Lumbar facet syndrome
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Facetal syndrome is a common cause of lower back pain. If you are living with this pain, rest assured: it is a condition that can be treated effectively. It affects millions of people. Unlike disc problems at the front of your spine, facet syndrome comes from the small joints at the back of each vertebral segment. These joints guide the movement of your spine while supporting weight during extension and rotation. When inflammation or wear and tear affects your facet joints, you experience specific pain. This pain worsens with certain movements. If you have lower back pain that worsens when you bend backward or turn, understanding the causes of lower back pain can help you identify the role of facet joints. Physical therapy treats your symptoms AND the movement problems that put too much stress on your facet joints. It is a proven approach that does not require surgery.
What is lower back facet syndrome?
Facetal syndrome is pain that comes from the small stabilizing joints between your vertebrae. It can be caused by inflammation, irritation, or wear and tear on these joints. It accounts for 15 to 40% of chronic lower back pain. It mainly affects rotational movements.¹
Facetal syndrome describes pain that comes from the paired joints in your lumbar spine.¹ These joints are located on the back side between two adjacent vertebrae. They form a three-joint system with the disc in front. Each facet joint contains a synovial membrane (protective covering), cartilage, and a fibrous capsule. These tissues are richly innervated by nerves. This is why they are very sensitive to stress and inflammation.² The joints guide how your spine moves. At the same time, they resist excessive rotation. The facet joints support about 16% of the load in a neutral posture. This load increases significantly when you lean backward or turn.³
To fully understand how facet joints contribute to the health of your spine, learning about spinal anatomy and how different structures cause back pain will give you the necessary foundation. Controlled diagnostic blocks (test injections) place facet joints on the same level as disc and sacroiliac joint problems as identifiable sources of pain.¹
What causes facet syndrome?
Facetal syndrome results from an acute injury such as whiplash or a fall. It can also be caused by repetitive stress related to sports or work. Degenerative changes with age are another cause. Excessive mobility in a neighboring segment can also create the problem. Poor posture and muscle imbalances increase mechanical stress on these joints.⁴
Pain in the facet joints develops as a result of sudden trauma or chronic overload.⁴ Sudden events such as car accidents, falls, or sports collisions can directly injure the facet joint capsules. They can stretch the ligaments or cause bleeding in the joint. Repetitive microtrauma comes from work activities involving frequent twisting, rotational lifting, or prolonged extension. This gradually stresses your facet joints beyond their tolerance. Athletes in gymnastics, diving, football, or weightlifting experience particularly high facet loads.
Wear and tear changes are another major cause. Facet joints gradually lose cartilage with age. They develop bone remodeling and thickening of the capsule.⁵ These processes of joint degeneration share the same mechanisms as osteoarthritis in other parts of the body. To better understand how progressive wear specifically affects the lumbar spine, see our comprehensive guide to lumbar osteoarthritis. These processes involve the same inflammatory chemicals and structural changes. Studies show wear changes in more than 80% of people over the age of 60. Studies show wear changes in more than 80% of people over the age of 60. Problems in neighboring segments after spinal fusion or disc wear increase mechanical stress on nearby facet joints. Body mechanics factors include an overly pronounced lumbar curve (hyperlordosis) and a forward-tilted pelvis. Weak core muscles and tight hip flexors also play a role. This creates abnormal load patterns that predispose individuals to facet syndrome.
What are the symptoms of facet syndrome?
Symptoms include localized pain in the lower back that worsens with extension and rotation. If you recognize these symptoms, know that this is a common condition that responds well to treatment. You experience morning stiffness that improves with movement. The pain may radiate to the buttocks or upper thighs. However, you do not have any real nerve symptoms below the knee. This is what distinguishes facet syndrome from nerve compression conditions.⁶
Facetal syndrome creates a specific pattern of symptoms. This distinguishes it from other sources of back pain.⁶ The main symptom is localized pain in the lower back. It is usually described as a deep, dull pain on one side of the spine. This pain predictably worsens when you lean backward, when you turn, and with combined movements. People often report difficulty standing for long periods of time (especially with an arched back), raising their arms above their heads, and performing rotational movements. For example, looking over your shoulder while driving or backing up your car can be painful. This pattern of pain that worsens with extension is typical of facet joints. To understand this mechanism and discover the appropriate exercises, see our guide on directional preferences.
