Facet Joint Syndrome

Facet joint syndrome (also known as zygapophysial joint disease) is a condition in which the facet joints of the spine become a source of pain. It is a highly prevalent degenerative process that increases with age and represents a significant cause of disability with major socioeconomic consequences. Chronic low back pain due to facet joint disease has a reported prevalence between 15% and 41%¹.

Facet joint syndrome is an articular disorder involving both the joints and their innervation, producing local and sometimes radiating pain. Cervical facet joint syndrome affects the neck, while lumbar facet joint syndrome involves the lower back. Approximately 55% of cases occur in the cervical spine and 31% in the lumbar region².

Anatomy

Facet joints are formed by the superior and inferior articular processes of adjacent vertebrae. Each spinal segment contains two facet joints. They are synovial joints enclosed by a fibrous capsule that surrounds the bone and cartilage surfaces, continuous with the periosteum.

The joint contains synovial fluid maintained by an internal membrane. Functionally, facet joints allow flexion and extension of the spine while restricting rotation and preventing vertebral slippage. Sensory innervation arises from the medial branch of the dorsal ramus¹.

Epidemiology

• Lifetime prevalence of low back pain in the U.S.: 65–80%

• More common in older adults due to degenerative changes

• Heavy physical work before age 20 increases risk of facet osteoarthritis

• Obesity contributes to degenerative joint changes

• Degenerative spondylolisthesis often arises from facet joint arthrosis, particularly at L4–L5

• Whiplash trauma can lead to cervical facet joint syndrome with a prevalence of 29–60% after injury¹

A cadaveric study by Eubanks et al. reported the prevalence of facet arthrosis as:

• 57% between ages 20–29

• 93% between ages 40–49

• 100% by age 60⁴

The most affected level and with the highest severity was L4–L5.

Etiology

The most common cause of facet joint disease is degenerative spinal change (spondylosis). It can result from:

• Natural wear and altered biomechanics (osteoarthritis)

• Trauma (sports injuries, accidents)

• Inflammatory conditions such as rheumatoid arthritis or ankylosing spondylitis

• Subluxation in spondylolisthesis

Degenerative facet pathology often leads to:

• Cartilage breakdown and inflammation

• Thickening and hypertrophy of the ligamentum flavum

• Osteophyte formation around the joint

• Increased subchondral bone volume with hypomineralization¹

Clinical Presentation

Lumbar Facet Joint Syndrome

• Unilateral low back pain

• Pain that may radiate into the buttock or posterior thigh when irritation is severe

• Upper facet joints may refer pain to the groin, while lower facets may refer pain to the posterior or lateral thigh

• L4–L5 and L5–S1 may refer pain to the calf and rarely to the foot⁵

Cervical Facet Joint Syndrome

• Unilateral neck pain, rarely radiating beyond the shoulder

• Pain aggravated by extension and rotation

• Palpable tenderness over the affected area

• May radiate to the upper back or occasionally the arm/fingers

Other potential causes of facet inflammation include:

• Rheumatoid arthritis

• Ankylosing spondylitis

• Reactive arthritis

• Synovial impingement or meniscoid entrapment

• Chondromalacia facetae

• Pseudogout

• Synovitis or pigmented villonodular synovitis

• Infection or synovial cysts⁵⁶

Facet pain is typically episodic, unpredictable, and worsened by extension or prolonged standing, while sitting may provoke symptoms in some cases⁹.

Differential Diagnoses

• Sciatica

• Hip osteoarthritis

• Sacroiliac joint pain

• Lumbar radiculopathy

• Myofascial pain

• Compression fractures

• Disc herniation

• Osteophytes

• Rheumatoid arthritis¹

Lumbar facet syndrome can mimic sciatica or disc prolapse due to “pseudoradicular” pain patterns¹⁰.

Diagnostic Procedures

The medial branch block is considered the gold standard for diagnosing facet joint pain. A positive response to two separate blocks at different levels confirms the diagnosis.

Imaging findings (X-ray, CT, MRI) may show joint space narrowing, hypertrophy, calcification, or osteophytes, but these changes can also appear in asymptomatic patients.

Tests and measures:

• Finger-floor test

• Lumbar rotation test

• Schober’s test

• Visual Analog Scale (VAS)¹¹

Physical Examination

Inspection:Evaluate paraspinal muscle symmetry, lordosis, and posture. Chronic pain may cause flattening of the lumbar curve.

Palpation: Palpate paravertebral regions and transverse processes for tenderness.

Range of motion: Pain typically worsens with extension and rotation.

Reflexes and sensation: Usually normal unless osteophytes or cysts compress nerves.

Strength testing: Manual testing typically normal but may show pelvic weakness or imbalance.

