doesn’t really have anywhere to go, and it’s not being actively pumped around through the knee,” Bowen says. “So the knees might actually feel a little bit more swollen. And that’s why those symptoms may start then.”
The Pain-Sleep Connection: Stopping the Cycle
Research suggests that a lack of sleep can exacerbate pain, and that pain can adversely affect sleep, according to the Sleep Foundation.
Studies suggest that “short sleep times, fragmented sleep and poor sleep quality often causes heightened sensitivity to pain the following day in chronic conditions like rheumatoid arthritis,” according to the foundation. There’s also an association between pain and trouble sleeping.
So what can you do about it? Experts suggest taking these steps to ease nighttime knee pain, which will improve your days as well.
— Treat the underlying problem.
— Practice good sleep hygiene.
— Don’t substitute sleep aids for treating the cause of the pain.
— Don’t use alcohol to “medicate” your pain.
— Make adjustments at bedtime to accommodate the joint — like using a knee pillow.
Treat the Pain
Frequently, the cause of knee pain isn’t curable — as with osteoarthritis. But that doesn’t mean it can’t be managed to relieve pain and improve function.
To start, make sure to get a proper diagnosis and determine your options to optimize knee function and soothe pain. That includes exercising regularly in ways that are appropriate for you — from walking to swimming — and eating a well-balanced diet that’s high in veggies, fruits and complex carbs, and low in processed foods — including refined carbs and sugar. For those who are overweight or obese, losing even a modest amount of weight can take pressure off joints and ease pain, orthopedic experts say.
You can also use non-medical measures to sooth knee arthritis pain. That includes applying heat to improve circulation to the area when the joint is stiff. You can also ice the joint to calm inflammation from rheumatoid arthritis or osteoatrthritis.
Taking an over-the-counter pain medication, such as acetaminophen or a non-steroidal anti-inflammatory drug (like ibuprofen or naproxen), may also help ease pain. But make sure to consider risks for any drugs, even OTC medications. For example: NSAIDs can be associated with stomach ulcers or kidney trouble, Bowen notes.
“People with stomach ulcers or history of kidney disease probably shouldn’t take (NSAIDs). But for short-term relief of musculoskeletal symptoms,” the medications work well, Bowen says. Just make sure to talk with your doctor before making any medication part of your routine — particularly if you’re thinking about taking them on an ongoing basis.
A variety of other treatments are also offered to manage osteoarthritis, including steroid injections in the joint to ease pain and physical therapy. For some with advanced arthritis in the knee, joint replacement surgery may be recommended after non-surgical approaches have been tried. “For the person who’s losing the ability to walk or losing the ability to sleep due to severe osteoarthritis, knee replacement really improves the quality of their life,” Bowen says. “It’s a good operation for the right person.”
Practice Good Sleep Hygiene
Treating your knee is only part of the equation. You also need to take care to improve your sleep habits. That’s because poor sleep habits can make it more likely that pain disrupt your sleep. And a lack of sleep can make pain worse
Along those lines, you’ve probably heard about the importance of good sleep hygiene before. It’s good advice to follow even when you don’t have knee pain:
— Keep a regular bedtime routine.
— Make sure your room is cool and dark.
— Only use your bed for sleep and for having sex.
— Before bed, avoid caffeine, heavy meals or any food or drink that will keep you up.
— Turning off screens — preferably an hour before bed.
Health care providers who are experts on sleep remind that staring at computer screens, TV screens, phone screens — you name it — before bed is robbing us of crucial zzz’s.
Exercise is one way to mitigate knee pain from osteoarthritis. “It hurts to move, especially with knee pain, but people who move overall experience less pain”, Bowen says. He suggests engaging in physical activities that put little or no pressure on the knee.
Bowen recommends these low-impact exercises:
— Elliptical workouts.
Don’t Just Rely on Sleep Aids
While you may choose to take a sleep aid temporarily for any number of reasons, experts generally recommend avoiding chronic use of the drugs. Courtney says generally he leaves decisions about sleep aids to patients and their primary care doctors.
However, he stresses that when it comes to knee pain, it’s important to address the underlying problem that’s causing it, rather than just getting through the night with sleep aids — which carry their own risks. “That’s not actually treating the symptoms of knee pain.”
Don’t ‘Medicate’ With Alcohol
The rules of imbibing in moderation apply: Women should have no more than one alcoholic drink, like a glass of wine or a beer, per day; men should have no more than two.
Drinking alcohol in excess can keep you up and undermine sleep quality. While a night cap might help you drift off to sleep, alcohol consumption decreases REM sleep, so that you don’t wake up as refreshed.
Drinking large quantities of alcohol before bedtime is associated with delayed sleep onset, according to the Sleep Foundation. That means people who drink before going to bed may need more time to fall asleep. “As liver enzymes metabolize the alcohol during their night and the blood alcohol level decreases, these individuals are also more likely to experience sleep disruptions and decreases in sleep quality,” according to the foundation.
A longitudinal study published in 2020 in Scientific Reports found that consuming “high volumes of alcohol or drinking hazardously may contribute to the prevalence of sleep problems in older age.” Beginning in 1985, researchers studied more than 7,000 London civil servants who were between the ages of 35 and 55 at the beginning of the study. “Those with disrupted sleep should consider reducing alcohol consumption and people in this age group, particularly men, should be discouraged from using alcohol as a sleep aid,” researchers concluded.
Make Accommodations for Your Knee at Bedtime
King suggests patients who have knee pain do three things around bedtime:
— Take a warm bath to combat soreness and stiffness around the knee.
— Apply a topical, non-steroidal anti-inflammatory cream to the joint (available over the counter and as a prescription).
— Use a “knee pillow.”
For side sleepers, put a pillow between your legs. Use any pillow that works for this — no need to buy a specific type or expensive one. “It’s more … trial and error for what feels good,” King says. “But it decreases the contact pressure between the two knees touching each other if you’re a side sleeper.”
If you sleep on your back, slide a pillow beneath your knee to slightly elevate it and provide extra cushion. The problem some back sleepers face is they have their leg out straight, which can increase the contact pressure between the knee cap and the femur, King says. And that can be painful for people with knee arthritis. “A knee pillow that goes underneath the knee and gives just a nice little bend can be pretty comfortable.”
Just remember: Whatever you do to get comfy at bedtime should be a supplement to — not a replacement for — treating the underlying knee problem, orthopedic experts emphasize. Managing what’s causing your knee pain can make a night and day difference.
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Update 04/15/21: This article was previously published and has been updated with new information.