Facet Joint Syndrome (Facet Arthropathy)

Key facts

What the facet joints are and why they hurt

Every level of the spine is a three-legged stool: the disc in front carries most of the load, and two facet joints at the back guide and limit movement. The facets are small, about the size of a thumbnail, and are true synovial joints with cartilage surfaces, a capsule and a lining that produces joint fluid. They allow you to bend and turn while stopping the vertebra from sliding too far. When you arch backward or twist, the facets take more of the load; when you bend forward, they unload.

Facet joints wear like knees and hips do. Cartilage thins, the joint enlarges, small spurs form, and the capsule becomes inflamed. This happens faster when the disc in front has flattened, because a thinner disc shifts more load to the joints behind it, which is why facet pain and degenerative disc disease so often coexist at the same level. In the neck, the joint capsule can also be strained by a whiplash injury, and that strain can become a persistent pain source.

Each facet joint is supplied by two tiny sensory nerves called medial branches, one from the level above and one from the same level. They carry pain from the joint and nothing else of consequence: no arm or leg strength, no skin sensation of note. That anatomy is the key to both diagnosing and treating facet pain, because those nerves can be numbed as a test and heated as a treatment without affecting anything else.

Symptoms and the extension-rotation pattern

Facet pain is a deep, aching pain in the back or neck, usually off to one or both sides of the midline rather than in the center, that behaves in a recognizable way:

• Worse arching backward, twisting, and standing or walking for long periods, because those load the joints. Rolling over in bed, getting out of a car, and reaching overhead are common triggers.
• Better bending forward and sitting, at least at first, because flexion unloads the joints. (Disc pain is the opposite: worse sitting and bending.)
• Stiff in the morning, easing after 20–30 minutes of moving.
• Refers in a predictable but non-nerve pattern. Lumbar facets refer to the buttock, hip and back of the thigh but rarely past the knee. Cervical facets refer to the back of the head (upper joints), the side of the neck and top of the shoulder (middle joints), and the shoulder blade (lower joints). Thoracic facets refer around the ribs.
• No true nerve signs. No tingling in the fingers or toes, no numbness in a strip of skin, no weakness. Facet pain does not pinch a nerve root.
• Tender to press directly over the joints, about a thumb's width from the midline.

Distinguishing it from its neighbors: sciatica goes below the knee with numbness; SI joint pain sits lower, at the top of the buttock, and is worse rising from a chair; disc pain is central and worse with sitting. In practice the patterns overlap and no single sign is reliable, which is why the diagnosis rests on a block rather than an exam.

How we diagnose it: the medial branch block

Imaging cannot diagnose facet pain. Facet arthritis is visible on X-ray, CT and MRI in most adults over 50, painful or not, and studies have found no reliable relationship between how bad the joints look and whether they hurt. An MRI is still useful to rule out other causes and to plan the procedure, but a report that says "facet arthropathy" does not tell us the facets are the source.

The medial branch block is the test. Under X-ray guidance, a small amount of local anesthetic is placed on the medial branch nerves that supply the suspected joints, usually two or three levels on one or both sides. This is a test, not a treatment: the anesthetic numbs the joints for a few hours, and what you do during those hours is the diagnosis. You go home with a pain diary and record your pain level and what you could do (arch, twist, stand, roll over) every hour until the anesthetic wears off. If the pain that normally stops you drops by 80% or more while the block is working, the facets are confirmed. If it drops by 30%, they are not the main source and we look elsewhere.

Two blocks, not one. A single block gives a false-positive result in roughly one in four to one in three people, because of placebo response, sedation and the normal ups and downs of pain. Guidelines from ASIPP and the multisociety facet consensus, and Medicare's coverage rules, therefore require two separate blocks on different days, each producing at least 80% relief for the expected duration of the anesthetic, before radiofrequency ablation is approved. Sedation is kept minimal so it does not blur the result. The block itself takes about 15 minutes.

See the medial branch block page for what the visit involves.

Treatment options, in order

Facet pain follows a well-defined path: conservative care first, then the diagnostic blocks, then radiofrequency ablation for those whose blocks confirm the joints. Ablation is the destination for most people who reach the block stage; steroid injections into the joint itself play a smaller role.

1. Activity, posture and medication

   Avoid sustained extension (overhead work, long standing, sleeping on the stomach). NSAIDs for flares if safe for you; acetaminophen; heat. Opioids are not indicated for facet pain. Learn more →

2. Physical therapy

   Flexion-biased mobility, core and hip strengthening to take load off the joints, and for the neck, deep neck flexor and scapular strengthening. A reasonable 6-week trial before proceeding to blocks. Learn more →

3. Medial branch blocks (two, on separate days)

   The diagnostic test described above. Confirms the facets are the pain source when each block gives at least 80% relief. Relief is meant to last hours only. Learn more →

4. Radiofrequency ablation

   A heated probe placed on each confirmed medial branch nerve under X-ray guidance creates a small lesion that stops the nerve carrying pain signals. Relief develops over 2–4 weeks and typically lasts 6–12 months or longer; some people have a few days to two weeks of increased soreness first. The nerves regrow, and the procedure can be repeated when pain returns, usually with similar results. In the landmark cervical trial, relief lasted a median of 263 days; in well-selected lumbar patients, more than half report at least 50% relief at one year. Learn more →

5. Facet joint steroid injection

   Steroid placed inside the joint itself. Used for an acute inflamed joint, for a synovial cyst, or when ablation is not possible; the relief is shorter and less consistent than ablation, and insurers do not accept its response as the diagnostic test for ablation. Learn more →

6. Surgical referral

   Rarely needed for facet pain alone. Fusion is considered only when facet pain coexists with instability or spondylolisthesis that is causing nerve symptoms. Learn more →

Cervical facet pain and whiplash

The facet joints are the most common source of chronic neck pain, and the evidence is strongest of all in neck pain after a car accident. In studies of people whose neck pain persisted for months after whiplash, about half had pain that could be traced to a facet joint with controlled blocks, most often C2–3 (which refers to the back of the head) and C5–6. Cervical radiofrequency ablation was first proven in exactly this group: in a randomized trial, patients whose facet pain had been confirmed with blocks had a median of 263 days of complete relief after ablation, compared with 8 days after a sham procedure, and repeat ablation restored relief when pain returned.

Cervical facet pain also explains a large share of "tension" headaches that start at the base of the skull, because the C2–3 joint and its nerve (the third occipital nerve) refer pain to the back of the head. See occipital neuralgia and cervicogenic headache and whiplash and auto injury.

What you can do now

• Avoid sustained arching. Do not sleep on your stomach; use a pillow under the knees on your back or between the knees on your side. Raise work to avoid reaching overhead for long periods.
• Move every 30 minutes if you stand for work. Put one foot up on a low rail or box; it flexes the spine slightly and unloads the joints.
• Heat before activity, ice after a flare.
• Build the hips and core. Strong gluteal and abdominal muscles reduce the shear on the lumbar facets. For the neck, chin tucks and shoulder blade squeezes.
• Keep a pain diary for a week: what you were doing, how long, and what settled it. Extension and rotation triggers point to the facets and help us choose which levels to test.
• If you have a block scheduled, do not take extra pain medication that day, and plan to do the activities that normally hurt so you can judge the result.

Frequently asked questions

Related care

Related treatments

Related conditions