Morning stiffness is another typical symptom. You experience significant stiffness upon waking, which gradually improves over 30 to 60 minutes with movement.⁷ Pain in the lumbar facet joints travels in recognizable patterns. The L1-L2 facets refer pain to the upper lumbar region. The L3-L4 facets refer pain to the back of the hip and the outside of the thigh. The L4-L5 or L5-S1 facets refer pain to the buttock and the back of the thigh.⁸ Although referred pain may travel down the thigh, it differs from radicular pain, which travels further down. See our guide on lumbar radiculopathy to understand the true nerve symptoms.
Important point: Facetal pain stops above the knee. It never produces true neurological symptoms such as numbness in specific areas of skin, specific muscle weakness, or changes in reflexes below the knee. Unlike facetal syndrome, a herniated disc directly compresses the nerves and causes neurological symptoms. To understand this important distinction, see our guide to lumbar disc herniation and its characteristic symptoms. This absence of neurological symptoms clearly distinguishes facet syndrome from disc herniation with nerve compression.How facet syndrome differs from other causes of back pain
| Characteristic | Facet syndrome | Herniated disc | Muscle tension |
|---|---|---|---|
| Location of pain | Next to the column, stops above the knee | Go down below the knee into the leg | Spreading throughout the lower back |
| Aggravated by | Lean backward + turn | Lean forward, remain seated | All movements at the beginning |
| Enhanced by | Lean forward, change position | Standing, walking | Rest |
| Neurological signs | None | Often present (numbness, weakness) | None |
| Morning stiffness | 30 to 60 minutes | Variable | 10 to 20 minutes |
| Quality of pain | Deep, dull pain | Acute, throbbing, like a shock | Deaf, tense |
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How is facet syndrome diagnosed?
The diagnosis is based on clinical examination. Pain is sought with extension-rotation movements. Localized sensitivity on the facet joints is also checked. Pain relief with facet diagnostic blocks is crucial. Imaging shows degenerative changes but does not confirm the source of pain. This is why clinical evaluation and diagnostic blocks are essential.⁹
Clinicians diagnose facet syndrome through manual examination rather than imaging alone.⁹ The process begins with a thorough history. Typical patterns are identified: localized pain next to the spine that worsens with extension and rotation. No nerve symptoms below the knee. Recognizable referred pain patterns. The physical examination includes tests designed to stress the facet joints and reproduce your familiar pain. The extension-rotation test (Kemp's test) combines lumbar extension with rotation and lateral flexion. This compresses the facet joint and may reproduce your pain.¹⁰
What clinical tests identify facet pain?
| Test name | Procedure | Positive result |
|---|---|---|
| Extension-rotation test | You lean backward, then turn and lean to the side. | Your usual pain returns |
| Quadrant test | Extension + lateral flexion + rotation with compression applied | Facet pain localized at the exact location |
| Facetta load test | The therapist presses down on a specific facet level. | You are sensitive at exactly this level. |
| One-leg extension | You stand on one leg while leaning backward. | Your pain increases on the side that is bearing weight. |
Why are diagnostic blocks used for confirmation?
