Lumbar Facet Joint Pain

Lumbar Facet Joint Pain

What is a lumbar facet joint?

The spine is made up of multiple bones, and the joints between them are called facet joints. They are like most other joints in the human body, in that they are surrounded by a capsule (ligaments), contain fluid, and are lined with cartilage. The lumbar facet joints are those in your lower back which can be a cause of low back pain.

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What causes facet joint pain?

Facet joint pain can be acute or chronic. Acute pain may come on suddenly, with a single, excessive force or motion, such as an awkward twist. Alternatively, it can occur due to repetitive stress, such as when undertaking a DIY project over the weekend.  Chronic facet joint pain is likely to come on slowly, from a gradual accumulation of stress. There is an immense list of factors that may contribute to facet joint pain, here are a few examples:

  • Stiff joints
  • Weak muscles
  • Poor fitness
  • Lack of sleep
  • Stress
  • Various medical conditions

What physically happens to a sore facet joint?

Firstly, a facet joint can become inflamed if it is placed under enough stress. Inflammation involves numerous processes, including increased blood flow to the injured area. Furthermore, fluid accumulates in the joint, along with certain white blood cells and proteins. This starts the healing process, but it also increases sensitivity of the joint. The fluid accumulation and swelling can stretch the joint capsule, further contributing to pain and stiffness.

Facet joint pain may be associated with degeneration (osteoarthritis), especially regarding longstanding pain. The term, ‘degeneration’, describes multiple changes to the joint, including: reduced joint space, cartilage loss, bony thickening, and potentially inflammation. However, one must understand that degeneration does not equal pain. Multiple studies have demonstrated that facet joint degeneration can be found in symptomatic and asymptomatic individuals. Furthermore, the presence of degeneration does not reflect previous pain, nor does it predict future pain.

A sprain is another potential (less common) cause of facet joint pain. This means that the ligaments/capsule around the joint have overstretched. Severity can vary, and inflammation will be involved to some degree.

The facet joint may be ‘locked’, which can cause somebody to feel like their back gets ‘stuck’. It has been proposed that a small, wedge-shaped structure in the joint can become caught in an awkward position, causing pain and limiting movement.

It is rare that anything more serious, such as a fracture, will happen to a facet joint. Issues like this are treated differently and will not be addressed in this blog.

So, when a facet joint is sore, the explanation may be that it is inflamed, degenerative, sprained, or locked. However, it is worth noting that these pathologies may be purely trivial when it comes to assessing and treating back pain. That is why X-rays, etc., are rarely required and far more importance is placed on clinical assessment.

There might be some other issues going on…

Facet joint pain may coexist with a disc injury. It would take a whole blog post to properly delve into disc injuries, so for now, it is simply worth noting that they can heal and they can be treated at the same time as a facet joint.

In back pain of relatively recent onset, the greatest contribution to the pain is usually from the joints. In longstanding cases of low back pain, it becomes more likely that muscles and nerves will be significantly involved.

Trigger points are a common muscular issue. Basically, they are tight and sensitive parts of a muscle, often referred to as ‘knots’.

Nerves are long, dynamic structures that stretch, compress and glide as you move your body. Sometimes facet joint pain is accompanied by neural tension or irritability, which needs to be addressed. This is not the same thing as ‘nerve pain’ or ‘sciatica’, etc.

Signs and Symptoms

Pain may be felt at the location of the facet joint, i.e., just off centre to the spine. However, a sore facet joint will commonly refer pain elsewhere. As a general rule, the upper lumbar facet joints refer pain into the flank, hip, and side of the thigh. The lower lumbar facet joints are more likely to refer pain to the back of the thigh, and occasionally as far down as the calf. The lowest facet joints (L5/S1) may produce the feeling of a ‘band’ of pain across the lower back.

Further signs and symptoms may include

  • Pain relieved by resting in a recumbent position (for a short while)
  • Pain relieved with movement/activity
  • Pain that is worst first thing in the morning, especially if inactive
  • Pain aggravated by backwards bending, rotation, compression, and/or prolonged standing

Physical Examination

Useful information can be gathered by observing you under various conditions, such as while sitting, standing, or moving. Posture may be relevant, for example, you could be standing in a way that places excessive force on particular facet joints. Furthermore, postural observation can provide clues as to what muscles are tight, what muscles are weak, and what muscles are doing all the work. Breathing mechanics can also be relevant to back pain, so, your physio will keep an eye on where the movement occurs when you breathe. For example, if it’s all coming from the chest and shoulders, you might be holding excessive tension in your abdominal muscles.

A vital part of the physical examination, your physiotherapist will ask you to move your lower back in various directions. They will take note of the range and quality of movement, as well as whether it makes your pain better or worse. Bending backwards is often sore with lumbar facet joint pain, and some more subtle movement tests may reveal a lack of control.

As you may expect, a physiotherapist will need to press around the sore area, starting gently of course! Firstly, it is useful to know what’s tender and what’s not. Furthermore, a physiotherapist can feel for muscle tightness and/or trigger points. Pressing on the facet joints is particularly helpful in diagnosing facet joint pain, allowing assessment of tenderness and mobility.

Pain is rarely due to an isolated problem, therefore any of the above tests can be applied to other structures, such as the hip joints, the facet joints in the upper back, and the muscles that surround said joints. Weak hip muscles are a common contributing factor to lumbar facet joint pain.

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Treatment

Manual therapy encompasses a variety of hands-on treatment methods, such as joint mobilisation and soft tissue massage. It is usually appropriate to start with gentle techniques, and gradually increase the intensity over subsequent sessions. Sore facet joints are often stiff, therefore responding well to mobilisation.

Just like manual therapy, exercises will start gently and progress as required. Everybody is different, so there is no ‘recipe’ of exercises to help with facet joint pain. For example, some people will need to increase their strength, others will need to work on their flexibility, and some will need to improve their muscle control. Furthermore, some people can get away with one or two exercises, whilst others will need a more comprehensive regime. A prescribed exercise program incorporating Pilates based exercises is an effective way to manage this condition. It can lead to improvements in multiple areas that are important regarding back pain, such as strength, body-awareness, and general fitness. These classes are available at our studio in Beechboro.

 

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A lot of good will come out of simply talking to your physiotherapist. In general, you will learn the “dos and don’ts”, allowing recovery to occur as quickly as possible. Furthermore, you will be given a diagnosis, which goes a long way. Knowledge is power, so please feel free to ask questions!

Finally, there are several additional treatment options to supplement those already listed, examples include:

  • Dry needling
  • Heat packs
  • Home-exercise equipment, e.g. massage balls and foam rollers
  • Therapeutic taping
  • Anti-inflammatory balms

References:

Brandt, K. D., Radin, E. L., Dieppe, P. A., & Van De Putte, L. (2006). Yet more evidence that osteoarthritis is not a cartilage disease.

Brukner, P., & Khan, K. (2011). Clinical sports medicine. (4th ed.). North Ryde, NSW: McGraw-Hill Education.

Exelby, L. (2001). The locked lumbar facet joint: intervention using mobilizations with movement. Manual Therapy6(2), 116-121.

Kahn, S. B., & Xu, R. Y. (Eds.). (2018). Musculoskeletal Sports and Spine Disorders: A Comprehensive Guide. Springer.

Hayek, S. M., Shah, B. J., Desai, M. J., & Chelimsky, T. C. (Eds.). (2015). Pain medicine: an interdisciplinary case-based approach. Oxford University Press.