- Aug 27

Facet joint pain and injury

What are facet joints?

This refers to the joints between vertebrae, in which there are two off on either side and are situated at the back. They have several roles including assisting in stability, transfer of load, allowing motion and restricting motions.

Can facet joints hurt?

Yes, the facet joint is made up of several structures including synovium, bone, capsule. The majority of these structures have nociceptors which are nerves that when activated can be interpreted as pain by the brain. These nerves can be activated for numerous reasons from trauma, cysts, infection and more (Yoo & Kim, 2024).

Issues with facet joint diagnosis and relevance?

So, we know structures facet joint structures can hurt. However, there is one issue, that is to diagnose it. The gold standard method to determine if a facet joint is the cause of pain is to use blocks. However, these are not readily available to the public, hard to interpret and have several other limitations (van den Heuvel et al., 2024).

Therefore, we are left with less accurate tools such as imaging and clinical assessments. These have major limitations, which can be demonstrated by the large inconsistency in prevalence studies (van den Heuvel et al., 2024). The main issue is that these methods are not able to accurately differentiate the exact structure responsible for the pain (van den Heuvel et al., 2024)(Hancock et al., 2007).

In fact, a test healthcare professionals have used to diagnose facet joint pain (Kemps sign) for a long time showed to have very little accuracy in ruling facet joint pain in or out (Stuber et al., 2014). Most signs and symptoms of facet joint issues can also occur in other back pain issues.

Imaging (even higher quality, e.g., MRI) doesn’t fare much better. Although it can identify structural changes at the facet joint, these changes are equally common in people without any pain (Brinjikji et al., 2015)(Kach et al., 2022)(Kim et al., 2019).

That is why once serious pathologies and neurological conditions are ruled out for lower back pain, we often refer to it as ‘non-specific lower back pain’. This is not to say it may not have a specific structure causing the pain, it merely refers to our inability to find it accurately. Additionally, the treatment may not actually be different anyway, more on this below.

Secondly, there is also a big question mark around the relevance of reaching a facet joint pain diagnosis (once more serious causes are not suspected).

What are your treatment options?

Hopefully by now it is clear that we may not be able to accurately identify the facet joint as the cause of lower back pain (once serious causes are no longer suspected) and even if we could it might not change the treatment significantly. The following advice can be utilized for majority of ‘non-specific’ spinal pain.

The first and best thing you can do is move. The spine is made to move, if it wasn’t it would be completely fused. Joints and surrounding structures remain healthy through regular movement. It doesn’t have to be intense but ideally it is done regularly.

Although the type of exercise/movement might not matter (Owen et al., 2020), the load, frequency, consistency, intensity may be more significant. This is where an appropriate healthcare professional such as a physiotherapist or exercise physiologist can help.

Injections

In the case the facet joint has been identified as a likely source of pain. More specific intervention can be tried. The first includes nerve ablation. There are several studies that have shown these to have good results in pain and subsequent disability (Lee et al., 2017). However, these results have been extensively questioned (van Kuijk et al., 2018). Further individual factors can have an impact on it’s success. E.g., less success seen in people with Depression or on workers compensation (Streitberger et al., 2011)(Christensen et al., 2017).

Other injections such as plasma-rich plasma, hyaluronic acid and medical ozone have very little high quality supporting evidence and are not recommended at this stage (Sanapti et al., 2018).

Psychological input

Lower back pain can be very severe in intensity and can negatively affect all portions of life including sleep, work capacity, social outings, hobbies, sports, and many more. This can be very challenging and lead to deterioration in mental health (Linton & Bergbom 2011). Psychotherapy may be a good option in assisting you in coping with pain, improve mental health, improve sleep and others (Cheatle et al., 2016). It has been suggested that it can result in better outcomes when combined with exercise therapy (Ho et al., 2020).

Western society is embedded with myths and incorrect narratives around lower back pain and unfortunately these can be harmful. This is a great fact cheat sheet with some great facts around back pain (co authored by Geraldton’s own Ivan Lin!)(O’Sullivan et al., 2020).

References

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Cheatle, M. D., Foster, S., Pinkett, A., Lesneski, M., Qu, D., & Dhingra, L. (2016). Assessing and Managing Sleep Disturbance in Patients with Chronic Pain. Sleep Medicine Clinics, 11(4), 531–541. https://doi.org/10.1016/j.jsmc.2016.08.004
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Hancock, M. J., Maher, C. G., Latimer, J., Spindler, M. F., McAuley, J. H., Laslett, M., & Bogduk, N. (2007). Systematic review of tests to identify the disc, SIJ or facet joint as the source of low back pain. European spine journal : official publication of the European Spine Society, the European Spinal Deformity Society, and the European Section of the Cervical Spine Research Society, 16(10), 1539–1550. https://doi.org/10.1007/s00586-007-0391-1
Ho, E., Ferreira, M., Chen, L., Simic, M., Ashton-James, C., Comachio, J., Hayden, J., & Ferreira, P. (2020). Psychological interventions for chronic non-specific low back pain: protocol of a systematic review with network meta-analysis. BMJ open, 10(9), e034996. https://doi.org/10.1136/bmjopen-2019-034996
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Van Kuijk, S. M. J., Van Zundert, J., Hans, G., Van Boxem, K., Vissers, K., van Kleef, M., & Rathmell, J. (2018). Flawed Study Design and Incorrect Presentation of Data Negatively Impact Potentially Useful Interventional Treatments for Patients with Low Back Pain: A Critical Review of JAMA's MinT Study. Pain practice : the official journal of World Institute of Pain, 18(3), 292–295. https://doi.org/10.1111/papr.12673
Yoo, Y. M., & Kim, K. H. (2024). Facet joint disorders: from diagnosis to treatment. The Korean journal of pain, 37(1), 3–12. https://doi.org/10.3344/kjp.23228

This blog was written by Samuel Bulten