Facet Joint Dysfunction

Normal Anatomy

Cervical Facet Joints

  • Diarthrodial joints
  • Upper cervical facets are horizontal
  • Orientation of facets gradually progresses into a more vertical position in an anterior posterior direction towards the lower cervical spine
  • Facet joints are surrounded by a fibrous capsule and lined by a synovial membrane
  • Articular cartilage, menisci, synovial folds and adipose tissue are also present
  • The number of synovial folds and meniscoid structures located in the facet joint can vary from person to person and could be a contributing factor to pathology
  • The fibrous capsules are highly innervated by mechanoreceptors (types I, II, and III)
  • Mechanoreceptors important for proprioception and nociceptive input modulate protective muscular reflexes to prevent joint instability and degeneration

Pathophysiology

  • Injury can occur to the joint surface cartilage or the surrounding capsular tissue
  • Inflammation of joint or soft tissue
  • Development of adhesions and scar tissue
  • Can lead to increased tone of surrounding muscle tissue
  • Overtime can lead to facet joint hypertrophy, thickening of capsular ligaments or osteophyte formation

Mechanism of Injury

Traumatic

  • Fracture (surgical emergency)
  • Dislocation (surgical emergency)
  • Whiplash Associated Disorder or hyperextension injury can cause nociception via two mechanisms:
  • Excessive compression of the facet joint
  • Excessive capsular ligament strain

Degenerative

  • Degeneration of facet joints is evident in most people over the age of 30 and may or may not contribute to symptoms
  • It is hypothesised that disc degeneration occurs first which results in reduced disc height and increased load on the facet joints
  • These changes are thought to eventually lead to facet joint degeneration (See Cervical Spondylosis Handout)

Associated Pathologies

  • Whiplash Associated Disorder
  • Cervical spondylosis
  • Cervical radiculopathy

Examination

Subjective

  • History of trauma / hyperextension injury (traumatic) or insidious onset (degenerative)
  • Ipsilateral neck pain
  • Facet joint referral pattern
  • Dull ache with sharp pains commonly felt on aggravating movements
  • Morning stiffness
  • Reduced ROM may be reported
  • Generally no neural symptoms reported
  • Pain referral patterns have been described in literature
  • C2-3 – posterior upper cervical region and head
  • C3-4 – posterolateral cervical region without extension into the head or shoulder
  • C4-5 – posterolateral middle and lower cervical region, and to the top of the shoulder
  • C5-6 – posterolateral middle and primarily lower cervical spine and to the top and lateral parts of the shoulder and caudally to the spine of the scapula
  • C6-7 – top and lateral parts of the shoulder and extends caudally to the inferior border of the scapula.

Objective

  • ROM reduced and painful
  • Compression - Extension, contralateral rotation and ipsilateral side flexion
  • Capsular stress - Flexion, ipsilateral rotation and contralateral side flexion
  • Capsular pattern may be present
  • Pain and stiffness on segmental mobility testing – PA’s, lateral glides.
  • Increased tone in surrounding musculature

Special Tests

  • Posterior-Anterior Segmental Mobility
  • Segmental Mobility
  • Extension - Rotation

Further Investigation

  • MRI
  • Diagnostic injections
  • CT Scan
  • Single-photon emission computed tomography (SPECT)

Management

Conservative

  1. Increase Range of Movement
  2. Decrease inflammation
  3. Cryotherapy
  4. NSAIDs
  5. Mobilisation
  6. Decrease muscle tone - paraspinals, trapezius, scalenes, sternocleidomastoid
  7. Soft tissue techniques
  8. Acupuncture / Dry Needling
  9. Stretches
  10. Increase movement through joint capsule
  11. Joint mobilisations
  12. PAs cervical / thoracic
  13. Manipulation
  14. Mobility exercises
  15. Cervical rotation / extension
  16. Thoracic rotation / extension
  17. Restore normal motor control and strength
  18. Deep cervical flexor / extensor strengthening
  19. Biofeedback for deep cervical flexor recruitment
  20. Scapular upward rotators / posterior tilt
  21. Restore dynamic stability
  22. Pertubation exercises
  23. Return to sport / activity specific exercises

