Lumbar Facet Syndrome

If you experience lower back pain that gets worse when you lean backward or twist your torso, you may be familiar with these concerns. Is it serious? Will it get worse? Our physical therapists work with people who have lower back pain and share these concerns. You’re not alone: facet joint syndrome is a recognized cause of chronic lower back pain. According to the literature, it accounts for approximately 15 to 41% of cases of chronic low back pain—a range that varies depending on the patients studied and the injections used to determine whether these joints contribute to the pain.^{1, 2, 3}

Good news: Physical therapy can help you resume your activities with a tailored program. It is one of the treatments typically offered first, but studies do not provide a precise success rate for confirmed facet joint pain.⁴ What science teaches us:

• Facet joints are normal structures that guide the movement of your spine. Irritation of these joints does not mean that your back is “broken.”⁵The model that explains lower back pain solely as a result of a spinal injury is no longer considered adequate.
• Wear and tear visible on imaging is common: osteoarthritis of the facet joints becomes very common with age. A study of lumbar spines obtained postmortem found facet osteoarthritis in all subjects over the age of 60.^{6, 7}
• Prolonged rest can increase stiffness and reduce function. A gradual return to activities is generally recommended.⁸
• Physical therapy combining manual therapy and exercise is generally recommended as a first-line approach. A randomized clinical trial supports individualized manual therapy for the clinical features of facet joint pain, and a Cochrane review supports exercise for chronic low back pain in general, although no study establishes this specific combination as a single universal protocol.^{9, 10, 4}

This guide will help you understand your facet pain, recognize its symptoms, and discover effective treatments. To understand how facet syndrome fits among other causes of lower back pain, consult our complete guide to back pain.

What is Lumbar Facet Syndrome?

Lumbar facet syndrome refers to pain attributed to the facet joints located at the back of the spine. These joints guide movement between the vertebrae and bear part of the load. However, their involvement cannot be confirmed by a single symptom or imaging study.

The facet joints form a system with the intervertebral disc. Together, these structures allow your lower back to bend forward, arch, and rotate.^{11, 2} Each joint contains a synovial membrane—a sac that produces lubricating fluid—cartilage, and a fibrous capsule.⁵ The cartilage itself does not contain nerves. The capsule and some surrounding tissues contain nerves whose signals may contribute to pain.

The facet joints bear part of the load on the spine. Studies of spinal segments obtained postmortem show that this load varies depending on posture and measurement conditions, particularly when the back is arched or twisted.^{12, 13, 14} In a study of 120 patients followed at a specialized clinic, injection tests attributed pain to the facet joints in 40% of patients and to the intervertebral discs in 26%. These proportions depend on patient selection and diagnostic methods; they do not represent all people with back pain.¹⁵

What Causes Facet Syndrome?

Possible causes of facet syndrome include trauma, repetitive stress, and age-related changes in the joints.^{16, 11} Posture can affect a person’s symptoms, but research does not allow us to predict pain based on a specific posture.^{17, 18}

Some activities involve repeated twisting, lifting, or arching of the back. If these activities worsen your symptoms, their duration or intensity can be adjusted. This does not mean that these activities have damaged your joints.

Facet joints gradually lose cartilage with age and undergo bone remodeling and thickening of the joint capsule.⁶ 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.

A very arched posture or certain movements can worsen symptoms in some people. The physical therapist assesses core strength and hip flexibility based on the activities that are difficult for the patient. These factors alone are not enough to explain the pain.

What are the symptoms of facet syndrome?

Possible symptoms of facet syndrome include localized pain in the lower back, which is sometimes worsened when you arch your back or twist. The pain may radiate to the buttocks or upper thighs. Pain below the knee, numbness, or weakness may suggest a nerve-related condition, but these symptoms alone are not sufficient to establish a diagnosis.¹⁹

Pain may be felt on one side of the lower back, sometimes as a deep, dull ache. Arching the back or twisting may make the pain worse in some people, but these reactions alone are not enough to identify the facet joints as the source of the pain.¹⁹

People often report difficulty with:

• Standing for long periods, especially in an arched position (like when waiting in line at the grocery store)
• Lifting arms above the head
• Looking over the shoulder while driving or backing up the car

Pain attributed to the facet joints can radiate in certain patterns, but these areas overlap significantly:

• The pain may remain near the lower back.
• It can also spread to the buttocks, hips, or thighs.
• The zones overlap between the different lumbar levels; therefore, their location does not allow for the identification of a specific joint.²⁰

How Facet Syndrome Differs from Other Causes of Back Pain

Important note: In the vast majority of cases, facet joint pain—which is associated with the small joints of the back—remains above the knee. In rare cases, a cyst, a fluid-filled sac, a thickening, or a mass may compress a nerve root—the point where a nerve originates—in that area. Pain below the knee, numbness, muscle weakness, and altered reflexes may then occur.¹⁶ To understand the difference between this and nerve compression, see our Guide to lumbar disc herniation.

