Facet Joint Pain: Causes, Exercises & Physio Treatment

Understanding Facet Joint Syndrome

The lumbar facet joints (zygapophyseal joints) are paired posterior joints connecting adjacent vertebrae, providing stability while guiding and limiting spinal motion. Each lumbar segment has two facet joints — one on each side — and these are richly innervated by the medial branches of the dorsal rami, making them capable of significant pain generation.

Facet joint syndrome is estimated to cause 15 to 40% of chronic low back pain cases, making it one of the most common yet under-diagnosed pain generators in spinal practice.

Causes of Facet Joint Pain

| Cause | Mechanism | |---|---| | Osteoarthritis | Cartilage loss, synovial inflammation, osteophyte formation | | Disc degeneration | Increased facet loading from reduced disc height | | Acute injury | Capsular sprain from sudden hyperextension or rotation | | Spondylolisthesis | Increased shear forces on facet joints | | Spondylosis | Age-related degeneration of posterior elements | | Repetitive extension loading | Manual workers, gymnasts, weightlifters |

Diagnosing Facet Joint Pain

Clinical Indicators

• Location: Unilateral or bilateral low back pain, occasionally referring to the buttock or posterior thigh (rarely below the knee)
• Aggravating factors: Lumbar extension, rotation, prolonged standing, getting up from a chair
• Relieving factors: Forward flexion, sitting, lying flat
• Physical examination: Tenderness over the affected facet joint level, pain reproduced with passive extension

Imaging

• X-ray: May show facet joint sclerosis, narrowing, or osteophytes
• MRI: Best for identifying facet hypertrophy, synovial cysts, or associated disc pathology
• Diagnostic nerve block: Gold standard — if medial branch block eliminates pain, facet origin is confirmed

Physiotherapy for Facet Joint Pain

Phase 1: Acute Management

• Positioning: Encourage flexion-bias positions; avoid sustained lumbar extension
• Thermal therapy: Heat application for muscle spasm relief
• Electrotherapy: IFT or TENS for pain modulation
• Activity modification: Avoid prolonged standing, downhill walking, heavy lifting

Phase 2: Specific Exercises

Flexion-Biased Exercises (open the facet joints, reduce load):

1. Knee-to-Chest Stretch — Supine, pull both knees to chest. Hold 30 seconds, 5 repetitions.
2. Seated Forward Lean — Sit on chair, lean forward with elbows on knees. 1 to 2 minutes.
3. Cat Stretch — On all fours, arch back upward (cat) then relax. 10 repetitions.
4. Partial Sit-Up — Gentle abdominal curl, not full range. 3 × 15 reps.

Core Stabilisation (prevent facet overloading):

• Transversus abdominis activation
• Bridge exercise (avoid hyperextension at the top)
• Dead bug
• Bird-dog (opposite arm and leg extension)

Phase 3: Functional Rehabilitation

• Progressive lumbar mobilisation into pain-free extension range
• Hip flexor stretching to reduce anterior pelvic tilt
• Ergonomic assessment for work postures
• Return-to-activity programme

Manual Therapy for Facet Pain

A physiotherapist may use:

• Joint mobilisation (Maitland Grade III-IV) at the affected level for pain relief and restoration of movement
• Manipulation for acute facet locking (when appropriate and not contraindicated)
• Soft tissue massage for paraspinal muscle guarding
• Dry needling to multifidus for trigger point deactivation

Interventional Pain Management

When physiotherapy alone provides insufficient relief:

1. Medial Branch Nerve Block — diagnostic and therapeutic injection under fluoroscopy or CT guidance
2. Intra-articular Facet Injection — corticosteroid injected directly into the joint
3. Radiofrequency Ablation (RFA) — thermal ablation of the medial branch nerve; provides 6 to 18 months of significant pain relief

For related guides, see degenerative disc disease treatment and spinal stenosis exercises.

References

• Cohen SP, Raja SN. Pathogenesis, diagnosis, and treatment of lumbar zygapophysial joint pain. Anesthesiology. 2007.
• Manchikanti L et al. Facet joint pain in chronic spinal pain. Pain Physician. 2004.
• Van Kleef M et al. Radiofrequency lesion adjacent to the dorsal root ganglion. Pain. 1996.