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Lumbar Facet Joint Pain and Chronic Overuse, Pain Management

Low back pain and facet osteoarthritis are among the most common musculoskeletal injuries reported today. Inside overuse, pain management, and pain prevention.

This overview is part of a Chronic Overuse Injuries Primer. View the introduction.
 

History/Pathogenesis

Chronic low back pain is one of the most common musculoskeletal, as well as societal issues, present in modern society, accounting for 80% to 90% of all healthcare expenditures.1 Lumbar facet joint pain syndrome (LFPS) is a major overuse-related component of all low back pain (LBP) that is characterized by high-grade cartilage necrosis, either bilateral or unilateral back pain that radiates to one or both buttocks, sides of groin, and thighs (usually stopping above knee) with possible neurogenic claudication. Facet joints play an important role in load transmission, as they help stabilize the spinal segment in motion during flexion and extension, as well as restrict axial rotation.

Facet joint degeneration can occur secondary to numerous causes (acute/subacute trauma), but the most common of these is repetitive overuse. Though there are different causes of degeneration, the resulting irritation of the joint/nerve root eventually leads to inflammation of the facet joints and surrounding tissues, which is believed to be responsible for the associated pain—facet joint pain syndrome.2-13

Prevalence/Epidemiology

General LBP is the most common pain syndrome and musculoskeletal injury in society today, with up to 84% of people experiencing it at some point in their life. Though prevalence reports are highly variable, lumbar facet joint pain is estimated to make up 15% to 45% of total LBP, with a definitive trend of increasing incidence with age. Facet osteoarthritis is reportedly the most common joint pathology.1,7,13-15

Image: iStock (Mintr)Prevalence if low back pain, lumbar pain is highly variable, with lumbar facet joint pain estimated to make up 15% to 45% of total low back pain and a definitive trend of increasing incidence with age. Facet osteoarthritis, in turn, is reportedly the most common joint pathology.

Signs/Symptoms

Axial facetogenic pain in the lumbar back is exacerbated by extension and lateral rotational movements and often accompanied by focal muscle spasm in the lumbar paraspinals and extensor muscles.

Patients tend to prefer to stand in a semi-flexed position, with some avoidance of pure standing/extension activities, and move slowly rather than to sit still. While discogenic pain tends to be sharp or burning and often shoots into the lower leg, facetogenic pain tends to remain in the lumbar/gluteal regions, with some occasional referred pain in the upper lower extremities or sacral/gluteal regions. Lumbar spondylolysis and spondylolisthesis patients tend to have referred pain into the gluteal and buttock regions, which is worse with extension and lateral side-bending.

High Risk Activities for LFPS

  • Primarily activities involving repetitive heavy lifting or strain on the back, especially when a rotational component is involved

Related Conditions or Risk Factors

  • Age
  • Gender, male higher risk
  • Spinal level (L4-L5)
  • Facet orientation (sagittally oriented)
  • Background of intervertebral disc degeneration—heavy labor done early in life

Studies have found relationship among patients who had a symptomatic:

  • Disc herniation
  • Degenerative spondylolisthesis at L4–L5 or L5–S1 level(s)
  • Increased severity of facet joint tropism

Can occur secondary to:

  • Repetitive overuse and microtrauma
  • Spinal strains and torsional forces
  • Poor body mechanics
  • Obesity
  • Degenerative lumbar spondylolysis and spondylolisthesis, frequently related to facet joint osteoarthritis 1,7,16,17

Physical Exam

Clinicians should perform a thorough neurological/musculoskeletal, directed exam with provocative maneuvers and specific pain centralization through postural changes to evaluate the correct diagnosis. Evaluation of upper/lower extremity flexibility and trunk motion, muscle imbalances, and ligamentous stability are necessary in the exam.

Evaluation of gait analysis and biomechanics should be reviewed as well as any footwear or orthotic/DME evaluation and inspection for wear patterns. Inspection/observation of any pain, tightness, and often spasms to the lumbosacral paraspinals. Repeated movement testing (flexion and extension) can be very useful to identify discogenic vs. facetogenic pain pathology.

Perform quadrant testing to identify instabilities and straight leg raises and slump test to assess dural inflammation. Assess strength/endurance of core trunk musculature. Perform myotomal and dermatomal scan to differentiate level of nerve root involvement. Special “Red-flag” clinical questions regarding bowel/bladder changes, “saddle” anesthesias, or visceral disease are necessary to determine the clinical urgency for potential spinal surgical referral/evaluation.