Diagnostic blocks provide the most definitive confirmation despite examination results. These procedures involve a guided injection of anesthetic medication. The injection is made into the nerves that supply specific facet joints. It can also be injected directly into the joint capsule.¹² A truly positive diagnosis requires significant pain relief (80% or more). This must occur after controlled blocks performed on separate occasions.¹² Single blocks have high false positive rates approaching 40%. That is why controlled comparative blocks are the gold standard.¹³
Imaging studies show structural changes in the facet joints. However, they cannot confirm whether these changes are causing your symptoms. If you have an MRI, don't be discouraged by the results: many people without symptoms show facet joint wear on imaging. Common findings include narrowing of the joint space, hardening of the bone (bone sclerosis), bone spurs, and enlargement. All of these indicate facet wear.⁵ At the same time, some people with severe pain have relatively normal imaging.⁹ That's why manual evaluation and diagnostic blocks are crucial for an accurate diagnosis.
How does physical therapy treat facet syndrome?
Physical therapy combines manual therapy to restore mobility to the facet joints. It uses specific exercises that target the spine stabilizers and mobility. It corrects posture and retrains movement. It treats both the symptomatic joints AND the underlying biomechanical factors that contribute to excessive load on the facets.¹⁴
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Manual therapy techniques play a central role. Therapists apply specific joint movements and manipulations to restore normal facet movement and reduce pain.¹⁵ Exercise programs strengthen the deep spinal muscles. This includes the multifidus (small muscle along your spine) and the transverse abdominis (deep belly muscle that acts as a natural belt). These deep muscles play an essential role in the stability of your spine. Learn more about our approach to stabilizing muscle exercises and how they protect your facet joints. These muscles provide dynamic support that reduces abnormal facet loading.¹⁶ Flexibility exercises address common restrictions in the hip flexors, hamstrings, and upper back. These restrictions contribute to compensatory lumbar mechanics.
Movement retraining helps you identify and avoid painful postures. It also helps you develop alternative movement strategies. Changing your faulty movement patterns is crucial for long-term recovery. Explore our movement retraining program to correct the mechanics that overload your facet joints. Education explains the mechanisms of pain, teaches self-management, and sets realistic expectations for recovery. The combined approach treats both symptoms AND underlying mechanical factors. In general, this produces better results than passive treatments alone.¹⁴
What movements relieve facet pain?
Flexion-based movements such as knee-to-chest stretches typically relieve facet pain. They open up the joint spaces. Gentle rotation exercises, cat-cow movements, and avoiding prolonged extension help manage symptoms. However, the choice of movements should be individualized based on the response of symptoms during assessment.¹⁷
[Helpful movements vs. harmful movements] Movements that typically help:- Knee-to-chest stretches (lying on your back)
- Cat-cow exercise (on all fours)
- Child's pose (kneeling stretch)
- Gentle rotation exercises (lying down with knees bent)
- Walking (gentle movement)
- Sitting position with slight forward lean
- Standing for long periods with your lower back arched (such as waiting in line at the grocery store)
- Activities with arms raised above the head
- Combination of leaning backward AND turning at the same time
- Gymnastics or butterfly stroke
- Golf swing (temporarily)
Movements based on flexion typically provide immediate relief. They open up the rear joint spaces and reduce compressive forces.¹⁷ Walking relieves facet pain better than staying still. It promotes fluid flow in the joints and prevents stiffness.¹⁸ The directional preference test guides individualized movement prescription. Therapists systematically test your response to repeated movements. This identifies the directions that produce improvement.¹⁹
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Book an appointmentWhat is the role of injections in facet syndrome?
Facetal joint injections provide temporary pain relief. This lasts from weeks to months. It allows for more effective participation in physical therapy. They serve diagnostic and therapeutic purposes but are not intended as standalone solutions. Radiofrequency ablation offers longer-lasting relief for facet-mediated pain confirmed after successful blocks.²⁰
Therapeutic facet injections combine an anesthetic medication with a steroid. They are injected into or around the joint.²¹ Data show modest short-term benefits. Pain relief typically lasts 3 to 6 months when effective.²² The temporary nature requires concurrent active treatment. The injections create a window during which physical therapy can progress more effectively.
