Early facet arthritis

Early facet arthritis in the lumbar spine will often narrow the foramen through which the femoral and sciatic nerve roots pass on their way to the leg. An important part of the history is whether the patient has more LBP or lower extremity pain.

The femoral nerve leaves the mid lumbar spine, passes through the pelvis and emerges via the groin on its way to the front of the thigh and the inner lower leg. Any weakness may affect the quadriceps muscle.

The sciatic fibres escapes from lower in the back and emerge from the buttock via a space between two muscles before passing down the back of the thigh and lower leg to the foot. Any paresis as it's called may primarily affect lifting the big toe, or raising the heel.

For more information about these nerves, use the search function in the navigation bar.

Joints need to move otherwise the hyaline cartilage lining the bones becomes starved of nutrients and oxygen; degenerative changes soon start. The trick is to keep them mobile, primarily with specific lower back exercises, but also perhaps with chiropractic manipulation if there are fixations; more about that later.

The foramen is bounded anteriorally by the disc and posteriorly by the facet joints. Both can cause severe nerve pain.

Early facet arthritis

The scenario is often complicated by trauma such as a fall on the buttocks or lower back in which the facets are forcibly jammed against each other, damaging the cartilage that lines the joint.

Other factors such as a short leg, or a childhood stress fracture as occurred in the case below, also contribute to the degenerative joint disease that plagues so many of us.

An insert in the shoe can correct for a leg length deficiency, but nothing other than good muscle tone and care with lifting can counter the effect of the stress fracture through the pars interarticularis; fortunately in this case it was on one side only so there was no forward slippage. That's known as a spondylolysthesis.

If the early facet arthritis is not correctly managed then the orientation of the joint gradually changes allowing for a forward slip of the vertebra above.

These progressive degenerative changes cause facet enlargement and ultimately the whole canal becomes narrowed; the condition is called spinal stenosis.

The secret is prevention; not allowing that early facet arthritis to progress to the full blown chronic nerve pain. That means exercise and an acceptance that lifting of grand pianos and even vacuuming sometimes has to be avoided. Many people have difficulties with prolonged sitting.

Notice that the so called scotty dog above has a collar; that's the stress fracture through the pars interarticularis. It's a narrow isthmus of bone between the superior and inferior facets. 

The following case file illustrates how early facet arthritis due to a stress fracture known as a pars defect resulted in advanced disc deterioration and chronic lower back pain.

A 69 year old woman consulted me five weeks ago with right lower back pain radiating to the lateral thigh.

She has had a strong back most of her life but about ten years ago began to experience episodes of LBP. They responded to medication, but the latest bout of pain which started some six month previously just continued to worsen.

Every morning she was wakened with fierce pain in the lower back, but during the day it was reasonable. Turning in bed was difficult as was prolonged sitting and cycling uphill. Walking relieved her difficulties.

When she was twenty one she had severe trauma, falling off a horse and fracturing her skull.

Lower back and leg pain

Lower back and leg pain needs to be carefully evaluated; in the absence of sciatic and femoral stretch tests we have to conclude, as in this case, that this is not a true pinched nerve.

Irritated perhaps, but more likely referred pain from another structure, often the hip or sacroiliac joint.

Significant disc degeneration is clearly visible.

Recent x-rays of her lower back revealed an old stress fracture though the pars at L5 (black arrow) and facet arthritis (red arrow).

On examination, forward bending immediately provoked lower back pain, but extension and lateral flexion were reasonably good. Sciatic stretch tests were normal and she was neurologically intact. L5 was extremely tender on deep palpation.

The right sacroiliac joint and L5 were only mildly fixated. Three right sacroiliac joint orthopaedic tests were strongly positive.


An accurate diagnosis was difficult. Despite radiating leg pain, the sciatic stretch tests were negative. Extension and lateral flexion were only mildly painful, making a diagnosis of a facet syndrome dubious. She had no strong signs of an injury to the disc, and by default a diagnosis of sacroiliac syndrome was made.

But what really helped her was gentle side posture drop technique on L5.

All in all, the L5/S1 disc, the facet joints and the sacroiliac joints are intimately involved and sometimes it's difficult making a precise diagnosis.

Response to treatment

She responded extremely well considering that she has had six months of pain waking her every morning.

Treatment consisted of prone drops on the sacroiliac joints using the Derefield protocol, side posture adjustment of L5 whilst lying on her right side and soft tissue therapy down the side of her leg.