Plan B

Injection

  • Intra-articular facet joint injections (limited evidence)
  • Medial branch nerve blocks (fair evidence)

Surgery

  • Radiofrequency neurotomy considered if medial branch nerve block is successful

References

(Pal and Routal, 2001, Ivancic et al., 2008, Kirpalani and Mitra, 2008, Narouze, 2009, Saayman et al., 2011, Bogduk, 2011, Falco et al., 2012, Schneider et al., 2012, Schneider et al., 2013, Schneider et al., 2014, Stamos et al., 2012, Dewitte et al., 2014)

Bogduk, N. (2011) 'On cervical zygapophysial joint pain after whiplash', Spine (Phila Pa 1976), 36(25 Suppl), pp. S194-9.

Dewitte, V., Cagnie, B., Barbe, T., Beernaert, A., Vanthillo, B. and Danneels, L. (2014) 'Articular dysfunction patterns in patients with mechanical low back pain: A clinical algorithm to guide specific mobilization and manipulation techniques', Manual Therapy, 20(3), pp. 499-502.

Falco, F. J., Manchikanti, L., Datta, S., Wargo, B. W., Geffert, S., Bryce, D. A., Atluri, S., Singh, V., Benyamin, R. M., Sehgal, N., Ward, S. P., Helm, S., 2nd, Gupta, S. and Boswell, M. V. (2012) 'Systematic review of the therapeutic effectiveness of cervical facet joint interventions: an update', Pain Physician, 15(6), pp. E839-68.

Ivancic, P. C., Pearson, A. M., Tominaga, Y., Simpson, A. K., Yue, J. J. and Panjabi, M. M. (2008) 'Biomechanics of cervical facet dislocation', Traffic Inj Prev, 9(6), pp. 606-11.

Kirpalani, D. and Mitra, R. (2008) 'Cervical Facet Joint Dysfunction: A Review', Archives of Physical Medicine and Rehabilitation, 89(4), pp. 770-774.

Narouze, S. (2009) 'Ultrasound-Guided Cervical Zygapophyseal (Facet) Intra-Articular Injection', Techniques in Regional Anesthesia and Pain Management, 13, pp. 133-136.

Pal, G. P. and Routal, R. V. (2001) 'The orientation of the articular facets of the zygapophyseal joints at the cervical and upper thoracic region', 198(Pt 4), pp. 431-41.

Saayman, L., Hay, C. and Abrahamse, H. (2011) 'Chiropractic manipulative therapy and low-level laser therapy in the management of cervical facet dysfunction: a randomized controlled study', J Manipulative Physiol Ther, 34(3), pp. 153-63.

Schneider, G. M., Jull, G., Thomas, K. and Salo, P. (2012) 'Screening of patients suitable for diagnostic cervical facet joint blocks--a role for physiotherapists', Man Ther, 17(2), pp. 180-3.

Schneider, G. M., Jull, G., Thomas, K., Smith, A., Emery, C., Faris, P., Cook, C., Frizzell, B. and Salo, P. (2014) 'Derivation of a Clinical Decision Guide in the Diagnosis of Cervical Facet Joint Pain', Archives of Physical Medicine and Rehabilitation, 95(9), pp. 1695-1701.

Schneider, G. M., Jull, G., Thomas, K., Smith, A., Emery, C., Faris, P., Schneider, K. and Salo, P. (2013) 'Intrarater and Interrater Reliability of Select Clinical Tests inPatients Referred for Diagnostic Facet Joint Blocks in theCervical Spine', Archives of Physical Medicine and Rehabilitation, 94(8), pp. 1628-1634.

Stamos, I., Heneghan, N. R., McCarthy, C. and Wright, C. (2012) 'Inter-examiner reliability of active combined movements assessment of subjects with a history of mechanical neck problems', Manual Therapy, 17(5), pp. 438-444.

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