How is Facet Syndrome Diagnosed?

The diagnosis of facet syndrome is based on the history of symptoms, physical examination, and, in some cases, diagnostic blocks—injections that help determine whether a joint is contributing to the pain.^{21, 19} No single clinical sign or set of signs alone confirms facet pain. Imaging shows structural changes, but it does not, on its own, prove that the facet joints are causing the pain.^{22, 23, 24}

The clinical examination begins with a detailed medical history. In particular, the examiner looks for pain near the spine and how it responds to movement, while also checking for signs that might indicate another cause.

The extension-rotation test (Kemp test) is often used in clinical practice, although a systematic review has questioned its diagnostic value due to what is considered low accuracy in the available studies.²⁵ During this test, you arch your back, turn, and lean to one side. The test may reproduce your pain, but it cannot, on its own, identify the source of the pain.

Diagnostic blocks

Diagnostic blocks can help the doctor determine whether the facet joints are contributing to the pain, especially when a procedure is being considered. The doctor injects an anesthetic—a drug that numbs the area—near the small nerves that supply these joints. The results should be interpreted with caution, as pain relief can also occur for other reasons.²⁶

A single-session block may yield a false positive—that is, it may suggest a facet joint origin that is not subsequently confirmed. Rates vary depending on the protocol and the patients studied.^{27, 28} Some guidelines recommend confirmation via two nerve blocks performed on separate occasions, while others accept a single session prior to radiofrequency ablation. The physician selects the protocol based on the specific situation; no nerve block guarantees a definitive diagnosis.²⁹

The role of imaging

Imaging studies show structural changes in the facet joints, but they cannot confirm whether these changes are causing your symptoms.²²If you undergo magnetic resonance imaging (MRI), don’t be discouraged by the results. Many people without symptoms show facet joint wear on imaging. Clinical evaluation guides care. Your doctor may recommend diagnostic nerve blocks in certain situations, especially before considering surgery. Undergoing an MRI too early, without warning signs, is generally not recommended in clinical practice. The literature presents a mixed picture: among workers with acute, disabling low back pain, early imaging without medical indication was associated with longer disability, whereas a randomized clinical trial conducted among patients referred to a specialist found a slight improvement in certain outcomes at 24 months with early imaging.³⁰

How does physiotherapy treat facet joint syndrome?

Physical therapy treats facet syndrome through education, a gradual return to activities, and tailored exercises. Manual therapy may also be used to temporarily relieve symptoms and improve movement. The treatment plan depends on the activities that are limiting you and your response to treatment.⁴

Manual therapy can complement an active rehabilitation program. Mobilization techniques may temporarily reduce pain or stiffness in some people, without realigning a joint or guaranteeing a lasting effect.³¹

Exercise programs can strengthen the core muscles, including the multifidus—a small muscle running along the spine—and the transverse abdominis, a deep abdominal muscle.³² The goal is to improve your ability to move and resume your activities. Learn more about our approach to exercises for the stabilizing muscles.

Mobility exercises may be recommended if stiffness in your hips, legs, or upper back is limiting an activity that is important to you.

Movement rehabilitation helps you adapt movements that worsen your symptoms and gradually resume them based on your tolerance. Explore our movement rehabilitation program.

The results of physical therapy vary depending on how long you’ve had your symptoms, any other health issues you may have, and the activities you’re working toward. Goals may include putting on your shoes, playing with your children, or returning to work with fewer limitations.

What Movements Relieve Facet Pain?

Walking, changing positions, or gentle stretching can provide relief for some people with facet joint pain. For example, you can try gently pulling your knees toward your chest if this movement provides relief. The physical therapist will choose exercises based on your response, since no single movement works for everyone.³³

A beneficial movement is one that makes an activity easier or reduces symptoms without causing lasting harm. Walking and changing positions can help some people stay active.⁸ For acute low back pain without sciatica, a Cochrane review concludes that bed rest is less effective than advising patients to stay active.

The directional preference test compares your response to several repeated movements to help select appropriate exercises.³³Centralization refers to the shift of symptoms from a distant region, such as the leg, to a region closer to the spine. Simple relief without this shift does not constitute centralization.³⁴

What is the role of injections in facet joint syndrome?

Injections can be used to confirm a diagnosis or to temporarily relieve pain, but their effectiveness and duration vary.³⁵ They are not a substitute for an appropriate, active treatment plan. Radiofrequency ablation uses heat to interrupt signals from small nerves following conclusive diagnostic blocks; its benefits remain variable.

