Why Is Osteoarthritis Knee Pain Worse At Night? | 5 Causes And Solutions

Written By on June 26, 2022 — Medically Reviewed By Mitch Torres (PT)

Up to 80% of patients with knee OA have sleep problems due to their condition. (1) But, why is osteoarthritis knee pain worse at night? Well, 5 things may cause this.

From hormones to anxiety, or even several nights of poor sleep in a row. Although for most, it’s likely a combination of these factors that makes their arthritis symptoms worse at night.

We’ll discuss them, and more importantly – how to solve each. Here’s what we’ll cover, tap on any of the bullets to go straight to its section:

5 things that make knee OA pain worse at night (and their treatments)

1) Poor sleep quality

Even one night of sleep issues can increase your pain sensitivity the next day. (2) This in turn increases your likelihood of having nighttime symptoms.

As a result, it can cause a vicious cycle where poor sleep increases pain, which disrupts your sleep even further.

Another problem with this is that it affects the circadian rhythm on a hormonal level.

See, poor sleep may promote the release of chemicals that cause inflammation and alter the release of melatonin.

Melatonin is a hormone that our body releases when it gets dark. It helps us transition into sleep and promotes quality rest. If something alters its rhythm, it can be harder to fall asleep. (3)

That, plus the pro-inflammatory chemicals and the increased sensitivity, makes poor sleep quality one of the main contributors to nighttime knee pain.

Solution: Practice good sleep hygiene

someone stretching their knee on the bed

Yes, I know it’s easier said than done. But working on your sleep hygiene can be the single best thing to do for long-term relief of knee pain at night.

The Sleep Foundation says this is about creating a set of routines that promote quality sleep. It will be tailored to each person, so it can be a trial-and-error process. The pay-off is absolutely worth it, though.

For people with knee osteoarthritis, a nighttime routine to promote sleep can look like:

  • Setting up a fixed wake-up time.
  • Avoiding naps during the day.
  • Using heat or cold therapy for knee pain relief before bed.
  • Having a set of stretches to relax the knee joint.
  • Massaging yourself to reduce stiffness.

For more ideas: Full list of home remedies for knee OA.

2) Anxious thoughts

Having worrying thoughts about your knee osteoarthritis is normal.

But if they are literally keeping you awake at night, if you’re thinking that you won’t get better and nothing will help… That’s a whole other matter.

That’s known as “pain catastrophizing.”

It’s characterized by feeling helpless towards your symptoms. You may also feel incapable of inhibiting pain-related thoughts. (4)

Research shows that this is directly related to worse pain and more sleep problems. (5) This demonstrates that taking care of your thoughts is just as important as caring for your body.

And to be completely honest, pain catastrophizing is not a problem you’d want to tackle on your own. See, this is a deeply ingrained thought pattern. If left unchecked, it can lead to chronic pain. (4)

Solution: Look for help

Some of the best ways to manage pain catastrophizing are through cognitive–behavioral therapy (CBT) and physical therapy (PT). (4)

CBT is a form of psychological treatment that helps you work through the causes of your catastrophizing. This is to find the best coping mechanisms according to your needs.

Whereas PT is a type of hands-on and movement-based treatment. Here, you’ll work with your physio to:

It’s best to combine both treatments, though. This will ensure you have all the tools needed to reduce catastrophizing. And of course, ease your knee pain at night for good. (4)

Learn more: How is physical therapy for knee OA done?

3) Central sensitization

Here, the nerves that transmit pain become overly sensitive. They basically crank up the volume of an otherwise normal pain signal.

This can happen as a consequence of lack of sleep and/or catastrophizing. It’s also a huge contributor to chronic pain.

And for OA, research shows that central sensitization is present in people with throbbing knee pain but in the early stages of degeneration. (5)

Solution: Take something to help you sleep

someone on the bed taking CBD

Taking certain medications for knee pain may reduce the symptoms, thus helping you sleep better. This can translate into less central sensitization, cutting the vicious cycle.

Nonsteroidal anti-inflammatory drugs usually do the trick for most people. But if you have other medical conditions, ask your doctor first before taking them.

Now, if you want to try a more natural route, some dietary supplements may help. Particularly:
  • Turmeric. It won’t act as quickly as painkillers, but it has way fewer side effects and other associated benefits.
  • CBD. Depending on the form, the effects can be felt between 20 minutes and 3 hours.

