Best and Worst Sleeping Position

Your sleeping position can help your pain as much as it can hurt. As a chiropractor with an evidence-based,  biomechanical approach, I derive my methods from principals in physiotherapy and biomechanics. Basically, my job is to find mechanical dysfunction that drives my patient’s symptoms and then fix it through joint & soft tissue manipulation, exercise, stretches, lifestyle advice, and activity modification.

I would say more than 3/4ths of my patients ask me about sleep habits. I’m sure you’ve heard the expression “You are what you eat,” but I’d go a step further and say “You are what you do!” Repetitive habits have a way of molding our bodies. That’s one of the reasons that we need to take a closer look at patient’s sleeping habits when they present with musculoskeletal issues.

Sleep habits are a challenging issue. People toss and turn and end up in a routine position because it feels comfortable, even if the position is bad for them. Habits are hard to break especially when you are only semi-conscious. The strategy here is to spend at least the first 10 minutes of rest in the desired position. After a while, you might find yourself falling asleep in this position. As more time passes, your body will accommodate and the new habit will bring about good positioning rather than bad.

Best Sleeping Position for Your Spine

There is no ONE BEST sleeping position: there are two (hahaha). That is to say that there are two particular positions that are mechanically kind to your body. There are also some sleeping positions to avoid. I’ll outline these and give you some tips & tricks along the way.

Side Sleeping Position

Side sleepers tend to roll their shoulders under their bodies. This can result in stress on the shoulder and shoulder blade (a particular problem for patients with shoulder pain). I can often tell which the patient’s favorite side is to sleep on because the scapula on that side will be shifted forwards and downwards: It’s what we call an anterior-rolled shoulder. In turn, this puts stress on the muscles that run up into the neck. It is very common to see patients have neck and upper back pain on the same side as their anterior-rolled shoulder. It’s also common to see this scapular malposition turn into a shoulder impingement syndrome that can damage the rotator cuff.

The solutions are two fold. First, we need to make sure that the patient has an appropriately sized pillow. That pillow needs to take up the space between the shoulder and the ear. This not only helps with the shoulder roll, but keeps the cervical spine (neck) straight when sleeping through the night.

I am not a fan of those costly orthopedic pillows with the indentations for the head. They are a waste of money as far as I’m concerned. Just about every patient who has gotten one (including myself) ends up hating them. Instead, it’s better to get a block pillow. These are pillows with flat edges instead of being dove-tailed. I don’t know about you, but I’ve never seen a human walking around with a recess in the top of their shoulder where a tapered pillow would fit. A flat-edged pillow works much better. Second, patients need to sleep more squarely in the side position and mind rolling the shoulder under them. Again, a good pillow can help fix this.

Semi-Side Sleeping Position

Another life hack here is the semi-side sleeping position. This is a strategy to keep the shoulder back while snoozing. It can actually be corrective. There’s nothing like fixing your body while you’re sleeping. When you lay in this way, you take stress off the neck and shoulder. The spine and head remain aligned. There is plenty of room to breath without turning the head too much. It also takes stress off the hips, pelvis and low back. Try and keep it symmetrical. Spend time in both the left and right positions.

To get into the left semi-side sleeping position…

1. Start on your stomach with your pillow placed under you longways.
2. Turn your head and body slightly to the right keeping your left shoulder down against the pillow.
3. Bend your right elbow and knee pointing them out to the right.
4. Keep your left hand down by your side and left leg relatively straight.
5. Place your right hand under your pillow.
6. Place your head on top of your hand.
7. Rest your left cheek/face comfortably on the side of the pillow facing slightly downwards.

Stomach Sleeping Position

This is not my favorite. It has some benefits, but usually doesn’t work out for two reasons. First, in order to breath, you have to turn your head rotating your neck about 80 degrees. That causes too much stress on the neck and you would likely wake up with stiffness and the classic cricked neck. Second, it can cause hyperextension of the lumbar spine (overarching of the low back). For patients with disc or facet joint pain, this can add insult to injury. It’s much better to sleep in the semi-side sleeping position above.

Back Sleeping Position

This can be quite good for your back. However, it’s not good to use a regular pillow. The height of your regular pillow would be too much in this position. Sleeping this way would cause your head to be pushed forward of your shoulders. The forward head position is a common dysfunction that needs corrected in patients. It is very similar to the mechanism of Tech-Neck. It can lead to stress on the neck and upper back muscles, disc displacement, and even tension headaches. This position can also worsen or lead to sleep apnea because the position narrows the upper airway. If you want to try to sleep on your back, roll up a large hand towel and put that under your neck. Not only does this fix the problems just mentioned, but it can also be corrective for someone that has lost the curve in their neck. This would be particularly useful for someone who has had whip-lash AKA cervical acceleration-deceleration injury.

Reclined Sleeping Position

I would recommend that everyone avoid this position if possible. Sleeping in a recliner does not fully allow the spine to unload throughout the night. This drives disc injury and facet compression. Discs need a break from gravity during the night in order to heal and remodel. The position is also associated with what we call a hyperkyphosis. This is were the upper and mid back are flexed forward leading to the characteristic humped back that we have all seen. The position also pushes the head forward (Just like the Tech-Neck mechanism above). The combination of the forward head and hyperkyphosis can also result in a Dowager’s hump. This is the bump at the base of the neck where it meets the shoulders.

Some patients may have to sleep in the reclined position to control vertigo, acid reflux, sleep apnea, or ironically back pain. If you do have to sleep in a reclined position (chair, or adjustable bed), then you should use a support under your mid back and lay back as far as you can tolerate to prevent a hyperkyphosis. You should also use a rolled towel beneath the neck or at least avoid any pillow that might push the head forward.

Soft VS Firm Mattress

I would never assume that one type of mattress works for all people. Everyone is different. Everybody has their own “Goldilocks Zone” in terms of firmness vs softness. Having said that, it is usually better to error on the side of firmness. You can always make a bed softer by adding toppers. It’s impractical to try and make a mattress firmer.

Firm Mattress Pros and Cons

Firm mattresses give better support to the spine. That means that the spine is more likely to be aligned during sleep. However, if the mattress is too firm, then it will cause pressure points. This is particularly true for the shoulders and hips of side-sleepers.

Soft Mattress Pros and Cons

On the other hand, a mattress that is too soft will allow the spine to dip and sag. The misalignment can cause pressure to build in the spinal joints and discs overnight. If the misalignment builds, it can result in painful joint and muscle dysfunction in the spine and hips.

Finding a Good Balance between Firm and Soft Mattress

A good mattress is a combination of firm and soft that fits each individual. This can be tricky for couples and they may have to consider a mattress with adjustable firmness. I suggest that patients do not rush to choose a mattress. In fact, I recommend taking several weeks to find the right one. My advise is to try no more than 4 each visit to the mattress store. Spend at least 10 minutes, if not more like 15-30, on each one. Take notes on your phone. Then do it again comparing different mattresses until you have a solid 2-3 that you like and choose between those. It’s an important enough decision to invest your time in. However, in my experience, some of the best mattresses are not expensive at all. I do not have a favorite brand or store. You do not need to spend thousands. Don’t get bullied into upgrades by the salesperson. At the end of the day, it’s your money and your body going onto that mattress.