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Sleep, Pain and Recovery

How sleep and pain affect each other, why surgery and shoulder problems disturb sleep, and what helps you rest and recover.

Overview

Preoperative sleep disturbance is highly prevalent in patients undergoing shoulder arthroplasty, with rates of 84-97% [1]. Minimal improvement in sleep quality is reported within the first 6 weeks postoperatively for these patients [1]. Similarly, sleep disturbance is common after rotator cuff repair [5]. Sleep quality worsens at 2 weeks after rotator cuff repair [5], but improves beyond baseline by 6 weeks [5]. Improvement of sleep disturbance after rotator cuff repair occurs at 3 months [2].

In contrast, patients with a history of sleep disorders did not report nor objectively experience worse sleep patterns perioperatively after total knee arthroplasty [3]. There is an initial stage of sleep disturbance immediately postoperatively after total knee arthroplasty [4]. Overall improvement in sleep quality is observed after total knee arthroplasty [4].

Background & Causes

Preoperative sleep disturbance is highly prevalent in patients undergoing shoulder arthroplasty, with rates of 84-97% [1]. Sleep quality shows minimal improvement within the first 6 weeks postoperatively after shoulder arthroplasty [1]. Sleep disturbance is common after rotator cuff repair [5]. Sleep quality worsens at 2 weeks after rotator cuff repair [5]. Sleep quality improves beyond baseline by 6 weeks after rotator cuff repair [5]. Improvement of sleep disturbance after rotator cuff repair occurs at 3 months [2].

Patients with a history of sleep disorders did not report nor objectively experience worse sleep patterns perioperatively after total knee arthroplasty [3]. There is an initial stage of sleep disturbance immediately postoperatively after total knee arthroplasty [4]. Overall sleep quality improves after total knee arthroplasty [4]. Sleep benefits after total knee arthroplasty are more domain-specific, with reductions in environmental disturbances suggesting meaningful improvements in select aspects of rest [8].

Melatonin is recommended postoperatively after arthroscopic rotator cuff repair to reduce sleep disturbance in the early postoperative period and potentially help with longer term functional outcome [7]. Melatonin, corticosteroids, and anticonvulsants provide inconsistent benefits for improving postoperative sleep quality in primary total joint arthroplasty patients [9].

Sleep and heart rate variability (HRV) show recovery toward baseline by post-call night 2 for orthopaedic surgeons and residents [10]. Evidence supports the pivotal role of sleep and cognitive skills in preventing sports injuries [13].

Symptoms & Presentation

Shoulder Arthroplasty: Preoperative sleep disturbance is highly prevalent, affecting 84-97% of patients [1]. Minimal improvement in sleep quality occurs within the first 6 weeks postoperatively [1].

Rotator Cuff Repair: Sleep disturbance is common after this procedure [5]. Sleep quality worsens at 2 weeks postoperatively [5]. Improvement beyond baseline occurs by 6 weeks [5], with further improvement of sleep disturbance noted at 3 months [2].

Total Knee Arthroplasty (TKA): Perioperative sleep dysfunction occurs during the perioperative period [6]. An initial stage of sleep disturbance is present immediately postoperatively [4]. Overall improvement in sleep quality is observed after TKA [4], with benefits being more domain-specific [8]. Reductions in environmental disturbances suggest meaningful improvements in select aspects of rest following primary total joint arthroplasty [8]. Notably, patients with a history of sleep disorders did not report nor objectively experience worse sleep patterns perioperatively following TKA [3].

Carpal Tunnel Release: This procedure leads to substantial improvements in subjective patient-reported sleep quality in carpal tunnel syndrome patients [12]. It also leads to substantial improvements in standardized patient-reported sleep quality [12]. Concordance between subjective sleep and standardized measures (PSQI/ISI) increases over time after carpal tunnel release [12].

Orthopaedic Surgeons: Sleep and heart rate variability (HRV) show recovery toward baseline by post-call night 2 for orthopaedic surgeons and residents [10].

