Lumbar facet syndrome

If you experience lower back pain that worsens when you bend backward or twist your torso, you may be familiar with this concern. Is it serious? Will it get worse? As physical therapists specializing in lower back pain, we see patients with these same concerns every day. You are not alone: facet syndrome (irritation of the small joints at the back of the spine) accounts^for 15 to 40% of chronic lower back pain.

^-Facet joints are normal structures that guide the movement of your spine. Irritation of these joints does not mean that your back is "broken.^"2 - Wear and tear visible on imaging is common: more than 80% of people over the age of 60 show facet changes, often without any pain.⁵ - Prolonged rest does not help. Appropriate movement promotes healing.18 - Physical therapy combining manual therapy and exercises is the recommended first-line approach.¹⁴

This guide will help you understand your facet pain, recognize the symptoms, and discover effective treatments. To learn more about facet syndrome among other causes of lower back pain, see our comprehensive guide to back pain.

What is lower back facet syndrome?

Facetal syndrome is pain originating from the small joints at the back of your spine. These joints, called facet joints, guide movement between the vertebrae and support part of the body's weight. Inflammation, irritation, or wear and tear on these joints causes localized pain that worsens with certain movements.

The facet joints form a system with the intervertebral disc. Together, they enable flexion, extension, and rotation movements of your lumbar spine. Each joint contains a synovial membrane (a lining that produces lubricating fluid), cartilage, and a fibrous capsule.² These tissues are richly innervated, which explains their strong reaction to stress and inflammation.

The facet joints bear approximately 16% of the load in a neutral posture. This load increases significantly when you lean backward or turn^. Controlled diagnostic blocks place the facets on the same level as disc problems as identifiable sources of pain^.

What causes facet syndrome?

Facetal syndrome can result from acute trauma such as a fall or car accident. It can also be caused by repetitive stress related to sports or work. Degenerative changes with age are another common cause. Poor posture and muscle imbalances increase mechanical stress on these joints^.

Repetitive microtrauma comes from work activities involving frequent twisting, rotational lifting, or prolonged extension. Athletes who participate in gymnastics, diving, soccer, or weightlifting experience particularly high facet joint loads.

Faceted joints gradually lose cartilage with age and develop bone remodeling and thickening of the capsule.⁵ These processes share the same mechanisms as osteoarthritis in other joints. To better understand how progressive wear and tear affects the lumbar spine, see our comprehensive guide to lumbar osteoarthritis.

An overly pronounced lumbar curve (hyperlordosis) and a forward-tilted pelvis create abnormal load patterns. Weak core muscles and tight hip flexors also contribute to the problem.

What are the symptoms of facet syndrome?

Symptoms include localized pain in the lower back that worsens with extension and rotation. You experience morning stiffness that improves with movement. The pain may radiate to the buttocks or upper thighs, but you do not have any real nerve symptoms below the knee^.

The main symptom is localized pain in the lower back, usually described as a deep, dull ache on one side of the spine. This pain predictably worsens when you lean backward, twist, or perform combined movements^.

People often report difficulty with: - Standing for long periods of time, especially in an arched position (such as when waiting in line at the grocery store) - Raising their arms above their head - Looking over their shoulder while driving or backing up their car

Stiffness upon waking is a typical characteristic. It gradually improves over 30 to 60 minutes with movement.⁷

Pain in the facet joints travels in recognizable patterns: - The L1-L2 facets refer to the upper lumbar region. - The L3-L4 facets refer to the back of the hip and the outside of the thigh. - The L4-L5 or L5-S1 facets refer to the buttock and the back of the^thigh.

How facet syndrome differs from other causes of back pain

How is facet syndrome diagnosed?

The diagnosis is based on clinical examination combined with specific tests. We look for pain with extension-rotation movements and localized sensitivity on the facet joints. Diagnostic blocks confirm the source of pain. Imaging shows structural changes but does not confirm on its own that the facets are the cause of your pain.⁹

The clinical examination begins with a thorough history. Typical patterns are identified: pain localized next to the spine that worsens with extension and rotation, without nerve symptoms below the knee.

