Lumbar spineNICE alignedJOSPT informed5 min read

What does facet-mediated low back pain look like in clinic?

History, examination and management of a likely facet-related presentation of non-specific low back pain, without over-medicalising.

Subjective triage

Localised, often one-sided low back pain, sometimes referring to the buttock or thigh above the knee.
Aggravated by extension, standing still and turning; eased by flexion and sitting.
Brief stiffness in the morning or after rest.
No dermatomal leg symptoms or neurological change.

Feature	Lumbar facet-mediated pain	Lumbar radiculopathy
Pain referral	Back, buttock, thigh — rarely below the knee	Leg-dominant, below the knee
Paraesthesia	Absent	Often present in a dermatome
Neural tests	Negative	Often positive
Aggravating	Extension and rotation	Flexion, sitting, coughing

Screen for serious pathology and inflammatory features, then reassure. Most low back pain is non-specific.

Refer only when red flags or failure to progress warrant medical review.

1
History
Right-sided low back pain, worse standing at work and reaching overhead.
2
Pattern
Localised, extension-provoked pain without leg symptoms suggests a somatic source.
3
Objective finding
Pain on extension–rotation; neurological examination and neural tests normal.
4
Diagnostic decision
Non-specific low back pain with facet-related features: education and progressive exercise.

Is the extension–rotation (quadrant) test diagnostic?

No single test confirms facet pain. Use test clusters with the history, and treat the patient as non-specific low back pain.

Should I tell patients their facet joints are ‘worn’?

Avoid structural, fear-provoking language. Explain that backs are strong and that pain often settles with movement and graded activity.

What exercise works best?

No single exercise is superior. Choose exercise the patient enjoys and progress the load gradually.