Fibromyalgia vs. Rheumatoid Arthritis: Patients with remission or mild fibromyalgia experience more severe symptoms and poorer quality of life than patients with remission or low disease activity rheumatoid arthritis [11].

Management

Patient Sleep Patterns and Recovery Trajectories

Preoperative sleep disturbance is highly prevalent (84-97%) in patients undergoing shoulder arthroplasty [1]. Minimal improvement in sleep quality is reported within the first 6 weeks postoperatively after shoulder arthroplasty [1]. Sleep disturbance is common after rotator cuff repair, with sleep quality worsening at 2 weeks and improving beyond baseline by 6 weeks [5]. Improvement of sleep disturbance after rotator cuff repair occurs at 3 months [2].

For total knee arthroplasty, there is an initial stage of sleep disturbance immediately postoperatively [4]. Overall sleep quality improves after total knee arthroplasty [4]. Sleep benefits are more domain-specific, with reductions in environmental disturbances suggesting meaningful improvements in select aspects of rest [8]. Patients with a history of sleep disorders did not report nor objectively experience worse sleep patterns perioperatively after total knee arthroplasty [3].

Carpal tunnel release leads to substantial improvements in both subjective and standardized patient-reported sleep quality in carpal tunnel syndrome patients, with increasing concordance over time [12]. Patients with remission or mild fibromyalgia experience more severe symptoms and poorer quality of life than patients with remission or low disease activity rheumatoid arthritis [11].

Pharmacologic and Clinical Interventions

Melatonin: Recommended postoperatively after arthroscopic rotator cuff repair to reduce sleep disturbance in the early postoperative period and potentially help with longer term functional outcome [7].

Dexamethasone: Doses of four, eight, and 16 mg effectively reduce pain and enhance sleep quality in patients undergoing total knee arthroplasty [14]. The 16 mg dose shows the most pronounced effects on pain and sleep quality at 12, 24, and 48 hours postoperatively [14].

Esketamine: Administered at 0.72 mg kg−1 in patient-controlled intravenous analgesia safely prevents postoperative sleep disturbance, improves analgesia, relieves anxiety and depression, and accelerates postoperative recovery in elderly patients who had total hip or total knee arthroplasty [15].

Other Agents: Melatonin, corticosteroids, and anticonvulsants provide inconsistent benefits for improving postoperative sleep quality in primary total joint arthroplasty patients [9].

Professional and Sports Health

Sleep and heart rate variability show recovery toward baseline by post-call night 2 for orthopaedic surgeons and residents following home call [10]. Sleep and cognitive skills play a pivotal role in preventing sports injuries [13].

Key Considerations

Preoperative and Early Postoperative Sleep Disturbance Preoperative sleep disturbance is highly prevalent (84-97%) in patients undergoing shoulder arthroplasty [1]. Minimal improvement in sleep quality is reported within the first 6 weeks postoperatively after shoulder arthroplasty [1]. Sleep disturbance is common after rotator cuff repair, with sleep quality worsening at 2 weeks [5].

Recovery Trajectories by Procedure After rotator cuff repair, sleep quality improves beyond baseline by 6 weeks [5], with further improvement of sleep disturbance occurring at 3 months [2]. Following total knee arthroplasty, there is an initial stage of sleep disturbance immediately postoperatively [4], but overall improvement in sleep quality is observed subsequently [4]. Patients with a history of sleep disorders did not report nor objectively experience worse sleep patterns perioperatively after total knee arthroplasty [3].

Pharmacological and Comorbidity Considerations Melatonin is recommended postoperatively after arthroscopic rotator cuff repair to reduce sleep disturbance in the early postoperative period [7]. Melatonin may potentially help with longer term functional outcomes after arthroscopic rotator cuff repair [7]. In contrast, melatonin, corticosteroids, and anticonvulsants provide inconsistent benefits for improving postoperative sleep quality in primary total joint arthroplasty patients [9]. More rigorous, standardized, and longer-term studies are needed to establish optimal pharmacological strategies for enhancing postoperative recovery in primary total joint arthroplasty [9].