For natural and quick relief, we’d recommend trying CBD for a few weeks. Apart from helping with pain, it can also promote relaxation and manage anxiety.

Further reading: How does CBD help knee arthritis?

4) Fewer distractions

During the day, your brain is distracted by all that’s around you – sounds, smells, movements… Everything.

But when you lay in bed, your senses aren’t as stimulated. The only thing left to do is hyper-focusing on how your body feels, or more specifically – your knee.

You’ll inevitably be more aware of how your joint feels.

This in turn will increase your perception of pain. The trick is that your symptoms are not worsening, you’re just paying more attention to them.

Then, add the fact that you’re very still. The lack of movement will reduce the amount of blood pumping through your joints, which can make them stiffer and uncomfortable.

Solution: Distract your brain

Yes, you read that right. To have a good night’s sleep you may need to keep your brain distracted with activities that promote rest.

Breathing exercises are one example. There are thousands of videos and apps with guided routines. They can keep your brain focused on the narrator’s instructions, instead of your pain.

Another option is trying a new sleep position that alleviates pain, such as:
  • Sleeping on your side with a knee pillow between your knees.
  • Sleeping on your back with a pillow under the joints.

These positions can make it more comfortable for you to lay in bed, thus helping you get better sleep.

5) Lack of movement during the day

Having a sedentary lifestyle can cause and worsen knee pain. And when it comes to bedtime, it can increase the stiffness and discomfort you feel before going to sleep.

Yet, adding some type of exercise to your daily routine can be as effective as taking NSAIDs – with none of the nasty side effects. (6)

This is because exercise (6, 7):

  • Improves muscle strength, which has a protective effect on your joints.
  • Promotes blood flow, nurturing the damaged tissues and flushing out inflammation.
  • Enhances your coordination, which reduces your risk of further injury.
  • Makes it easier for you to do your daily activities.
  • Helps you sleep better.

Yet, the main challenge with physical activity is not starting – it’s sticking to it.

Solution: Do a physical activity you actually enjoy

someone doing Pilates

It’s true that for knee OA, certain activities can definitely help. Like walking, yoga, tai chi, pilates, and strength training. (7)

If you want to try each one out, by all means, do. But remember that the fact that they are backed up by research doesn’t mean they’re the best for you.

Because as beneficial as strength training is, if you don’t like it, it will be extremely hard for you to stick to it for the long term. And that’s where the magic happens.

Your adherence is far more important than the type of physical activity you do.

So, try different types of exercise. Give yourself time to find the one you enjoy.

And if you really don’t like doing physical activity, that’s also fine. See it as brushing your teeth – it’s boring, but we all have to do it at least once a day to avoid going to the dentist.

If that’s you, stick to the exercise you hate less and reap those benefits!

Related: Ranking of the best 15 treatments for knee OA.

What if these remedies don’t work?

Sometimes you can do everything right, but the arthritis pain at night is still there. In that case, here are other things you can try:

Take a 10-15 min daily walk under the sun every morning

This apparently simple activity can kill two birds with one stone – improve hormonal imbalances and add more physical activity to your day.

See, when you expose yourself to sunlight in the morning, the nocturnal release of melatonin tends to happen sooner. This means it can make it easier for you to fall asleep at night. (8)

Combine this with sleeping in as much darkness as possible and a sound nighttime routine. These will have a major impact on the melatonin rhythm as well. (8)

And for the walking part – that is the single best physical activity you can do to manage your knee OA pain. 10 minutes is the bare minimum, but taking a 6000-step stroll can seriously improve your symptoms in the short and long term. (9)

Wear a knee brace during the day

These devices work by providing external support to your knee, which in turn can help relieve pain during your daily tasks. (7) This means you won’t “accumulate” the symptoms for bedtime.

Now, there are several designs available when it comes to knee osteoarthritis:

  • Knee sleeves – these compress the joint, which promotes blood flow and helps with pain management.
  • Hinged braces – with side stabilizers and other features to add stability.
  • Unloader braces – designed for decompressing one side of the joint, thus aiding pain.

The best brace for you will depend on your individual needs. Yet, there are thousands of options available out there. This can be a blessing and a curse when it comes to choosing the right garment.

This will help: The best knee braces for osteoarthritis available.