Radiofrequency ablation (RFA) uses heat energy to damage the nerves that supply the affected facet joints. This provides longer-lasting relief.²³ RFA typically provides relief that lasts 6 to 24 months. However, the nerves eventually regenerate. This requires repeated procedures.²³ Success depends critically on careful patient selection through controlled diagnostic blocks. Most pain specialists limit facet injections to 3-4 procedures per year. Repeated steroid injections can potentially accelerate cartilage degradation.²⁴ Integrating procedures with active rehabilitation produces better long-term results than injections alone.²⁵
How does posture affect facet joint pain?
Poor posture, particularly excessive lumbar lordosis (too much curvature) and anterior pelvic tilt (pelvis tilted forward), increases compression and pain in the facet joints. Correcting posture through awareness, strengthening weak muscles, and stretching tight areas reduces mechanical stress on the facet joints and improves symptoms.²⁶
An overly pronounced lumbar curve positions the spine in relative extension. This brings the rear vertebral elements closer together and increases facet compression. Studies show that an arched posture increases facet joint load by approximately 16% in a neutral position and by more than 30% in extended positions.³ People who habitually adopt arched standing postures subject their facet joints to sustained excessive compression. This contributes to pain.
Posture assessment identifies individual flaws. These include increased lumbar curvature, forward pelvic tilt, weak abdominal muscles, tight hip flexors, and weak gluteal muscles. Corrective strategies combine posture awareness training, abdominal and gluteal strengthening, hip flexor stretching, and work area changes. This includes proper lumbar support on the chair and regular position changes.²⁶
What is the prognosis for facet syndrome?
Rest assured: most cases of facet syndrome respond well to conservative treatment within 6 to 12 weeks. Acute episodes typically resolve more quickly than chronic presentations. Long-term management focuses on posture, flexibility, and strength. This helps prevent recurrences and maintain function.²⁸
Acute episodes of facet syndrome typically respond favorably to non-surgical treatment within 4 to 8 weeks.²⁸ These acute presentations without major underlying wear often resolve completely with appropriate activity modifications, manual therapy, and progressive rehabilitation. Persistent and chronic facet syndrome (symptoms lasting longer than 12 weeks) typically requires 6 to 12 weeks of consistent physical therapy for significant improvement.²⁹
Younger people without major wear changes generally experience faster recovery. This is compared to older individuals with established facet wear. People who actively participate in prescribed exercises, change painful activities, and address postural factors achieve superior results.¹⁴ Recurrence rates are substantial. Studies suggest that 40 to 60 percent experience at least one recurrence within two years.³¹ Prevention strategies focus on maintaining core strength, flexibility, optimal posture, and activity changes. This significantly reduces the risk of recurrence.
The good news is that success rates with combined physical therapy reach 60 to 85% for significant pain reduction and functional improvement.¹⁴ Wear and tear changes are normal aging processes. Many people with imaging evidence of facet joint wear maintain excellent function. They achieve this through appropriate self-management strategies learned during physical therapy.
What is the difference between facet syndrome and osteoarthritis?
Facetal syndrome describes acute or intermittent joint irritation. Often, there are no structural changes. Facetal osteoarthritis involves chronic degenerative changes visible on imaging. Treatment approaches overlap, but facetal syndrome typically has a better prognosis for complete resolution of symptoms.³²
Facetal joint syndrome is a clinical diagnosis. It describes pain in the facet joints regardless of the underlying structural condition. This includes both acute inflammatory episodes in structurally normal joints AND pain in joints with wear changes. Facetal wear or osteoarthritis specifically describes structural changes visible on imaging. This includes joint space narrowing, bone spurs, and enlargement.⁵
Since facet joints can develop wear and tear over time like other joints, it is important to understand how lumbar osteoarthritis affects the spine. Facet osteoarthritis is a progressive degenerative process that can contribute to chronic facet syndrome. Check out our detailed guide to lumbar osteoarthritis to better understand this condition. This helps distinguish acute syndrome from chronic arthropathy. Many young people experience acute facet syndrome without evidence of osteoarthritis on X-rays. These cases involve irritation of the joint capsule without structural wear. Conversely, many people show significant facet wear on imaging but remain completely symptom-free.⁹
Treatment approaches overlap substantially. Physical therapy forms the basis for each.¹⁴ However, facet syndrome without major wear typically responds more quickly and completely to treatment. For individuals with vertebral slippage (spondylolisthesis) due to facet degeneration, there is a significant connection between progressive arthropathy and spinal instability.
