Zygapophyseal or facet joints are synovial diarthrotic plane joints that are formed by the articulation of the inferior

articular process of the superior vertebrae and the superior articular process of the inferior vertebrae. Facet joints
are the cornerstone of the formation and function of the three joint complex which facilitates spinal functioning. The
three joint complex is comprised of interconnected paired facet joints and a vertebral body and function to stabilize
the spine whilst allowing mobility (Alexander C.E, Varacallo M 2019) (Perolat et al. 2018) (Hancock et al 2007) ( Lyle
et al 2005).

According to Stuber et al. 2014, facet joint pain is defined as pain that originates from any of the structures related
to the facet joint, this includes the facet joint itself, joint capsule and synovial membrane. Pain in these structures
typically results a subjective referred pain phenomenon which involves dull, deep, diffuse type pain due to changes
in structural integrity. While alternate presentations include localised pain in the associated spinal region where the
dysfunction is present, this pain is typically unilaterally located and is aggravated when the facet joints are loaded,
such as during spinal extension or during compression caused by force through a superior to inferior vector
(Alexander C.E, Varacallo M 2019) (Perolat et al. 2018) ( Lyle et al 2005) (Manchikanti et al 2004).

There was a lack of quantity and quality of orthopaedic tests for the spinal facet joints found in the literature of
scientific peer review journals. This gap in scientific evidence is a concern for the chiropractic profession due facet
joint dysfunction having a prominent place in education and clinical practice. The clinical usefulness of any
orthopaedic test is largely determined by the accuracy with which it identifies the target tissue by either by
stretching, compressing or contracting certain tissue structures ( Simpson et al. 2006) The ideal orthopaedic test
would always provide true-positives and true-negatives. It is, therefore, necessary to consider sensitivity and
specificity of the tests in question. Where sensitivity is the proportion of those with the disorder in whom the test
result is positive. While specificity is the proportion of those without the disorder in whom the test result is negative
( Simpson et al. 2006).

When considering the orthopaedic tests found through research that create the greatest load on the facet joint they
include combinations of extension, lateral flexion and rotation with kemps test variations being most common along
with P-A springing (Triano et al. 2013) (Hestbaek et al. 2009) (Stuber et al. 2014). Although no specific sensitivity and
specificity could be found for either of these tests; in a journal in the chiropractic & manual therapies data base
reported the validity of provocation of pain by movement and seated forced extension with added manual pressure
had ranges of sensitivity (0.22–0.44), specificity (0.98–1.0), depending on the direction of movement and suggested
that moving the spine through these orthopaedic manoeuvres is favourable (Triano et al. 2013).

The Kemp’s test is typically described as having a patient perform a combination lateral flexion, rotation and
extension of the spinal region of interest, with a positive test defined as a reproduction of the patient’s pain (Stuber
et al. 2014) Currently, the literature supporting the use of the Kemp’s test is limited and indicates that it has poor
diagnostic accuracy as no reliable specificity and sensitivity could be located. Therefore, it is debatable whether
clinicians should continue to use this test as the research indicates that the value of a positive Kemp’s test in
diagnosing facet joint pain is highly dubious (Stuber et al. 2014) This topic is controversial and despite the lack of
evidence, it is interesting that a recent survey of Canadian chiropractors stated that they “often/almost always” use
the Kemp’s test as a diagnostic procedure for the facet joints of the cervical spine (82.4%), thoracic spine (69.8%),
and lumbar spine (82.2%) (Stuber et al. 2014) Along with a workshop held in conjunction with the 2008 annual
congress of The European Chiropractors Union, revealed that majority of the chiropractors in attendance suggested
that a positive Kemp’s test would aid in diagnosing facet syndrome (Stuber et al. 2014) This was contradicted in a
recent survey of faculty members of an American chiropractic college, nearly half of the respondents disagreed with
the statements: “A positive Kemp’s test is a strong indicator that facet syndrome is present” and “A negative Kemp’s
test is a strong indicator that facet syndrome is not present” (Stuber et al. 2014). Due to this contradicting
information found from research it shows that further research is required to obtain the clinical effectiveness in
using a kemps test to diagnose a facet joint in lesion.

P-A Springing: simply involves the clinician applying posterior-to-anterior (P-to-A) pressure to the region of the spine
loading the facet joints as the patients lies prone to create segmental extension in order to reproduce familiar pain
and symptoms. No sensitivity or specificity was found for this orthopaedic test and dependent on the ability to
reproduce pain on provocation and under some research was considered a chiropractic special test (Hestbaek et al.
2009).
Due to this lack of evidence it is suggested that over-reliance on a single orthopaedic test is not appropriate due to
the lower quality within the metrics of sensitivity and specificity. A known way to improve the clinical diagnostic
process where sensitivity and specificity lacks is to cluster orthopaedic tests and to use these clusters to either rule in
or out differential pathologies( Simpson et al. 2006) (Florkowski 2008) ( Hegedus et al 2015). Although, from
research there is no specific orthopaedic test cluster that is known to help differentiate into a likely diagnosis of
facet joint in lesion. Due to facets being loaded in many orthopaedic tests, other tests to rule out differential
diagnosis maybe lead to a likely diagnosis of a facet joint dysfunction. As a result of little to no research for any
particularly excellent tests, it is also important to recognise that our clinical impressions will not be just gained
through orthopaedic tests as it will be conducted after a thorough history, followed by GORP with paying particular
attention to range of motion and palpation regarding facet dysfunction.

Due to this lack of research there is no ‘gold standard’ orthopaedic exam that can be implemented to confidently
identify and diagnose facet pain. Therefore, one should continue to base clinical impressions on multiple tests and a
thorough history ( Simpson et al. 2006). According to chiropractic and manual therapies database five or more of the
following criteria have been indicated to have a positive likelihood ratio of 9.7 and negative likelihood ratio of 0.17,
these include age greater than 50 years, pain in the paraspinal region, absence of pain when moving from sitting to
standing position, pain that is relieved when sitting or walking, in addition to the diagnosis of disc derangement
being investigated and disproven in conjunction with a positive kemps test (which is only possible in the lumbar
spine) (Triano et al. 2013). This clearly demonstrates the importance of conducting a through history and
investigating location, aggravating and relieving factors.