You may need knee replacement surgery

One of the many criteria for knee osteoarthritis surgery is having pain so severe it doesn’t let you sleep. Other signs include (7, 10):

  • Nothing can relieve knee pain.
  • The symptoms severely affect your daily life.
  • Home remedies, physical therapy, and injections don’t ease symptoms anymore.
  • Your x-rays show signs of severe degeneration.

People that qualify for knee surgery tend to have great outcomes. However, total replacement isn’t the only surgical approach available for osteoarthritis patients. (7, 10)

There are several procedures available for knee wear and tear. Your surgeon will recommend the one that best fits your goals, lifestyle, and current health.

FAQs

How can I stop arthritic knee pain at night?

Try changing your sleep position or taking some meds before going to bed. Having a bedtime routine can also help. If none of that works, consult with a physical therapist for tailored solutions.

Why does my knee joint flare up at night?

Several things cause this. Hormone fluctuations, anxiety, lack of movement during the day, and central sensitization are common causes.

How should I sleep with arthritis in my knee?

Sleeping on your side with a pillow between your knees may help. Or sleeping on your back with a pillow under the knees.

Conclusion: Why do arthritic knees hurt more at night?

Most of the time, knee osteoarthritis gets worse at night because of a combination of factors, like the ones mentioned above.

The good news is that the solutions for all of them are largely under your control. It may not be easy, but it’s certainly doable.

Yet, sometimes you may be doing everything right but the knee pain won’t budge. In that case, please seek help. Discuss it with your health care providers, as you may need other treatments to ease the symptoms.

Resources

  1. Dai, Zhaoli et al. “Sleep Quality Is Related to Worsening Knee Pain in Those with Widespread Pain: The Multicenter Osteoarthritis Study.” The Journal of rheumatology vol. 47,7 (2020): 1019-1025. DOI: 10.3899/jrheum.181365
  2. Finan, Patrick H et al. “The association of sleep and pain: an update and a path forward.” The journal of pain vol. 14,12 (2013): 1539-52. DOI: 10.1016/j.jpain.2013.08.007
  3. Jahanban-Esfahlan, Rana, et al. “Melatonin in regulation of inflammatory pathways in rheumatoid arthritis and osteoarthritis: involvement of circadian clock genes.” British journal of pharmacology vol. 175,16 (2018): 3230-3238. DOI: 10.1111/bph.13898
  4. Quartana, Phillip J et al. “Pain catastrophizing: a critical review.” Expert review of neurotherapeutics vol. 9,5 (2009): 745-58. DOI: 10.1586/ern.09.34
  5. Campbell, Claudia M et al. “Sleep, Pain Catastrophizing, and Central Sensitization in Knee Osteoarthritis Patients With and Without Insomnia.” Arthritis care & research vol. 67,10 (2015): 1387-96. DOI: 10.1002/acr.22609
  6. Song, J et al. “Reallocating time spent in sleep, sedentary behavior and physical activity and its association with pain: a pilot sleep study from the Osteoarthritis Initiative.” Osteoarthritis and cartilage vol. 26,12 (2018): 1595-1603. DOI: 10.1016/j.joca.2018.07.002
  7. American Academy of Orthopaedic Surgeons Management of Osteoarthritis of the Knee (Non-Arthroplasty) Evidence-Based Clinical Practice Guideline (3rd Edition). https://www.aaos.org/oak3cpg Published on August 31, 2021.
  8. Mead, M Nathaniel. “Benefits of sunlight: a bright spot for human health.” Environmental health perspectives vol. 116,4 (2008): A160-7. DOI: 10.1289/ehp.116-a160
  9. White, Daniel K et al. “Daily walking and the risk of incident functional limitation in knee osteoarthritis: an observational study.” Arthritis care & research vol. 66,9 (2014): 1328-36. DOI: 10.1002/acr.22362
  10. The Royal Australian College of General Practitioners. Guideline for the management of knee and hip osteoarthritis. 2nd edn. East Melbourne, Vic: RACGP, 2018. Retrieved on December 2021 from: https://www.racgp.org.au/download/Documents/Guidelines/Musculoskeletal/guideline-for-the-management-of-knee-and-hip-oa-2nd-edition.pdf

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Author
Mich Torres (PT)
Mitch is a physical therapist, personal trainer, and nutrition coach. Fascinated with the knee joint, Mitch poured that passion into writing about knee pain and how to overcome it with movement. His goal is to teach you how to apply this knowledge into your daily life, so you can keep knee pain away for good.

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