The best sleeping positions for back pain

If you’re wondering whether the position you sleep in impacts your back pain, here’s the short answer - yes. But first, here are a couple of terms to get out of the way before we start:

• Supine: lying face-up on your back
• Prone: lying face-down on your stomach

So what does the evidence say?

A review study looked at adults with low back pain and their sleeping positions. Supine sleepers reported the lowest pain and the highest sleep quality. Prone sleepers reported the worst back pain, and side sleepers were somewhere in the middle, depending on the use of support pillows [1].

As far as review studies go, this one featured very few original papers that were included for analysis. A total of six studies were examined, so take the results with a grain of salt. I’d phrase it like this: there appears to be a directional effect of supine and side-lying being (potentially) beneficial for back pain, and a probable reason to try switching out of a prone sleeping position if you’re suffering from back pain.

Why supine helps

When you lie flat on your back, your lumbar spine is supported along its length by the mattress, and a pillow under the knees brings the hips into a small amount of flexion. That small bend takes tension off your hip flexors and flattens the lower back slightly (reduces degree of lordosis). This is pretty comfortable for most people, and, subjectively, I think it feels pretty good! I often take this a step further and bring my knees into a flexed 90 degree position while lying supine for a couple minutes as I settle into bed.

However, I mostly sleep on my side. I have for years. Sometimes I sleep on my back when I’m really tired but I can’t claim that I’m the perfect spine-sparing sleeper.

If you want to try sleeping supine:

1. Lie flat on your back with one pillow under your head (duh).
2. Place a second pillow, or a soft supportive object, under your knees.
3. Let your arms rest at your sides or across your stomach. Or be a weirdo like me and raise your arms above your head.
4. Aim to fall asleep in this position for 7 nights in a row before judging it.
   • I’m going to try it too. Practice what you preach right?

Why prone is the worst option

Face-down sleeping forces your lumbar spine into sustained extension for hours. Sustained extension compresses the posterior elements of the spine like the articular facet joints. Not to mention, prone sleeping requires your neck to rotate 90 degrees so you can breathe. Both of those positions are fine for short periods. Held for six to eight hours…not so much. The review study found that prone sleepers consistently reported the highest pain scores and the poorest sleep quality across the included studies [1].

If you are a lifelong stomach sleeper, you won’t be able to switch overnight. You can try out other positions but don’t worry if the change takes time. Just off the top of my head, you could try out putting a pillow beneath your hips while lying on your tummy. This is the same idea as the pillow under your knees when sleeping supine - it will cause a bit of hip flexion and promote a more neutral lumbar spine posture.

Again, that’s just me spit-balling something and definitely not a research-backed claim.

How to make side-lying work

Side-lying is the most common sleeping position, and it can be perfectly fine for your back, if you set it up correctly. Women everywhere, I will only admit this once, there may be a potential use for the 75 throw pillows that you insist be present on every bed. But only 1-2 of them per person. Placing a pillow between your knees prevents the top leg from dropping. This reduces rotational forces on the pelvis and lumbar spine.

Try it out:

1. Lie on your side with your head supported so your nose lines up with your chest.
2. Place a firm pillow between your knees, thick enough that your top knee stays at the same height as your hip.
3. Hug a second pillow with your top arm so your shoulder does not collapse forward.

If your back pain is provoked by bending forward, you may do better with your hips and knees slightly bent. If your back pain is provoked by standing or arching backward, you may do better with more hip and knee flexion, which flattens the lumbar spine a bit more.

A quick word on mattresses

People ask about mattresses constantly, and the honest answer is that the evidence is limited and mixed.

A 2003 study in the Lancet randomized 313 adults with chronic low back pain to either a firm or medium-firm mattress for 90 days, and the medium-firm group showed lower pain and disability [2]. Medium firmness is probably fine for most people. There’s no strong evidence that an expensive mattress fixes back pain. Fix your position first. Then if pain persists, it might be worth looking into a mattress replacement.

What to do this week

Pick either the supine or side-lying position and commit to it for 7 nights. BYOP (yes, I mean bring your own pillows). Pay attention to your pain when you wake up and when you end your day. Take a quick note and rate it 0-10. At the end of the week you will have actual data on whether the change is moving you in the right direction.

That is the whole experiment. It costs nothing and takes a week.

As always, have a great weekend.

Best,

Mitch

Want to know which back pain pattern matches you? Take my free 2-minute quiz and find out.

References

[1] Saini et al., 2025 — 10.1002/msc.70114. Relationship Between Sleep Posture and Low Back Pain: A Systematic Review. Musculoskeletal Care, 23(2).

[2] Kovacs et al., 2003 — 10.1016/S0140-6736(03)14792-7. Effect of firmness of mattress on chronic non-specific low-back pain: randomised, double-blind, controlled, multicentre trial. Lancet, 362(9396), 1599-1604.