Common Sleeping Mistakes That May Be Making Your Musculoskeletal Pain Worse

You spend roughly one-third of your life sleeping, which means you spend about 2,500 hours per year in whatever position you choose to sleep in. If you're dealing with neck pain, low back pain, or shoulder problems, those hours can either support your recovery or work against it. But with so much conflicting advice out there—from well-meaning friends, internet forums, and even some healthcare providers—what does the actual research say about sleep positioning?

Let's look at what the evidence tells us about pillows, mattresses, sleep positions, and separate fact from fiction.

Pillows and Neck Pain: Finding What's Best for You

The "right" pillow is one of the most common questions patients ask, and for good reason. Your pillow directly affects the alignment of your cervical spine (the neck portion of your spine) throughout the night. The truth is, there is not one "right" choice for everyone.

What the Research Shows

A systematic review published in the Journal of Pain Research found that pillow height significantly affects neck pain, but there's no one-size-fits-all answer. The ideal pillow height depends primarily on your preferred sleep position and your shoulder width.

For side sleepers

Research indicates you need a pillow thick enough to fill the space between your ear and the mattress, keeping your neck in neutral alignment. A study by Gordon et al. found that side sleepers experienced the least neck pain with pillows between 10-15 cm (4-6 inches) in height when compressed under the weight of your head. If you have broader shoulders, you'll generally need a thicker pillow.

For back sleepers

The evidence supports using a thinner pillow, typically 6-10 cm (2.5-4 inches) when compressed. A pillow that's too thick forces your neck into excessive flexion (forward bending), which can strain the muscles and joints at the back of your neck.

For stomach sleepers

This is actually the position most clinicians recommend avoiding if you have neck pain, because it requires you to rotate your neck to one side for extended periods. If you must sleep on your stomach, research suggests using a very thin pillow or no pillow at all under your head. When stomach sleeping, the thicker the pillow, the more neck stress from rotation/extension, which is hard on your joints.

Pillow Material Matters

Beyond height, pillow material has been shown to make a difference as well. A randomized controlled trial published in Sleep Science compared different pillow types and found that pillows with cervical support contours (rolls or curves that support the natural curve of your neck) reduced neck pain more effectively than standard flat pillows.

Memory foam and latex pillows that maintain their shape throughout the night performed better than traditional feather pillows, which compress unevenly and lose loft. However, personal preference matters—if you can't sleep comfortably on a pillow, it won't help your pain regardless of its theoretical benefits.

The Pillow Replacement Rule

Here's something most people don't know: pillows have an expiration date. Research shows that pillows lose approximately 10% of their supportive properties each year due to compression and breakdown of materials. If your pillow is more than 3 years old, it's likely not providing adequate support anymore, regardless of its original quality.

Mattress Firmness: Debunking the "Firm is Better" Myth

For decades, people with back pain were told to sleep on the firmest mattress possible. The thinking was that a firm surface would prevent the spine from sagging. But modern research has shown this is not accurate.

What Science Actually Says

A landmark randomized controlled trial published in The Lancet studied 313 adults with chronic non-specific low back pain. Non-specific LBP generally means there's not an acute injury we can point to as the cause of the pain. Most people (85-90%) fall into this category.

Participants were randomly assigned to sleep on firm, medium-firm, or soft mattresses for 90 days. The results surprised many clinicians: medium-firm mattresses produced the best outcomes for reducing pain and improving sleep quality.

Those sleeping on medium-firm mattresses reported twice the improvement in pain-related disability compared to those on firm mattresses.

The firm mattress group actually had the worst outcomes overall.

Why Medium-Firm Works Best

The explanation lies in understanding spinal biomechanics and pressure distribution. Your spine has natural curves: a lordosis (inward curve) in your neck and low back, and a kyphosis (outward curve) in your mid-back. These curves need support, not elimination.

A mattress that's too firm creates pressure points at your shoulders and hips while failing to support the natural curve of your low back. This is called "hammocking," where your lower back sags because it's not being supported by the mattress.

A mattress that's too soft allows excessive sinking, which can cause your spine to curve in unnatural ways and creates difficulty changing positions during the night.

A medium-firm mattress provides the Goldilocks combination: enough give to accommodate your body's pressure points while maintaining enough support to keep your spine in neutral alignment.

The Personalization Problem

That said, "medium-firm" is somewhat subjective. Body weight, body shape, and specific conditions all influence what works best for you. Some research suggests that heavier individuals may benefit from slightly firmer mattresses, while lighter individuals may find medium or even medium-soft more comfortable.

The best practical advice? When mattress shopping, spend at least 10-15 minutes lying in your typical sleep position. If you feel pressure building at your shoulders or hips, or if your low back feels unsupported, keep looking.

Side vs. Back Sleeping: Position-Specific Recommendations

Your sleep position affects more than just your pillow choice—it can directly impact specific musculoskeletal conditions.

Recommendations for Low Back Pain

For side sleepers

Research published in the Journal of Physical Therapy Science examined sleep positions in people with chronic low back pain. The findings showed that side sleeping with a pillow between the knees produced the best outcomes for most people.

Here's why this works: when you lie on your side without knee support, your top leg rotates your pelvis forward, creating torque (twisting force) through your lumbar spine. Placing a pillow between your knees keeps your pelvis in neutral alignment and reduces this rotational stress.

