Lower back pain arises from multiple areas in the back. Whiles many are familiar with back pain from injured discs, pain may also arise from small joints in the back called the facet joints. Facet joint pain is a cause of lower back pain that is frequently overlooked.
What are Facet Joints?
The facet joints are small joints in the back that connect the spinal segments. They provide mobility and allow the body to bend and twist. As nerves exit the back, they pass by the facet joints. Healthy facet joints have cartilage, which allows the back to move smoothly.
Facet joint pain presents slightly differently than pain from discs. For example, facet joint pain tends to worsen with standing and back extension while disc pain tends to worsen with sitting and bending forward. Interestingly, the pain produced from facet joints can present in areas distant from the joint called a referral pattern. For example, pain from the low back facet joints can be felt in the lower lumbar area or the back of the thighs. The referral pattern makes accurate diagnosis more difficult.
Diagnosis
Facet joint pain can be challenging to diagnose accurately. Not only can it present with a referral pattern, but imaging with an x-ray or MRI is often not helpful because it is so common to have arthritis changes in the back whether pain is present or not. For example, it is not unusual for two people to have moderate facet arthritis on an x-ray where one person has severe pain and the other person has no pain. Because of this, the clinical exam is very important.
The activities that worsen pain during the day and findings on the exam suggest the clinical diagnosis. For instance, if there is pain with facet loading (leaning back with a twist), that is suggestive of facet joint pain. Perhaps the most accurate way to diagnose facet pain is with an anesthetic block, however, this is quite invasive. With a block, if the injection relieves all back pain, that suggests the pain source is from the facet joint. If the injection only relieves some of the back pain, that suggests there are multiple pain generators, such as the discs and the facet joints.
Treatment
Initial treatment for facet joint pain is similar to other lower back pain conditions. Typically, it starts with an exercise program that focuses on core strengthening and stretching. Core exercise strengthens the muscles that support the back, while stretching restores the range of motion to the muscles. Restoring the range of motion reduces irritating forces on the facet joints. Key muscle groups to stretch include the low back, front and side of the hip, and back of the legs. Lunges are a great active stretch for the front of the hip. The “cat” and “cow” yoga postures are a good low backstretch. A guide to stretching the key muscle groups are the yoga postures displayed below.
Importantly, if symptoms are not improving with a home program, a physical therapist or chiropractic professional can provide a more individualized and guided program. Part of their assessment includes evaluating for abnormal movement patterns or poor motor control that need specific corrective exercises. Once control is restored, strengthening can resume. If after many months of an individualized exercise program symptoms are still not improving there are more invasive treatments available. These treatments include steroid injections or a procedure called radiofrequency nerve ablation. Procedural treatments are most appropriate for facet joint pain limited to just 1 or 2 levels.
Summary
In summary, lower back pain can arise from the small joints in the back called the facet joints. To improve facet joint pain, start with core strengthening and stretching. If symptoms are not getting better, consider seeing a physical therapist or chiropractic professional who can evaluate for proper movement patterns. Lastly, if symptoms persist, there are more invasive options available for facet joint pain limited to 1 or 2 levels.
