After 60: rheumatologists reveal the best sleeping position for sore knees

The pain always seems louder at night. You find a position that feels almost bearable, then your knee throbs, you turn, and the ache snaps you awake again. By morning you’ve slept, but not really. Rheumatologists say the way you arrange your legs, pillow and mattress can quietly decide whether your knee calms down or keeps arguing till dawn.

You can’t change the joint overnight. You can change the forces on it. A few centimetres here or there – a folded pillow between the knees, a towel under the ankle, a slight tilt of the pelvis – can shift pressure away from sore structures and give inflamed tissue room to breathe. The “best” position isn’t glamorous. It is the one your knees can tolerate for hours without complaint.

Sleep doesn’t need to be perfect. It needs to be repeatable.

Why knees hurt more in bed after 60

During the day you keep moving, and movement acts like a pump: joint fluid circulates, muscles share the load, and pain messages have competition from everything else you’re doing. At night, you lie still. Swollen tissue stiffens, and any sustained twist or compression has hours to build irritation. The brain also has fewer distractions, so background pain steps into the foreground.

With age, several things often pile up together: osteoarthritis, an old meniscus tear, a bit of bursitis, maybe a replaced joint on one side and a “just about coping” knee on the other. Muscles around the hip and thigh are usually a little weaker, so the joint relies more on bone-on-bone support. That’s why position suddenly matters. If gravity pushes the joint into a stressed angle all night, no tablet will fully out‑shout it.

A consultant rheumatologist once put it bluntly to a patient: “You can’t out‑medicate bad mechanics.” Night‑time comfort becomes a small engineering project: angle, padding, support.

The position most rheumatologists start with

When specialists are asked for a default recommendation, they nearly always begin in the same place: lying on your back with the knees slightly bent and supported. It looks simple. The details matter.

On your back, the weight goes through the back of the thigh instead of directly into the kneecap or the inside of the joint. If you slide a cushion or a rolled towel under your knees so they rest in a gentle bend, you reduce pull on the tendons and the capsule around the joint. The kneecap sits more comfortably in its groove, and many people feel an immediate drop in sharp, front‑of‑knee pain.

Where people get stuck is the “flat soldier” version. Legs locked straight, heels digging into the mattress, lower back arched. That posture strains hamstrings, tugs on the back of the knee and can make arthritic joints feel like they’re being wedged open. The fix is small: a soft wedge under both knees, enough lift to take the edge off the stretch without jamming them into a tight bend.

“Think of it as putting the knee in mid‑range, not fully straight, not fully bent,” one rheumatologist explained. “That’s where arthritic joints are usually happiest.”

How to try the back‑lying position tonight

• Lie on your back, head supported in your usual pillow.
• Slide a medium pillow, firm cushion, or folded blanket under both knees.
• Adjust the height so your knees are bent roughly 20–30 degrees – a slight hill, not a ramp.
• If your lower back feels hollow, add a thin towel under your pelvis or try a slightly thicker knee pillow.

Stay there for a couple of minutes before you commit. If a different ache appears (hip, back, heel), tweak the angle rather than immediately abandoning the position.

Side sleeping: the second‑best option, done properly

Many people simply cannot sleep on their back, no matter how sensible it sounds. They turn to the side automatically. Rheumatologists don’t fight that preference; they modify it. Side sleeping can be kind to knees if you stop them collapsing into each other.

When you lie on your side without support, the top knee tends to fall forwards and down. Inside structures are squeezed, ligaments are twisted, and the joint can sit slightly rotated for hours. People often wake with a deep, nagging ache on the inside of the knee or a burning tenderness along the outside. The goal is to keep knee, hip and ankle more or less stacked in a straight line.

Putting a pillow between the knees is not a lifestyle hack from a magazine; it is a mechanical intervention. A pillow that’s too soft or too thin collapses by midnight and the pain returns. One that keeps the knees hip‑width apart and stops the top leg rolling over can transform a restless night.

Setting up a knee‑friendly side‑sleep

• Choose a medium‑firm pillow, or a purpose‑made knee pillow, thick enough to keep your thighs parallel.
• Lie on your less painful side if you have a “better” knee; this takes pressure off the sore one.
• Place the pillow between your knees and, if possible, down to your ankles, so the whole leg is supported.
• Keep your top knee directly above the bottom one, not dropped forwards towards the mattress.

If the outside of the lower knee hurts where it presses into the bed, add a small, soft pad (even a folded flannel) under that area to spread the pressure. Side sleeping works best when both knees feel equally “held”.

Positions rheumatologists quietly ask you to avoid

There is no universal ban list, but certain routines raise eyebrows in clinic because they overload specific parts of the joint.

