Updated: May 5, 2022
The facet joints are smaller joints on the back side of your spinal vertebrae. You can see them illustrated in the image below courtesy of spineuniverse.com
Each vertebrae has two facet joints, one that connects to the bone above and one that connects to the bone below. You have facet joints throughout your spine, but the most commonly injured ones are in your lumbar spine or low back. The bones are separated by a joint capsule to allow for movement. This joint capsule is filled with fluid to decrease pressure between the bony surfaces. If you picture bending forward, your facet joints separate, while bending backwards brings them closer together.
The facet joints are important because it is estimated that 15% of low back pain is related to facet joint dysfunction (spineuniverse.com). This dysfunction is often called “facet joint syndrome” when referring to the pathology that takes place. Now that you understand the anatomy, let’s take a look at what causes facet joint syndrome.
Facet Joint Syndrome
Facet joint syndrome is difficult to quantify because it typically involves wearing and breaking down of the joint capsule and bony surfaces. However, this is a normal part of aging and wear and tear. The diagnosis is usually related more to symptoms and presentations, which I will discuss below.
Typically, there is a loss of space in one or more joints from uneven load. This can be related to a loss of height at the segment, which occurs with disc degeneration. This can force load onto the facet joint, resulting in breakdown. Disc degeneration is often due to hypermobility at a segment, and this is similar to facet joint syndrome. Facet joint syndrome is typically found at the L4-S1 segments at the bottom of the lumbar spine, an area that typically moves more than surrounding areas. This creates wear and tear that can lead to dysfunction.
Facet Joint Symptoms
Facet joint symptoms can be difficult to determine. The main cause of pain is the medial branch nerve, which provides sensory information from the joint. The nerves are pictured below, courtesy of laplataphysicalmedicine.com
Damage to the joint can result in irritation of the nerve. Unfortunately, the nerve does not follow clear pathways similar to other nerves, so symptoms can be confusing. Usually, there is pain local to the affected joint. For example, facet joint dysfunction in your lower lumbar spine will result in low back pain, sometimes in the center or to one side depending on the joint.
Pain can radiate from the affected joint depending on the path of the nerve. Commonly, lumbar facet joint irritation can result in pain in the buttocks region, while cervical facet joint irritation can radiate into one or both shoulders. The pain is often described as a dull, achy pain. It is typically worsened with compression of the facet joints, which occurs with extension or bending backwards. Rotation and sidebending towards the affected joint can also cause symptoms, particularly if the facet joint on one side has more irritation.
Due to pain with extension, walking and standing are typically the most painful positions. Sitting allows for flexion and increased joint space, so that position is often best tolerated. Sleeping on your back or stomach can increase pain as well due to the extended position of your spine. These are all generalizations, as individuals’ symptoms often present in different ways.
Facet Joint Syndrome Diagnosis
Diagnosis of facet joint syndrome can be difficult. X-rays can reveal bony overgrowth or a decrease in joint space and MRIs can show if there is any soft tissue damage in the region, but these are not definitive. The gold standard for diagnosing facet joint syndrome involves an x-ray fluoroscopy injection with a corticosteroid. The physician will use an x-ray to visualize the facet joint that is assumed to be the cause of pain and a corticosteroid will be injected into the joint space. The steroid should decrease inflammation temporarily. If symptoms are significantly reduced after the injection, then the diagnosis is confirmed. If there is no relief, then it is assumed that some other area is the cause of pain.
Diagnosis can also be made based on symptoms such as dull pain with extension. Sometimes facet pain can be caused by a traumatic event such as a quick rotation or extension while lifting heavy weight. Pain with pressure on the irritated facet joint is another clinical sign. If you are lying on your stomach and a provider pushes on the corresponding spinal segment, it should replicate your symptoms for a positive test. These clinical tests are not perfect, but they can guide treatment.
What Is the Best Treatment for Facet Joint Pain?
The first course of action for suspected facet joint pain is physical therapy. Trigger point dry needling can be effective if nearby muscles are creating compression of the irritated facet joint. Relieving muscle spasms in the area with manual therapy or isometric exercises can be helpful for pain relief.
If physical therapy is not providing significant relief, then an injection may be warranted. A corticosteroid injection can provide long lasting relief if applied in the correct area. The steroid decreases inflammation, which allows exercise to progress to hopefully provide long term relief.
The next step after corticosteroids do not provide relief is a medial branch block. This involves an injection directly into the irritated nerve to eliminate the pain signals that are being sent from it. The nerve can eventually recover, but this also opens up a window of opportunity for physical therapy and exercise management of symptoms.
If all other injections fail, then a radiofrequency ablation may be appropriate. This involves using a needle to burn the nerve that is causing the pain. The nerve can eventually grow back, but relief can last for a couple of years or indefinitely. As with other injections, the goal of the radiofrequency ablation is to allow for exercise progression that is not limited by pain.
The final treatment option is spinal fusion of the involved segments. If the joints are too irritated, then fusing them can decrease the pain by eliminating movement and strain. Fusions are difficult because other segments have to provide mobility to compensate and they can lead to a cascade of other difficulties down the road. However, if nothing else is working, they are a possible treatment technique. Of course, all of these decisions should be made by you and your medical provider based on your individual presentation and desire.
Facet Joint Pain Exercises
Exercises for facet joint pain follow a typical course. At first, you should be performing movements that do not irritate the joint before gradually progressing into more provocative movements as tolerated. The goal is to allow healing to occur and gradually reintroduce daily activities and ascertain how they are tolerated.
As I mentioned before, bending forward is typically well tolerated in facet joint syndrome. Exercises promoting a flexed posture using a posterior pelvic tilt can be beneficial, as they are less aggravating to the low back. Facet symptoms in the neck can similarly benefit from chin tuck exercises. Seated exercises can also be beneficial, so strengthening from a seated position and using machines to prevent spinal stress can be a temporary option. Biking can provide excellent endurance training without too much stress.
Isometric exercises are also typically well tolerated in certain positions. Isometric refers to exercises where the muscle length is not changing. A plank is a good example of an isometric exercise as you resist gravity without moving. Rotational isometrics are also a great introduction as the small muscles in your back that control rotation are very close to the facet joint. Band or pulley exercises that resist rotation can be helpful.
Finally, you want to progress extension and rotational exercises. Gradually building up walking tolerance is important for cardiovascular conditioning as well as desensitizing your body to an extended position. Performing your exercises in standing can be a good start before progressing to movements such as a deadlift or rotation with a cable. Eventually, you can start overhead lifting, which will create extension and shear through your low back, but it is an essential movement for day to day activities. Adding rapid movements such as medicine ball throws are a good final progression for facet pain.