Diagnostic Tests

Diagnostic testing if indicated would be to evaluate with baseline x-rays, L/S MRI or CT scans, musculoskeletal diagnostic U/S testing, bone scan/bone density testing, single-photon emission computed tomography (SPECT- if indicated), or possibly EMG/NCS testing (especially to differentiate with radiculopathy or neuropathic conditions).

Differential Diagnosis

  • L/S discogenic disorders
  • Seronegative spondyloarthropathies
  • Musculoskeletal-ligamentous strain
  • Occult lesion
  • Spinal infection
  • Stress/compression fractures
  • Pars interarticularis defects

Prevention

Clinicians should advise patients on proper biomechanics (especially when lifting) to prevent strain. Low back braces/lifting aids may be beneficial.

Acute Treatment

Relative rest; analgesia through appropriate doses of NSAIDs and with physical modalities such as ice, therapeutic ultrasound, topical anesthetic skin refrigerant and electrical stimulation; DME with various L/S support bracing. Back School or McKenzie methods emphasizing self-correction, proper posture, body mechanics, and self-management techniques. Encourage active approaches to problems with movement-based therapy.

Long-Term Treatment/Rehab

Treatment usually begins with conservative treatment to provide symptomatic relief. Temporary neck bracing and/or lumbar supports may be necessary. Therapy should work to improve flexibility/strength of the lumbar spine and core muscles, as well as improve biomechanics. If conservative treatment fails, minimally invasive intervention in combination with continued therapy may be implemented. Facet joint injections can be utilized as both a diagnostic and treatment tool through means of local temporary relief. Epidural injections can be utilized as a temporary treatment method in patients experiencing radicular pain.

Radiofrequency nerve ablation (RFNA) works to relieve symptoms by burning the nerve endings around the damaged joint. Though symptom relief via RFNA treatment typically lasts longer than facet joint (FJI)/medial nerve (MBB) injections or epidurals, the nerve(s) can grow back over time, meaning that this method is also temporary (but usually longer lasting than FJIs/MBBs). Minimally invasive treatment may provide symptom relief and help patients better participate in therapeutic treatment.

Regenerative medicine techniques, such as platelet-rich plasma and stem cell injection options, are now on the forefront of research and for potential treatments for chronic overuse musculoskeletal/sports injuries. They should be considered on a case-by-case setting for LFPS. Range of motion in spinal flexion and extension as well as gluteal and lower extremity stretching may be helpful to regain flexibility. For the lumbar spine, improve the overall strength and conditioning of the core stabilizers (eg, transversus abdominis, internal obliques, erector spinae, multifidi, semispinalis, and lumbar transversospinalis). Strength training should be sport- or activity- specific exercises.2,18-21

Practical Takeaways 

  • LFPS is a major overuse-related component of all LBP that is characterized by high-grade cartilage necrosis, either bilateral or unilateral back pain that radiates to one or both buttocks, sides of groin, and thighs (usually stopping above knee) with possible neurogenic claudication.
  • Signs and symptoms include axial facetogenic pain in the lumbar back that is exacerbated by extension and lateral rotational movements and often accompanied by focal muscle spasm in the lumbar paraspinals and extensor muscles. Patients tend to prefer to stand in a semi-flexed position, with some avoidance of pure standing/extension activities, and move slowly rather than to sit still.
  • Perform diagnostic testing if indicated: evaluate with baseline x-rays, L/S MRI or CT scans, musculoskeletal diagnostic U/S testing, bone scan/bone density testing, single-photon emission computed tomography (SPECT, if indicated), or possibly EMG/NCS testing (especially to differentiate with radiculopathy or neuropathic conditions).
  • Facet joint injections can be utilized as both a diagnostic and treatment tool through means of local temporary relief. Epidural injections can be utilized as a temporary treatment method in patients experiencing radicular pain.
  • Radiofrequency nerve ablation (RFNA) works to relieve symptoms by burning the nerve endings around the damaged joint. Though symptom relief via RFNA treatment typically lasts longer than facet joint (FJI)/medial nerve (MBB) injections or epidurals, the nerve(s) can grow back over time, meaning that this method is also temporary (but usually longer lasting than FJIs/MBBs).
Additional chronic overuse injuries in this primer:
 
Last updated on: May 29, 2020
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Iliotibial Band Friction Syndrome
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