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Our physical therapists at Physioactif provide comprehensive assessment and treatment for facet syndrome. We combine manual therapy, targeted exercises, and movement retraining. Find out everything you need to know about physical therapy and how we can help you.
We develop individualized programs that address your symptoms AND the underlying mechanical factors. Whether you are experiencing acute pain after an injury or managing chronic symptoms, our approach provides the tools for effective self-management. Contact Physioactif today to schedule your evaluation. Early treatment produces the best results.
References
- Manchikanti L, Boswell MV, Singh V, Pampati V, Damron KS, Beyer CD. Prevalence of facet joint pain in chronic spinal pain of cervical, thoracic, and lumbar regions. BMC Musculoskeletal Disorders. 2004;5:15.
- Bogduk N. The innervation of the lumbar spine. Spine (Phila Pa 1976). 1983;8(3):286-93.
- Adams MA, Hutton WC. The mechanical function of the lumbar apophyseal joints. Spine (Phila Pa 1976). 1983;8(3):327-30.
- Cohen SP, Raja SN. Pathogenesis, diagnosis, and treatment of lumbar zygapophysial (facet) joint pain. Anesthesiology. 2007;106(3):591-614.
- Gellhorn AC, Katz JN, Suri P. Osteoarthritis of the spine: the facet joints. Nat Rev Rheumatol. 2013;9(4):216-24.
- Schwarzer AC, Aprill CN, Derby R, Fortin J, Kine G, Bogduk N. Clinical features of patients with pain stemming from the lumbar zygapophysial joints. Spine (Phila Pa 1976). 1994;19(10):1132-7.
- Fujiwara A, Kobayashi N, Saiki K, Kitagawa T, Tamai K, Saotome K. Association of the Japanese Orthopaedic Association score with the Oswestry Disability Index, Roland-Morris Disability Questionnaire, and short-form 36. Spine (Phila Pa 1976). 2003;28(14):1601-7.
- Fukui S, Ohseto K, Shiotani M, et al. Referred pain distribution of the cervical zygapophyseal joints and cervical dorsal rami. Pain. 1996;68(1):79-83.
- Cohen SP, Huang JH, Brummett C. Facet joint pain—advances in patient selection and treatment. Nat Rev Rheumatol. 2013;9(2):101-16.
- Laslett M, Öberg B, Aprill CN, McDonald B. Zygapophysial joint blocks in chronic low back pain: a test of Revel's model as a screening test. BMC Musculoskeletal Disorders. 2004;5:43.
- Dreyfuss P, Dreyer S, Griffin J, Hoffman J, Walsh N. Positive sacroiliac screening tests in asymptomatic adults. Spine (Phila Pa 1976). 1994;19(10):1138-43.
- Bogduk N, Holmes S. Controlled zygapophysial joint blocks: the travesty of cost-effectiveness. Pain Med. 2000;1(1):24-34.
- Schwarzer AC, Aprill CN, Derby R, Fortin J, Kine G, Bogduk N. The false-positive rate of uncontrolled diagnostic blocks of the lumbar zygapophysial joints. Pain. 1994;58(2):195-200.
- Poetscher AW, Gentil AF, Lenza M, Ferretti M. Conservative treatment in patients with moderate to severe lumbar spinal stenosis: a systematic review. Sao Paulo Med J. 2014;132(6):379-85.