Special tests:

• Kemp’s test

• Springing test¹²

Treatment and Follow-Up

Conservative management is first-line:

• NSAIDs

• Weight reduction

• Muscle relaxants

• Physiotherapy

• Massage

If symptoms persist:

• Medial branch block for diagnostic and temporary relief

• Radiofrequency ablation (RFA) for longer-lasting pain reduction (6–12 months)

• Surgery only in specific cases (e.g., spondylolisthesis grade I–II)

Physiotherapy Management

Patient Education

• Explain the benign nature of the condition

• Address fear-avoidance beliefs and anxiety

• Teach ergonomic posture and activity modification⁹

Relative Rest

• Avoid prolonged bed rest (>2 days)

• Encourage gentle mobility and gradual return to activity⁹

Reducing Lumbar Lordosis

• Teach pelvic tilt exercises in sitting, standing, or supine positions¹²

Pain Reduction

Evidence supports combining spinal manipulation (SMT) and core stabilization exercises (TSE), with or without NSAIDs, for improved outcomes¹³.

Short-term relief may also come from:

• Heat or cold therapy

• Mobilization and gentle stretching¹⁴¹⁵

Stretching and Strengthening

Stretching should target muscles contributing to increased lumbar lordosis and include:

• Hamstrings

• Quadriceps

• Hip abductors

• Gluteal muscles

• Abdominal muscles⁹¹²

Stabilization Training

• Teach neutral spine control in daily movements

• Progress to eccentric and dynamic exercises under therapist supervision⁹

Deep Core Activation

Focus on deep stabilizers:

• Transversus abdominis

• Multifidus

• Internal obliques

Moon et al. describe a 16-exercise program emphasizing abdominal hollowing and multifidus activation at L4–L5, improving neuromuscular control⁵.

Clinical Summary

Facet joint syndrome is a common cause of axial back or neck pain, often misdiagnosed due to overlapping symptoms. Diagnosis relies primarily on clinical findings and medial branch blocks. Conservative management through exercise, education, and physiotherapy remains the cornerstone of treatment, while interventional options such as radiofrequency ablation can provide effective pain relief when indicated.

Sources

1. Curtis L, Shah N, Padalia D. Facet Joint Disease. StatPearls [Internet]. 2020 Apr 20.Available: https://www.ncbi.nlm.nih.gov/books/NBK541049/(accessed 15.6.2021)

2. Varlotta GP, Lefkowitz TR, Schweitzer M, Errico TJ, Spivak J, Bendo JA, Rybak L. The lumbar facet joint: a review of current knowledge: part 1: anatomy, biomechanics, and grading. Skeletal Radiol. 2011 Jan;40(1):13-23..

3. Eubanks JD, Lee MJ, Cassinelli E, Ahn NU. Prevalence of lumbar facet arthrosis and its relationship to age, sex, and race: an anatomic study of cadaveric specimens. Spine (Phila Pa 1976). 2007 Sep 1;32(19):2058-62.

4. Binder DS, Nampiaparampil DE. The provocative lumbar facet joint. Curr Rev Musculoskelet Med. 2009;2(1):15-24.

5. Moon HJ, Choi KH, Kim DH, et al. Effect of lumbar stabilization and dynamic lumbar strengthening exercises in patients with chronic low back pain. Ann Rehabil Med. 2013;37(1):110-117.

6. Cohen SP, Raja SN. Pathogenesis, diagnosis, and treatment of lumbar zygapophysial (facet) joint pain. Anesthesiology. 2007 Mar;106(3):591-614. 

7. Bob & Brad- Top 3 Signs Your Back Pain is Facet Joint Syndrome. https://www.youtube.com/watch?v=zqbXyreyss0

8. Holder LE, Machin JL, Asdourian PL, Links JM, Sexton CC. Planar and high-resolution SPECT bone imaging in the diagnosis of facet syndrome. J Nucl Med. 1995 Jan;36(1):37-44.

9. Marc Safran, James E. Zachazewski,David A. Stone “Instructions for Sports Medicine Patients”, p362

10. Schütz U, Cakir B, Dreinhöfer K, Richter M, Koepp H. Diagnostic value of lumbar facet joint injection: a prospective triple cross-over study. PLoS One. 2011;6(11):e27991.

11. Christopher M. Norris. Back stability. Integrating science and therapy. Second edition. Oxford, United kingdom, 2008 (p. 15)

12. MALANGA G. et al, Lumbosacral Facet Syndrome Treatment & Management., 2013

13. Bronfort G, Goldsmith CH, Nelson CF, Boline PD, Anderson AV. Trunk exercise combined with spinal manipulative or NSAID therapy for chronic low back pain: a randomized, observer-blinded clinical trial. J Manipulative Physiol Ther. 1996 Nov-Dec;19(9):570-82.

14. Bob & Brad: Top 3 Exercises for Facet Joint Syndrome. https://www.youtube.com/watch?v=oIZlz7oH-ag

15. Back Intelligence: Lumbar Facet Joint Pain Relief- 3 Exercises. https://www.youtube.com/watch?v=oIZlz7oH-ag

16. Gerard Malanga, Erin Wolff. Evidence-informed management of chronic low back pain with trigger point injections The Spine Journal, Intervention Review Article 2008. Volume 8 Issue 1 Page 243-252.