Many people with front‑of‑knee pain or advanced osteoarthritis find these particularly troublesome:

• Sleeping on your stomach with the knees pressed into the mattress and the feet hanging off the edge of the bed.
• Curling into a tight foetal position with the knees pulled right up towards the chest for hours.
• Twisting partly onto your stomach with one leg straight and the other hooked up and across the body.

Stomach sleeping tends to push the kneecap hard into the bed and twist the lower back and hips. A tight foetal curl can pinch already‑inflamed tissue on the inside of the knee. The twisted half‑prone position often combines the worst of both: rotation, compression and uneven strain.

If these are the only ways you ever fall asleep, change doesn’t need to be instant. Start your night in a knee‑friendlier posture and allow yourself to drift into old habits later. Even two hours in a better position is a win.

Small adjustments that make any position kinder

Sometimes the “best position” is the one you’ll actually keep. If changing your whole sleeping style feels impossible, rheumatologists focus on add‑ons that soften whatever posture you choose.

A few low‑effort tweaks that often pay off:

• Use a pillow under or between the knees every night, not just on bad days. Consistency reduces flare‑ups.
• Keep a slight bend in the knees, avoiding fully straight, locked positions if they feel tight or sore.
• Pad bony points – a thin cushion under the calf, ankle or outside of the knee can stop hot spots.
• Consider a softer top layer on a very firm mattress, such as a 5–7 cm memory‑foam topper, so the knee sinks slightly instead of being forced up.
• Wear soft, seamless sleep trousers or knee sleeves if contact with the sheet triggers pain.

Some people sleep better with a very light knee support or sleeve at night, especially after a day of heavier activity. Others find any extra pressure aggravating. The test is simple: if the joint feels stiffer and angrier in the morning, it’s probably too tight or not for you.

Evening habits that set your knees up for calmer nights

Position is only half the story. The state of the joint at bedtime matters. A knee that’s hot, swollen and irritated at 9pm will rarely be silent at 3am, even in the ideal posture. The aim is to arrive at the pillow with the volume already turned down.

Think in terms of a brief, doable “knee wind‑down”, not a new fitness regime:

• Gentle movement: 5–10 minutes of easy bending and straightening of the knee in a chair, or short indoor laps, keeps fluid moving.
• Cool or warm packs: a cool pack (wrapped in a cloth) can soothe heat and swelling; some prefer mild warmth for stiffness – try each on different evenings and note which leads to better sleep.
• Leg elevation: sitting with your leg raised on a footstool or the sofa arm for 15–20 minutes before bed can reduce ankle and knee puffiness.
• Pain relief timing: if you use prescribed or over‑the‑counter pain relief, ask your clinician whether taking it 30–60 minutes before bed would provide steadier night‑time cover.

As one rheumatology nurse likes to say: “Don’t ask your sleeping position to fix a knee that’s already furious. Calm it first, then protect it.”

A simple decision guide you can use tonight

You don’t need a full assessment to make a sensible first choice. Use this quick map as a starting point and adjust over a few nights.

Main problem you notice at night	Position to try first	Extra tweak
Sharp pain at the front of the knee	On your back, knees on a pillow	Slightly higher pillow, avoid heavy blanket pressing on knees
Deep ache on the inside of one knee	Side lying on the opposite side, pillow between knees	Keep top leg stacked, not rolled forwards
Both knees sore and stiff on waking	Back‑lying with gentle bend, or side‑lying with firm knee pillow	5–10 min gentle bends before bed
Newly replaced knee on one side	Back‑lying early on; later, side‑lying on non‑operated side with thick pillow	Ask your surgeon/physio for any specific limits

Treat this as an experiment, not a verdict. Change one thing, test it for two or three nights, then adjust again. The goal is fewer wake‑ups, less morning stiffness and a sense that the joint is no longer the loudest thing in the room.

FAQ:

• Is there one “perfect” sleeping position for everyone with knee pain? No. Rheumatologists usually start with back‑lying with slightly bent knees or supported side‑lying, then adapt based on where your pain sits and what you can maintain through the night.
  
• Can I still sleep on my side if both knees are arthritic? Yes, as long as you use a firm pillow between knees (and ideally ankles) to stop them pressing and twisting against each other. Some people alternate sides during the night to share the load.
  
• Should I wear a knee brace in bed? Light, stretchy sleeves can feel comforting for some, but rigid braces and tight straps often increase stiffness and disturb sleep. If you’ve been given a brace for daytime, ask your clinician before using it overnight.
  
• Does my mattress need replacing to help my knees? Not always. A very old, sagging mattress can worsen alignment, but many people do well by adding a moderate‑thickness topper or adjusting pillows before investing in a new bed.
  
• When should I see a doctor about night‑time knee pain? If pain wakes you most nights, is getting worse, is linked to redness, heat or sudden swelling, or you’ve had recent injury or surgery, it’s worth a medical review rather than only adjusting sleeping position.