The extension-rotation test (Kemp's test) is the most commonly used test. It combines lumbar extension with rotation and lateral flexion, which compresses the facet joint and may reproduce your familiar pain.¹⁰

Diagnostic blocks

Diagnostic blocks provide the most definitive confirmation. These procedures involve a guided injection of anesthetic (a medication that numbs) into the nerves that supply specific facet joints.¹²

A truly positive diagnosis requires major pain relief (80% or more) after controlled blocks performed on separate occasions.¹² This is why controlled comparative blocks are the gold standard.¹³

The role of imaging

Imaging studies show structural facet changes, but they cannot confirm whether these changes are causing your symptoms.⁹ If you have an MRI, don't be discouraged by the results. Many people without symptoms show facet wear on imaging. That's why clinical 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 with specific exercises that target the spine stabilizers. It also corrects posture and retrains movement. This approach treats both the symptomatic joints AND the biomechanical factors that contribute to excessive load on the facets^.

Manual therapy ^techniques play a central role. Physical therapists apply specific joint movements and mobilizations to restore normal facet movement and reduce pain.

Exercise programs strengthen the deep spinal muscles, including the multifidus (a small muscle along your spine) and the transverse abdominis (a deep muscle in your abdomen that acts as a natural belt).^These muscles provide dynamic support that reduces abnormal facet load. Learn more about our approach to exercises for stabilizing muscles.

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. Explore our movement rehabilitation program.

Success rates with combined physical therapy reach 60 to 85% for significant pain reduction and functional improvement.¹⁴ This means being able to resume your daily activities: bending down to put on your shoes, playing with your children, returning to work without limitations.

What movements relieve facet pain?

Flexion-based movements such as knee-to-chest stretches typically relieve facet pain by opening up the joint spaces. Gentle rotation exercises and avoidance of prolonged extension help manage symptoms. Movement selection should be individualized based on symptom response during assessment^.

Movements based on flexion typically provide immediate relief. It's like opening a door that was stuck: the joint spaces open up and this reduces pressure.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. Physical therapists systematically test your response to repeated movements to identify the directions that produce improvement^.

What is the role of injections in facet syndrome?

Facetal joint injections provide temporary pain relief lasting from weeks to months, allowing for more effective participation in physical therapy. They serve diagnostic and therapeutic purposes but are not intended as standalone solutions. Radiofrequency ablation (destruction of nerves using heat) offers longer-lasting relief for pain confirmed after successful blocks^.

Therapeutic facet ^injections combine an anesthetic with a steroid (cortisone). Relief typically lasts 3 to 6 months when effective^. The temporary nature requires active treatment at the same time. The injections create a window during which physical therapy can progress more effectively.

Radiofrequency ablation (RFA) uses heat energy to deactivate the nerves that supply the affected facet joints^. RFA typically provides relief that lasts 6 to 24 months. However, the nerves eventually grow back, requiring repeated procedures^.

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 (excessive curvature of the lower back) 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^.

An overly pronounced lumbar curve positions the spine in relative extension, which brings the rear vertebral elements closer together and increases facet compression. Studies show that an arched posture increases facet load by approximately 16% in a neutral position to over 30% in extended positions^.

Corrective strategies combine training in postural awareness, strengthening of the abdominals and glutes, stretching of the hip flexors, and changes in the work area (appropriate lumbar support, regular position changes)^.

What is the prognosis for facet syndrome?

^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 to prevent recurrence.

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) generally requires 6 to 12 weeks of consistent physical therapy for significant improvement.

People who achieve the best results are those who: - Actively participate in the prescribed exercises - Change activities that cause pain - Address^postural factors

Recurrence rates are substantial. Studies suggest that 40 to 60% experience at least one recurrence within two years.³¹ This is why prevention strategies are important: maintaining core strength, flexibility, optimal posture, and changes in activity.

The good news is that success rates with combined physical therapy reach 60 to 85% for significant pain reduction.¹⁴ Many people with facet wear visible on imaging maintain excellent function thanks to 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 without 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 and tear changes.

Facetal osteoarthritis specifically describes structural changes visible on imaging: narrowing of the joint space, bone spurs, and enlargement.⁵

To better understand this degenerative condition, check out our detailed guide to lumbar osteoarthritis.

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 considerably. Physical therapy forms the basis for each.¹⁴ However, facet syndrome without major wear typically responds more quickly and completely to treatment.

Ready to treat your facet pain?

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.

Discover our comprehensive approach to back pain and schedule an appointment for your evaluation. Early treatment produces the best results.

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