Facet Joint Syndrome: Pain Exacerbation Pattern
Low back pain from facet joint syndrome is typically exacerbated by extension and rotation (turning or spinal rotation), not by prolonged sitting, Valsalva maneuver, flexion, or the Spurling test.
Clinical Pain Pattern
Facet-mediated low back pain demonstrates a characteristic pattern that helps distinguish it from other causes of lumbar pain:
Movements That Worsen Facet Pain
Extension and rotation movements are the classic exacerbating factors for facet joint syndrome, as these motions load and compress the facet joints 1.
Pain with extension-rotation maneuvers is commonly associated with facet-mediated pain, though this finding alone is not pathognomonic 2.
Lower lumbar facet joints (L4-5, L5-S1) typically refer pain to the groin and deep posterior thigh, while upper lumbar facet joints cause pain in the flank, hip, and upper lateral thigh 2.
Movements That Do NOT Typically Worsen Facet Pain
Absence of exacerbation by forward flexion is actually more frequent in patients with true facet-mediated pain (responders to facet blocks) 1.
Relief when recumbent is characteristic of facet syndrome, suggesting that axial loading positions like prolonged sitting are less problematic than extension-based activities 1.
Absence of exacerbation by coughing (Valsalva-type maneuvers) helps distinguish facet pain from discogenic or radicular pain, where increased intrathecal pressure worsens symptoms 1.
Diagnostic Considerations
Key Clinical Discriminators
A study identified seven variables more frequent in patients who responded to facet blocks 1:
- Older age
- Absence of exacerbation by coughing
- Relief when recumbent
- Absence of exacerbation by forward flexion
- Absence of worsening by hyperextension alone
- Pain with extension-rotation (combined movement)
When four of these seven variables were present, sensitivity was 81.8% and specificity 77.8% for identifying facet-mediated pain 1.
Important Caveats
No single physical examination finding reliably predicts facet-mediated pain, with studies showing no statistically significant association between clinical features and response to facet blocks in isolation 2.
Pain below the knee is highly questionable for facet origin and suggests alternative pathology such as radiculopathy 2.
The gold standard for diagnosis requires controlled comparative local anesthetic blocks (double-injection technique) with ≥80% pain relief, as clinical examination alone is insufficient 2.
Common Pitfall
The Spurling test mentioned in the question is a cervical spine maneuver (cervical compression with rotation) used to evaluate for cervical radiculopathy, not lumbar facet syndrome 3. This test is irrelevant to lumbar facet joint evaluation and should not be confused with lumbar extension-rotation testing.