The most common cause of lasting neck pain is invisible on every scan you have had.

CERVICAL FACET SYNDROME

The most common cause of persistent neck pain is a structure that does not appear as a cause on any scan you have had. That is not a gap in the imaging. It is what facet pain is.

What the facet joints do

Behind each disc, at every level, sit two small paired joints that guide and limit movement. They are true synovial joints with a capsule and a nerve supply, and like any joint they can become a pain source — from arthritis, from repeated loading, or from a whiplash event that strained the capsule.

Studies using controlled diagnostic blocks put facet joints among the leading sources of chronic neck pain, with prevalence rising with age. In a population that has had neck pain for months, this is the structure to think of first.

What it feels like, and the map that gives it away

Facet pain is axial — in the neck itself rather than down the arm — and each level refers in a reasonably consistent pattern that has been mapped experimentally.

• C2-3 — into the back of the head. This is the classic cervicogenic headache level.
• C3-4 — the upper neck and the base of the skull.
• C4-5 — the base of the neck and the top of the shoulder.
• C5-6 — over the shoulder blade and the supraspinous fossa. Commonly mistaken for a shoulder problem.
• C6-7 — lower, toward the spine of the scapula.

It is usually worse with extension and rotation — reversing the car, looking up — and eased by sitting still with support. It does not produce numbness or true weakness. When those appear, the diagnosis is a nerve root, not a facet.

Why your imaging did not find it

Facet arthropathy is visible and is not the same thing as facet pain. It is present in most people over fifty and in plenty who have never had a symptom. Meanwhile a facet joint can generate substantial pain while looking unremarkable.

So the scan has no useful correlation in either direction. This is the single hardest idea to accept after a year of being told the imaging shows nothing serious, and it is why the diagnosis is made with a block.

How it is treated, in order

First, load and movement. Deep cervical flexor work, restoring rotation, and reducing the sustained-extension exposures that provoke it. A meaningful share of people do not need anything else.

Where that plateaus, the question becomes whether the facets are confirmed as the source. If they are, radiofrequency neurotomy is the durable option and the evidence supports it in that selected group. Intra-articular steroid has weaker support and a shorter effect, and we will say so rather than offer it as an equivalent.

What we will not do

We will not ablate on imaging. We will not treat axial neck pain as facet pain because it sounds like it. And we will not run a series of intra-articular injections into a joint that has never been confirmed, which is a common and expensive pattern.

Whiplash, and why these joints come up so often afterward

The facet capsules are strained in the rapid extension-flexion of a collision, and the cervical facet joints are the most frequently identified source of chronic pain after whiplash when controlled diagnostic blocks are used to look for it.

That is a specific and useful fact for anybody carrying neck pain from a crash that “should have settled”. The structure most likely responsible is the one that does not appear on the imaging that reassured everybody.

Two different injections, frequently confused

An intra-articular injection puts steroid inside the joint. A medial branch block anesthetises the nerves supplying it. They sound interchangeable and are not: the block is diagnostic and leads somewhere, the intra-articular injection is therapeutic and has weaker and shorter-lived support in the cervical spine.

If you have had “facet injections” that helped briefly and then stopped, it is worth establishing which of the two you actually had. It changes what the result meant.

What the loading work actually is

Deep cervical flexor endurance training, restoring rotation into the range that provokes it rather than avoiding that range, and scapular work where the shoulder blade has stopped contributing. Progressed weekly, measured, and boring.

A meaningful proportion of people with facet-mediated pain do not need anything else, which is why this comes before any conversation about blocks. What it cannot do is reach a joint that has become an established pain generator — and telling those two groups apart is what the diagnostic question is for.

Why it is worse in the morning for some and the evening for others

Morning stiffness that eases within thirty minutes is typical of a degenerate joint. Pain that builds through the day points at load and cadence rather than at the joint surface. Morning stiffness lasting well over an hour, particularly with other joints involved, is a different question entirely and belongs with rheumatology.

What people ask about facet pain

If it does not show on a scan, how do you know it is real?

By anesthetising the nerves that supply the joint and watching the pain go. That is a positive test rather than an absence of findings, and it is more specific than anything imaging offers for this structure. What a diagnostic block proves.

Is facet pain the same as arthritis in my neck?

Not quite. Arthritis is what the joint looks like; facet pain is what it does. Plenty of arthritic facets are silent and some painful ones look normal. How a cervicogenic headache is identified.

Can it cause headaches?

Yes, and commonly. The C2-3 joint in particular refers into the back and top of the head, and it is one of the more treatable causes of a headache that has been managed as migraine for years. What ablation does to the nerve.

Will physical therapy fix it?

It genuinely helps a proportion of people and it is the right first move. What it cannot do is reach a joint that has become an established pain generator, which is where the diagnostic question starts. Which exercises help, and which make it worse.

Related reading

• Diagnostic medial branch block
• Radiofrequency neurotomy
• Cervicogenic headache
• Why your MRI is normal
• Whiplash that never finished
• Is it my neck or my shoulder?

Facet pain after a collision is the most common version of this, and it has its own page: after a collision.

Facet joints are paired, which is why the side your pain is on narrows the structure before anyone has examined you. It is also the usual answer to why a neck cracks in the first place.