What is facet joint pain?

Behind the disc at every level sit two small joints. Each is built exactly like a knee: cartilage on both surfaces, a fluid-filled capsule, a synovial lining, and a dense supply of nerve fibers through the medial branches. They wear and swell the way a knee does. The difference is size. And nobody ever tells you your back pain is arthritis of a joint the size of your thumbnail.

Here is the trap. A worn facet on your MRI proves nothing on its own, because most people your age have one. What proves the facet is hurting is that numbing its nerves stops the pain. Manchikanti and colleagues applied paired diagnostic blocks to 500 patients with chronic spinal pain. The facets were to blame in 31% of the lumbar cases and 55% of the cervical ones. A single lumbar block gave a false positive 27% of the time. That is why the test is done twice here. And it is why a medial branch block, not an injection into the joint, settles the diagnosis.

What causes facet joint pain?

There are three drivers, and only one of them is in the joint. The first is load transfer. Adams and Hutton showed the lumbar facets carry a rising share of the load as the disc in front of them loses height. Fujiwara and colleagues mapped how disc degeneration and facet arthritis progress together, level by level. Lose a few millimeters of disc, and a joint built to guide motion starts bearing weight. Arching back and twisting load it hardest. Think of the forklift operator twisting to look behind him at the Gateway Commerce Center outside Edwardsville. Or the picker reaching overhead, the farmer turning in the tractor seat, the pipefitter arching under a run at the Wood River refinery.

The second driver is metabolic. It is the one a purely mechanical clinic misses. The synovium (the joint lining) is immune tissue. Courties and colleagues describe how fat-made hormones and the low-grade inflammation of metabolic syndrome drive cartilage loss and synovitis, apart from body weight. That is why the knees of a lean person with insulin resistance still break down, and why facets do too. The facet sits in the same bloodstream as the knee. The third driver is the schedule: twelve-hour rotations, sleep that comes in the daytime, and a commute across the river. The commute adds hours of sitting bent forward to a day that ends standing and arched back. The joint feels all three at once.

How is facet joint pain diagnosed?

The pattern comes first. Facet pain sits in the low back, on one side or both. It is worse standing and arching back, and often stiff in the morning. When it spreads, it goes to the buttock or thigh but rarely past the knee. A picture like that earns a diagnostic block. A block that relieves the pain earns a second one on a different day. Two concordant blocks (two that match) earn a conversation about radiofrequency ablation. Cohen and the 2020 multispecialty working group set out that sequence as guideline practice, and it is the sequence here. For a patient driving in from Belleville, about 40 minutes with the roads clear and no traffic, each block is a short visit, scheduled so the crossings are counted, not assumed.

What is the best treatment for facet joint pain?

Radiofrequency heat interrupts the medial branch so the joint stops reporting. The joint is not repaired. The arthritis goes on. The nerve regrows over months to a year or more. At that point the procedure can be repeated, if the first one earned it. That window is the whole point. It is wasted if the joint is loaded exactly the way it was before. So the 40 to 50 percent of the protocol that is not a needle is prescribed alongside it. Hip extensor strength, because a lumbar facet doing the hip’s job is overloaded on every step. Walking, because cartilage has no blood supply and feeds only on repeated loading. Insulin and weight, because lowering both quiets the synovitis that the fat hormones were driving. Sleep, because the pain threshold and the morning stiffness both move with it. Guarding is treated as a symptom in its own right. Our own licensed, pain-trained behavioral clinician uses Acceptance and Commitment Therapy, with no referral out. That is because a back held rigid to protect a joint loads that joint harder than movement ever did.

Steroid into the joint itself is a different procedure with weaker evidence. It is offered here only where the block sequence is not the right path; the facet joint injection page says so plainly. Surgery is not part of the treatment plan for facet pain on its own.

Frequently asked questions

Can I see you for facet joint pain without a referral?

Yes. Facet joint visits are booked directly. Some insurance plans still want a referral from your primary doctor before they cover the visit, so check yours. The diagnosis rests on a medial branch block, and this post on diagnostic blocks shows how the result is scored.

Does facet joint pain show up on an MRI?

Facet arthritis shows up on most scans of most adults over fifty. So the picture cannot tell you whether that joint is the one hurting. The only test that can is numbing its nerves, which is what a medial branch block is for.

How long does radiofrequency ablation last for facet pain?

Months to more than a year in most patients whose two diagnostic blocks matched. That is because the medial branch regrows on its own timeline. The radiofrequency ablation page covers what happens when it does.

Why does my back hurt more standing than sitting?

Standing and arching back close the facet joints and load their cartilage. Sitting opens them. That pattern is the opposite of a disc-driven nerve root problem. It is one reason the history is taken before any needle, as what a diagnostic block tells you explains.

Can facet joint pain cause leg pain?

It spreads to the buttock and the back of the thigh, usually stopping above the knee. It comes without the numbness or weakness of a nerve root. Pain that runs below the knee in a line is more likely the condition on the sciatica page.

How many trips across the river does a facet work-up take?

Typically a first visit, two block days and an ablation day, sequenced with the drive in mind, with telehealth follow-up where clinically appropriate. First visit from Illinois lays the sequence out.

What are the symptoms of facet joint pain?

Pain in the low back, on one side or both. It is worse when you stand or arch backward, and often stiff first thing in the morning. When it spreads, it goes to the buttock or thigh and rarely past the knee, without the numbness or weakness of a pinched nerve. On exam, pressing on one level of the spine usually matches the pain.

Is walking good for facet joint pain?

Yes. Cartilage has no blood supply of its own. It feeds only on the squeeze-and-release of regular movement, so walking is prescribed, not just allowed. It works best with hip extensor strength, because a facet joint doing the hip’s job every time you step and stand is overloaded. It also works best with the insulin, weight and sleep work that quiets the inflammation.

What should you not do with facet joint pain?

Do not hold your back rigid to protect it. Guarding loads the joint harder than movement ever did. Do not treat a worn facet on an MRI as proof; most adults over fifty have one. Twisting and arching load the joint hardest, so notice how often your work asks for them. And after an ablation, do not go back to loading the joint exactly as before, or the relief window is wasted.

Related reading

• Medial branch block
• Radiofrequency ablation
• Facet joint injection
• What a diagnostic block tells you
• Sacroiliac joint pain
• Metabolic health and pain
• PRP injections and orthobiologics for joints and tendons