Long-Term Outcomes and Comorbidities While sleep benefits after total joint arthroplasty were more domain-specific, reductions in environmental disturbances suggest meaningful improvements in select aspects of rest [8]. Patients with obstructive sleep apnea may experience higher rates of medical complications in the short term following total shoulder arthroplasty [16]. There is no difference in orthopedic or mortality outcomes in the long term for patients with obstructive sleep apnea following total shoulder arthroplasty [16]. Patients with remission or mild fibromyalgia experience more severe symptoms and poorer quality of life than patients with remission or low disease activity rheumatoid arthritis [11].

Key Evidence

  • [L4] Preoperative sleep disturbance was highly prevalent (84-97%), and minimal improvement was reported within the first 6 weeks postoperatively. (10.1177/17585732261450975)
  • [L1] Future studies looking at the various factors related to the disturbance and improvement of sleep in patients with RCTs are needed. (10.1177/23259671251397512)
  • [L3] Patients who have a history of sleep disorders did not report nor objectively experience worse sleep patterns perioperatively. (10.1016/j.arth.2026.03.072)
  • [L3] We observed an overall improvement in sleep quality after total knee arthroplasty, although there was an initial stage of sleep disturbance immediately postoperatively. (10.1016/j.jisako.2024.100373)
  • [L3] Sleep disturbance is common after rotator cuff repair, with sleep quality worsening at 2 weeks and improving beyond baseline by 6 weeks. (10.1016/j.jse.2026.02.011)
  • [L4] This review summarizes the incidence, influencing factors, interventions, and potential mechanisms of sleep dysfunction during the perioperative period of TKA to optimize perioperative management and support the future development of high-quality clinical intervention randomized controlled trials. (10.1186/s13018-025-06416-5)
  • [L1] Based on this investigation, we recommend the use of melatonin postoperatively after aRCR to reduce sleep disturbance in the early postoperative period and potentially help with longer term functional outcome. (10.1177/2325967125s00014)
  • [L3] While sleep benefits after TKA were more domain-specific, reductions in environmental disturbances suggest meaningful improvements in select aspects of rest. (10.1016/j.arth.2025.05.020)
  • [L1] Melatonin, corticosteroids, and anticonvulsants provide inconsistent benefits, underscoring the need for more rigorous, standardized, and longer-term studies to establish optimal pharmacological strategies for enhancing postoperative recovery. (10.1016/j.arth.2025.08.071)
  • [L2] Sleep and HRV show recovery toward baseline by post-call night 2. (10.2106/jbjs.er.24.01411)
  • [L4] Despite being in a mild activity or remission stage, RFM patients experience more severe symptoms and poorer QOL than RRA patients. (10.1186/s12891-025-08323-6)
  • [L2] Carpal tunnel release leads to substantial improvements in both subjective and standardized patient-reported sleep quality in CTS patients, with increasing concordance over time. (10.1016/j.jhsg.2025.100870)
  • [L5] Evidence supports the pivotal role of sleep and cognitive skills in preventing sports injuries. (10.1016/j.asmr.2025.101077)
  • [L1] Dexamethasone at doses of four, eight, and 16 mg effectively reduces pain and enhances sleep quality in patients undergoing TKA, with the 16 mg dose showing the most pronounced effects at 12, 24, and 48 hours postoperatively. (10.1016/j.arth.2024.09.006)
  • [L1] Esketamine (0.72 mg kg−1) in PCIA safely prevents postoperative sleep disturbance, improves analgesia, relieves anxiety and depression, and accelerates postoperative recovery in elderly patients who had THA or TKA. (10.1016/j.arth.2025.06.009)
  • [L3] The findings of this study suggest that patients with OSA may experience higher rates of medical complications in the short term, but no difference in orthopedic or mortality outcomes in the long term. (10.1016/j.jse.2025.03.003)