For back sleepers

For back sleepers with low back pain, placing a pillow under your knees can help maintain the natural lumbar curve and reduce pressure on the spinal discs and facet joints (the small joints that connect vertebrae to each other).

For stomach sleepers

Interestingly, a study in the Archives of Physical Medicine and Rehabilitation found that people who regularly slept prone (on their stomach) had higher rates of chronic low back pain—likely because this position increases lumbar extension (arching of the low back) and can compress facet joints. Sleeping with a pillow under your pelvis can help support your low back in this position.

Recommendations For Shoulder Pain

If you have shoulder pain, especially from rotator cuff problems or shoulder impingement (a condition where tendons get pinched in the shoulder), sleep position becomes critical.

Research in the Journal of Shoulder and Elbow Surgery found that sleeping on the painful shoulder significantly worsened symptoms and slowed recovery. The compression and reduced blood flow to the shoulder tissues throughout the night can impede healing.

The best option? Sleep on your non-painful side or on your back. If you're a side sleeper, some patients benefit from hugging a pillow or body pillow, which prevents the shoulder from rolling forward into internal rotation (a position that can aggravate some shoulder conditions).

For people with bilateral (both sides) shoulder pain, back sleeping with arm support may be necessary. Some patients find relief by placing small pillows or rolled towels under each forearm, which prevents the shoulders from rolling inward.

Recommendations For Hip Pain and Hip Osteoarthritis

People with hip osteoarthritis (wear and tear arthritis) often struggle with sleep. A study in Clinical Biomechanics examined hip joint loading in different sleep positions using pressure-sensing mats.

The findings: back sleeping distributed pressure most evenly across the hips and produced the lowest joint loading forces. Side sleeping on the painful hip should be avoided, as it significantly increases compressive forces through the joint.

Side sleepers with hip pain should sleep on the non-painful side with a thick pillow between the knees extending down to the ankles. This prevents adduction (the top leg dropping down toward the mattress), which creates shear forces across the hip joint.

Common Misconceptions Addressed

Myth 1: "There's one perfect sleep position for everyone"

Reality: The research is clear that optimal sleep position depends on your specific condition, body type, and personal factors. What works for neck pain might not work for low back pain. The goal is neutral spinal alignment, which looks different for different people.

Myth 2: "You should stay in one position all night"

Reality: Healthy sleep actually involves multiple position changes throughout the night—typically 10-30 movements. This is normal and healthy, as it prevents pressure buildup and maintains circulation. The goal isn't to stay perfectly still but to start in a supportive position and avoid positions that aggravate your specific condition.

Myth 3: "An expensive mattress is always better"

Reality: Research shows that mattress price doesn't correlate with pain relief or sleep quality. A study in Sleep and Health found no relationship between mattress cost and clinical outcomes. What matters is the firmness level and how well it matches your needs, not the brand name or price tag.

Myth 4: "Sleeping without a pillow is always bad"

Reality: For stomach sleepers, sleeping without a head pillow (while using a pillow under the pelvis) may actually reduce neck strain. The evidence doesn't support a universal need for head pillows in all positions.

Putting It All Together: Your Sleep Setup Action Plan

Based on the evidence we've reviewed, here's how to optimize your sleep setup:

Step 1: Assess your primary complaint

• Identify what hurts most and when (morning pain, nighttime pain, etc.)

Step 2: Evaluate your current setup

• How old is your mattress? (Most need replacing every 7-10 years)

• How old are your pillows? (Replace every 2-3 years)

• What position do you naturally sleep in?

Step 3: Make evidence-based changes

• Choose pillow height based on sleep position and shoulder width

• Aim for medium-firm mattress support

• Add positional pillows (between knees, under knees, etc.) as needed

• Avoid sleeping on painful areas when possible

Step 4: Give it time but trust your body

• Allow 1-2 weeks to adjust to changes

• Track your symptoms—are mornings better or worse?

• If pain worsens after 2 weeks, reassess your choices

Step 5: Consult with your healthcare provider

• If sleep positioning changes don't help within 4-6 weeks, there may be other factors contributing to your pain that need professional assessment

The Bottom Line

The evidence on sleep positioning is nuanced but actionable. There's no single "best" position for everyone, but there are better and worse choices depending on your specific musculoskeletal condition. Medium-firm mattresses work best for most people, pillow height should match your sleep position and body dimensions, and avoiding positions that compress or stress injured areas accelerates healing.

Most importantly, the "perfect" sleep setup is the one that allows you to sleep comfortably through the night while maintaining neutral spinal alignment. Pay attention to how your body responds, make evidence-informed adjustments, and don't be afraid to experiment within these guidelines to find what works best for you.

References

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3. Erfanian P, Tenzif S, Guerriero RC. Assessing effects of a semi-customized experimental cervical pillow on symptomatic adults with chronic neck pain with and without headache. J Can Chiropr Assoc. 2004;48(1):20-28.

4. Kovacs FM, Abraira V, Peña A, et al. Effect of firmness of mattress on chronic non-specific low-back pain: randomised, double-blind, controlled, multicentre trial. Lancet. 2003;362(9396):1599-1604.

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10. Verhaert V, Druyts H, Van Deun D, et al. Estimating spine shape in lateral sleep positions using silhouette-derived body shape models. Int J Ind Ergon. 2012;42(6):489-498.