Therapeutic facet joint injections combine an anesthetic with a steroid (cortisone).³⁷ Relief from these injections is by no means guaranteed. A Cochrane review concluded that there is insufficient evidence to support intra-articular facet injections for chronic low back pain, a conclusion also confirmed by more recent systematic reviews focusing specifically on these injections.^{38, 39, 36} If an injection provides relief, this respite may help you resume certain activities. The active program remains tailored to your abilities, with or without an injection.

Radiofrequency ablation (RFA) uses heat energy to deactivate the nerves that supply the affected facet joints.⁴⁰ When successful, radiofrequency ablation of the facet nerves provides relief that, according to widespread clinical belief, lasts 6 to 12 months. Research, however, paints a more mixed picture: randomized multicenter trials found no clinically significant improvement compared to exercise alone, and a more recent meta-analysis reported small average gains compared to a sham procedure, steroids, or usual care, without reaching a clinically significant threshold.^{41, 42} The nerves may regrow, and the pain may return. A new treatment may be discussed depending on the benefits achieved and your situation.⁴⁰A clinical trial published in JAMA in 2017 involving more than 600 people—a population that included several presumed causes of low back pain, not just facet joint pain—showed no clinically significant improvement with radiofrequency ablation for chronic low back pain.⁴¹

Repeated steroid injections may potentially accelerate cartilage degradation. This finding comes from a systematic review of articular cartilage in general, not specifically of the lumbar facet joints; extrapolation to the facet joints remains plausible but indirect.⁴³ Active rehabilitation remains an important part of the treatment plan, regardless of whether or not you undergo a procedure. The studies cited here do not demonstrate that an injection improves the effectiveness of this program.

How Does Posture Affect Facet Pain?

Posture can affect symptoms during an activity, but no specific posture can predict who will experience facet joint pain. Studies on the lumbar curve and low back pain have yielded mixed results and do not demonstrate that a more pronounced lumbar curve causes this pain.^{44, 45} The goal is to find several comfortable positions and to adjust your posture based on your activities.

A position with a pronounced arch in the back may trigger symptoms in some people, but this response varies and does not, by itself, confirm the source of the pain.

Possible strategies include trying different positions, doing appropriate exercises, and regularly changing your posture while working. You may want to try a lumbar support if it improves your comfort.

What is the Prognosis for Facet Syndrome?

Improvement in pain and functional ability is still possible with facet syndrome, even after several months. The extent of this improvement and the time it takes vary from person to person. A study on chronic low back pain in general—not facet syndrome specifically—shows that some people recover within the following year.⁴⁶

A recent episode may improve with appropriate activities and gradual progression. The timeframe cannot be predicted accurately based on the diagnosis alone.⁴⁷

Your plan can help you:

• Do exercises that are appropriate for your abilities
• Adapt activities that cause pain so you can resume them gradually
• Try different positions depending on what feels comfortable to you⁴

Back pain may return after an improvement. The risk varies, and the studies cited here do not provide specific figures for facet syndrome. Continuing to engage in appropriate activities and knowing how to adjust your level of exertion can help you manage a new episode.

The good news is that conservative management—including physical therapy—is generally the first-line treatment for facet syndrome, even though the evidence specifically supporting physical therapy for this particular condition remains limited.^{4, 23} Visible changes on imaging do not necessarily prevent you from staying active. Physical therapy can provide you with strategies to manage your symptoms and continue your activities.

What is the difference between facet joint syndrome and osteoarthritis?

Facet syndrome refers to a possible source of pain, while facet osteoarthritis describes structural changes visible on imaging. Both may be present at the same time, and the extent of the changes seen on imaging does not always correspond to the severity of the symptoms.⁴⁸

Facet syndrome refers to pain attributed to these joints, with or without visible osteoarthritis. A physical examination and, in some cases, diagnostic nerve blocks help evaluate this possibility. They do not allow us to conclude that all pain stems from joint inflammation.

Facet osteoarthritis specifically refers to structural changes visible on imaging: narrowing of the joint space, bone spurs, and enlargement.⁶

To better understand this degenerative condition, explore our detailed guide on lumbar osteoarthritis.

Pain attributed to the facet joints can occur without visible osteoarthritis. Conversely, changes consistent with facet joint osteoarthritis may be present in people without pain.^{22, 24, 49}

Treatment approaches overlap. Physical therapy can help patients resume activities in both situations, but imaging alone cannot predict the speed or extent of improvement.⁴

Ready to treat your facet joint pain?

Physioactif can help you assess your facet joint pain and develop a personalized recovery plan. Our physical therapists combine education, targeted exercises, and, when necessary, manual therapy. Learn everything you need to know about physical therapy and how we can help you.

We develop personalized programs based on your symptoms, your abilities, and the activities you want to resume. Whether your pain is recent or chronic, the plan is designed to give you practical tools to manage it.

Learn about our comprehensive approach to back pain and schedule an appointment if the pain is concerning you or limiting your activities.

References

The references for this article include the following studies and guides.

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