- Bronfort G, Haas M, Evans R, Leininger B, Triano J. Effectiveness of manual therapies: the UK evidence report. Chiropr Osteopat. 2010;18:3.
- França FR, Burke TN, Caffaro RR, Ramos LA, Marques AP. Effects of muscular stretching and segmental stabilization on functional disability and pain in patients with chronic low back pain: a randomized, controlled trial. J Manipulative Physiol Ther. 2012;35(4):279-85.
- Maitland GD. Vertebral Manipulation. 5th ed. London: Butterworth-Heinemann; 1986.
- Hurwitz EL, Morgenstern H, Chiao C. Effects of recreational physical activity and back exercises on low back pain and psychological distress: findings from the UCLA Low Back Pain Study. Am J Public Health. 2005;95(10):1817-24.
- Long A, Donelson R, Fung T. Does it matter which exercise? A randomized controlled trial of exercise for low back pain. Spine (Phila Pa 1976). 2004;29(23):2593-602.
- Manchikanti L, Singh V, Falco FJ, Cash KA, Pampati V. Lumbar facet joint nerve blocks in managing chronic facet joint pain: one-year follow-up of a randomized, double-blind controlled trial. Pain Physician. 2008;11(2):121-32.
- Ribeiro LH, Furtado RN, Konai MS, Andreo AB, Rosenfeld A, Natour J. Effect of facet joint injection versus systemic steroids in low back pain: a randomized controlled trial. Spine (Phila Pa 1976). 2013;38(23):1995-2002.
- Cohen SP, Doshi TL, Kurihara C, et al. Multicenter, randomized, comparative cost-effectiveness study of targeted steroid injection with medication and physical therapy vs. medication and physical therapy alone in the treatment of low back pain. Pain. 2012;153(11):2192-203.
- Maas ET, Ostelo RW, Niemisto L, et al. Radiofrequency denervation for chronic low back pain. Cochrane Database Syst Rev. 2015;(10):CD008572.
- Wernecke C, Braun HJ, Dragoo JL. The effect of intra-articular corticosteroids on articular cartilage: a systematic review. Orthop J Sports Med. 2015;3(5):2325967115581163.
- Dreyfuss P, Halbrook B, Pauza K, Joshi A, McLarty J, Bogduk N. Efficacy and validity of radiofrequency neurotomy for chronic lumbar zygapophysial joint pain. Spine (Phila Pa 1976). 2000;25(10):1270-7.
- Claus AP, Hides JA, Moseley GL, Hodges PW. Is 'ideal' sitting posture real?: measurement of spinal curves in four sitting postures. Man Ther. 2009;14(4):404-8.
- O'Sullivan K, O'Keeffe M, Forster BB, Qamar SR, van der Westhuizen A, O'Sullivan PB. Managing low back pain in active adolescents. Best Pract Res Clin Rheumatol. 2019;33(1):102-21.
- Henschke N, Maher CG, Refshauge KM, et al. Prognosis in patients with recent onset low back pain in Australian primary care: inception cohort study. BMJ. 2008;337:a171.
- Pengel LH, Herbert RD, Maher CG, Refshauge KM. Acute low back pain: systematic review of its prognosis. BMJ. 2003;327(7410):323.
- Foster NE, Thomas E, Bishop A, Dunn KM, Main CJ. Distinctiveness of psychological obstacles to recovery in low back pain patients in primary care. Pain. 2010;148(3):398-406.
- Stanton TR, Henschke N, Maher CG, Refshauge KM, Latimer J, McAuley JH. After an episode of acute low back pain, recurrence is unpredictable and not as common as previously thought. Spine (Phila Pa 1976). 2008;33(26):2923-8.
- Kalichman L, Hunter DJ. Lumbar facet joint osteoarthritis: a review. Semin Arthritis Rheum. 2007;37(2):69-80.