References

[1] Sleep quality after shoulder arthroplasty – A systematic review. Shoulder & Elbow. 2026. DOI: 10.1177/17585732261450975

[2] Improvement of Sleep Disturbance After Rotator Cuff Repair Occurs at 3 Months. Orthopaedic Journal of Sports Medicine. 2025. DOI: 10.1177/23259671251397512

[3] Sleeping Patterns in Patients Undergoing Total Knee Arthroplasty: A Prospective Study Using a Wearable Device. The Journal of Arthroplasty. 2026. DOI: 10.1016/j.arth.2026.03.072

[4] Sleep quality improves after total knee arthroplasty: Addressing early disturbance and risk factors. Journal of ISAKOS. 2025. DOI: 10.1016/j.jisako.2024.100373

[5] How patients sleep after rotator cuff repair: a prospective analysis of pain, position, and recovery. Journal of Shoulder and Elbow Surgery. 2026. DOI: 10.1016/j.jse.2026.02.011

[6] Perioperative sleep disturbances in total knee arthroplasty: incidence, mechanisms, and management strategies. Journal of Orthopaedic Surgery and Research. 2025. DOI: 10.1186/s13018-025-06416-5

[7] Effects of Melatonin on Sleep Quality following Arthroscopic Rotator Cuff Surgery: A Prospective, Randomized Controlled Trial. Orthopaedic Journal of Sports Medicine. 2025. DOI: 10.1177/2325967125s00014

[8] Do Patients Sleep Better at Home or in the Hospital Following Primary Total Joint Arthroplasty?. The Journal of Arthroplasty. 2025. DOI: 10.1016/j.arth.2025.05.020

[9] Limited Efficacy of Pharmacological Interventions for Improving Postoperative Sleep Quality in Primary Total Joint Arthroplasty Patients: A Systematic Review and Meta-Analysis of Randomized Controlled Trials. The Journal of Arthroplasty. 2026. DOI: 10.1016/j.arth.2025.08.071

[10] Erratum: Home Call and Sleep in Orthopaedic Surgeons. A Prospective, Longitudinal Study of the Effect of Home Call on Sleep in Orthopaedic Attending Surgeons and Residents. Journal of Bone and Joint Surgery. 2026. DOI: 10.2106/jbjs.er.24.01411

[11] Quality of life, pain, depression, fatigue and sleep in patients with remission or mild fibromyalgia: a comparison with remission or low disease activity rheumatoid arthritis and healthy controls. BMC Musculoskeletal Disorders. 2025. DOI: 10.1186/s12891-025-08323-6

[12] Concordance Between Subjective Sleep and PSQI/ISI in Carpal Tunnel Syndrome Patients: A Comparative Study Before and After Surgery. Journal of Hand Surgery Global Online. 2026. DOI: 10.1016/j.jhsg.2025.100870

[13] Sleep Quality and Cognitive Skills Impact Neurocognitive Function and Reduce Sports‐Related Injury Risk. Arthroscopy, Sports Medicine, and Rehabilitation. 2025. DOI: 10.1016/j.asmr.2025.101077

[14] Comparison of Dexamethasone at Three Doses Administered Postoperatively for Improving Pain Control and Sleep Quality in Patients Who Underwent Total Knee Arthroplasty: A Triple Blind Randomized Controlled Trial. The Journal of Arthroplasty. 2025. DOI: 10.1016/j.arth.2024.09.006

[15] Effect of Esketamine for Patient-Controlled Intravenous Analgesia on Postoperative Sleep Disturbance in the Elderly After Total Hip or Knee Arthroplasty: A Prospective, Randomized, Double-Blind, and Controlled Trial. The Journal of Arthroplasty. 2026. DOI: 10.1016/j.arth.2025.06.009

[16] Outcomes following total shoulder arthroplasty in patients with obstructive sleep apnea. Journal of Shoulder and Elbow Surgery. 2025. DOI: 10.1016/j.jse.2025.03.003

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