An intensive exercise programme based on that found in the navigation bar on your right was mandatory.

After five treatments she reported having 90% less pain and she had been on a 15 mile cycle with no pain. Prolonged sitting at her computer remains problematic.

Her next consultation will be in three weeks times. Thereafter I anticipate that an occasional, but regular treatment will be necessary; perhaps every six weeks.

Here's an interesting question. Why didn't her early facet arthritis not progress with advanced degenerative change? Was it because three times a week she cycles fifteen odd miles? Was it perhaps because she absolutely adores salmon, rich in omega-3 oil? Or, something quite unknown?

In any event, this lady has been doing something right. I wonder how many women of sixty nine could cycle fifteen miles?

Useful links

» Facet arthritis

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Interesting challenges of the day

1. Mr S is a 76 year old man with neck pain of some 9 months duration. Luckily, most of the discomfort is upper cervical which is only rarely arthritic; his lower cervical spine is a degenerative mess that I've left alone. After seven treatments his pain and stiffness is 50 percent better, and he's happy in the circumstances. He can sleep through the night now and that makes a huge difference.

2. Mr P is 32 year old man with very severe lower back pain radiating to the big toe which is 30 percent numb. He had an episode three weeks ago, took anti inflammatories and was soon better as is typical of the medial disc herniation. But before it healed, after a trivia it came roaring back, much worse. The characteristic crossed sign was evident; sitting in a chair, straightening the right leg provoked severe left back pain and tingling in the leg. He's doing well.

3. Severe lower back pain is scary; just ask Mrs P. Just watching her get out of the car I she was in trouble; she had a slipped disc at L4 making her lean towards the opposite side; luckily she had no pain in the leg. Despite family pressure that this was far too severe for a chiropractor, she persevered. Within five days she was standing upright, and after two weeks almost painfree. 

Despite a hectic job, she wisely took my advice and stayed home for what I call exercising bed rest.

4. Mr S has had lower back, groin and back of thigh and calf pain for fourth months.

He has a pincer deformity in the hip causing the stabs in the groin, and a degenerative facet causing the sciatica. Both are responding well to chiropractic and he's well pleased; sixty five percent better after three treatments.

5. Mr T is a wise man; he's taken a warning TIA seriously and has lost 15 pounds, and has at least as much again to lose. A change to a low starch diet and half hour daily walk has made the difference; but the walking is making his foot and back miserable. The expensive orthotic is hopeless; luckily his hips and back are fine, but he needs a simple heel lift.

6. I too have had serious lower back issues, luckily fixed by my own chiropractor; so I too have to do my exercises, take care when lifting supers full of honey, gardening and using the chainsaw. Regaining the function of your spine is just as important as the pain.

7. My own granddaughter, only 7 is hypermobile giving her pelvic, knee and ankle issues. Xrays show a mildly dysplastic hip. Years ago we would have called it growing pains. She too regularly needs chiropractic care and luckily responds well. Increased range of motion is more difficult than too stiff in my opinion. Our care is for kids too.

8. This 65 year old lady is a serious gardener; every day she is bending, lifting and digging for 2 to 3 hours a day. It regularly catches her in the sacroiliac joint, so she has a treatment once a month that sorts it out. She does her lower back exercises faithfully.

9. This 88 year old lady is an inspiration; every day she is busy in the community. With a nasty scoliosis she manages very well with a chiropractic adjustment every six weeks and exercises faithfully done.  

10. Mr X is a 71 year old retired man who wants to continue with maintenance care every six to eight weeks; he had suffered from two years of lower back pain when he first came a year ago. He has no discomfort now after 8 chiropractic treatments, but is aware that danger lurks.

11. Mrs C has been having severe headaches, and taking a lot of analgesics. It's a non complicated upper cervical facet syndrome, and she's doing well.

12. Mr D is a 38 old year man with chronic shoulder pain after a rotator cuff tear playing cricket. It responded well to treatment, but he knows he must do his exercises every day; for two years he couldn't sleep on that shoulder.

13. Mr D, a 71 year old man, has a severe ache in the shoulder and midback since working above his head. Trapped nerve tests are negative but he has advanced degenerative joints of Luschka; after just two treatments he is 50 percent better. Can we reach 90?

And so the day goes; chiropractors shouldn't be treating the elderly most medical sites state but that's so much bunkum.

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Interesting questions from visitors

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