Thursday, November 02, 2006

Cervical Facet Syndrome

The damage Nytro has done to my manly physique has now been properly diagnosed. (Yeah, yeah, I know she accuses me of overtraining, but acceptance of responsibility is not how I roll.)
I went back to the Greatest Intergalactic Sports Chiro Group In The Universe yesterday and put additional brains on the problem. Doc JD moved me around, carefully listened to the subtle nuances of the pain that Nytro has inflicted, and put his finger right on the problem:
Cervical Facet Syndrome in the facet between c-6 and c-7.
NOT an overuse injury that is a function of overtraining, per se (take that Nytro, Maria Gratia and all the doubters who poo-pooed my heroic volume), but more a function of acute irritation and over-extension as from a bad bike fit. (That's my story and I'm sticking to it.) So let this be a lesson to all: if you hurt on your bike, GET FITTED. I am paying a whole lot more at the Chiros than I would have paid for a proper bike fit.
The technical lowdown can be found in an article by Robert E Windsor, MD, FAAPMR, FAAEM, FAAPM, President and Director, Georgia Pain Physicians PC; Clinical Associate Professor, Department of Physical Medicine and Rehabilitation, Emory University, which is excerpted below:

In 1933, Ghormley coined the term facet syndrome to describe a constellation of symptoms associated with degenerative changes of the lumbar spine (Ghormley, 1933). Recently, the term cervical facet syndrome has appeared in the literature and implies axial pain presumably secondary to involvement of the posterior elements of the cervical spine.

Many pain generators are located in the cervical spine, including the intervertebral disks, facet joints, ligaments, muscles, and nerve roots. The facet joints recently have been found to be a possible source of neck pain, and the diagnosis of cervical facet syndrome is often one of exclusion or not considered at all. Clinical features that are often, but not always, associated with cervical facet pain include tenderness to palpation over the facet joints or paraspinal muscles, pain with cervical extension or rotation, and absent neurologic abnormalities (Fukui, 1996). Imaging studies usually are not helpful, with the exception of ruling out other sources of pain, such as fractures or tumors.

Patients with cervical facet joint syndrome often present with complaints of neck pain, headaches, and limited range of motion (ROM). The pain is described as a dull aching discomfort in the posterior neck that sometimes radiates to the shoulder or mid back regions. Patients also may report a history of a previous whiplash injury to the neck.

Clinical features that often, but not always, are associated with cervical facet pain include tenderness to palpation over the facet joints or paraspinal muscles, pain with cervical extension or rotation, and absent neurologic abnormalities.

Each facet joint seems to have a particular radiation pattern upon painful stimulation. Even in subjects without neck pain, stimulation of the facet joints by injecting contrast material into the joints and distending the capsule produces neck pain in a specific pattern corresponding to the specific joint. . . . The C6-C7 joint refers pain to the top and lateral parts of the shoulder and extends caudally to the inferior border of the scapula.

Kibler et al have defined 3 phases of rehabilitation of soft tissue injuries (Cole, 1998). The goals of the first phase are to reduce pain and inflammation, and increase the pain-free ROM. Ice is indicated during the acute phase to decrease blood flow and subsequent hemorrhage into the injured tissues, as well as reducing local edema. Application of ice also can reduce muscle spasm. Therapeutic modalities such as ultrasound and electrical stimulation may also reduce painful muscle spasms as well. Manual therapy, joint mobilization, soft tissue massage, and muscle stretching often are helpful. Passive range of motion (PROM) and then active range of motion (AROM) exercises in a pain-free range should be initiated in this phase. Finally, strengthening should begin with isometric exercises and progress to isotonic as tolerated.
Recovery Phase Rehabilitation Program Physical Therapy Patients should transition into the recovery phase of rehabilitation when they are nearly pain free. The goals of this phase are to eliminate pain and further increase ROM, strength, and neuromuscular control. Manual therapy with soft tissue massage and mobilization still may be required, but emphasis is placed on improving strength, flexibility, and neuromuscular control.
Maintenance Phase Rehabilitation Program Physical Therapy Patients are ready for the final phase of rehabilitation after they have achieved full and pain-free ROM, and a significant improvement in strength. The goals of the maintenance phase are to balance strength and flexibility, and to increase endurance.
Nonsteroidal anti-inflammatory drugs (NSAIDs) are helpful in reducing pain and inflammation, and cyclo-oxygenase (COX-II) inhibitors have been introduced as options that cause less gastric irritation. Tricyclic antidepressants, such as amitriptyline and doxepin, and some antiseizure medications, such as gabapentin, carbamazepine, and divalproex, are useful in alleviating neuropathic pain. Non-narcotic and narcotic pain medications may be needed for moderate to severe pain. Muscle relaxants, such as baclofen and tizanidine, are very helpful in reducing the associated muscle spasm that often accompanies facet pain. If the patient is having problems sleeping, then a short course of a sleeping aid, such as zolpidem, temazepam, and zaleplon may be of benefit.

Return to play is an individualized process for athletes with cervical facet joint syndrome. No specific time frame exists for a particular injury. Safe return to play is allowed after the appropriate sport-specific rehabilitation program is completed and the athlete demonstrates full pain-free ROM and proper neutral spine posture with sport-specific activities.


Brent Buckner said...

Thanks for the pointer re: importance of bike fit.

I hope you respond to treatment quickly and well!

Wendy said...

Diagnosis is half the battle! Follow the treatment plan as you would your training plan and I'm sure you'll be back in action in no time!

(I'm sure that your facet problem does relate to bike fit, but facet joint syndrome is also secondary to arthritis. No need to ask how I know!)

Laurie said...

Any estimation as to when you will be back to your normal tri-ing self?

Veeg said...

G-Dawg, I think you just broke my brain.

the Dread Pirate Rackham said...

holy cow. all I saw was "muscle spasm" and "drugs" and "syndrome." it doesn't sound fun. thanks for throwing yourself on that sword for our benefit.

greyhound said...

Laurie, in answer to your question, the relief that I got from Doc JD, Mistress Arlene (the sadistic massage therapist) and the proper use of ice has been remarkable. Sitting at my desk, my neck feels almost normal, and most of the shoulder pain is gone.

I am now able to run with only mild (medicated) discomfort. I will not try to swim or lift weights until I am totally pain free. I am hoping that will be within a couple of weeks. Last will be a bike fit before getting back on my steed. I may have to do the road bike for awhile before taking to the aero bars.

Flatman said...

sounds VERY painful and bad. take it easy, bro. you need to FULLY heal before easing back into this whole deal. you'll be glad you took some time off in the long run.

21st Century Mom said...

That sounds remarkably like what I have suffered in the past. I continue to have poor ROM in my neck and upper back but I never really tried to fix it, either.

I'm glad you are on the mend.

Geek Girl said...

Just goes to show, even the tiniest mal adjustment, when multplied over many miles and hours, can cause chaos. Get well soon!

JohnnyTri said...

Great Write up on Facet Syndrome! Thanks. Being a fellow chiro I get adjusted regularly to keep all them bones greased up, helps alot.

Sasha said...

I want to tell about nice exercise complex named as Isometric Exercises.
I use them for one year and I feels very good. It takes only 20 minutes per day.
You can check Isometric exercises at