Lumbar Facet Dysfunction & the Use of Mulligans SNAG Technique: A Case Report

Bedard, R, Lazenby, T, Millspaugh, R & Geisler, P (2009). Athletic Training Education Program
Department of Exercise and Sport Sciences

Facet Joint Function:

Background:

To guide & limit movement of a spinal segment

Lumbar spine facet joints:
Prevent significant rotation in the transverse plane
Permit flexion & extension in the saggital plane
Permit minimal lateral flexion

18 y. o., female collegiate volleyball player presented with

chronic low back pain x 4 yrs
Prior treatment unsuccessful alleviating symptoms
Impact landing increased low back pain
Physical Exam:
PTP over L. SI jt, sacrum, & L4-5 facets
R. inominate anteriorly rotated
Pain with trunk flex, ext, & combined ext/rot
movements bilaterally
(+) Stork Standing Test bilaterally
(-) SLR bilaterally
(-) Radiculopathy bilaterally

Differential Diagnosis:
L4-5 Lumbar Spine Facet Joint

Facet Joint Anatomy

Facet Joint Injury Theories:

Both theories may cause pain and reflex muscle spasms
Entrapment Theory:
Joint meniscoid becomes trapped within the joint
Extrapment Theory:
Joint meniscoid becomes trapped within the
subcapsular space, pinched between the capsule and
bony lip

Uniqueness:
Use of a weight bearing manual mobilization technique that
incorporates movement, while the mobilization force is
applied to restore facet joint mechanics

Intervertebral disc lesion

Facet sprain
Spondylolysis
Spondylolisthesis
SI Joint Sprain
Muscle strain/imbalance

Case Management:
Initial Management:
Ice & IFC E-stim for pain management post activity
Muscle Energy techniques to correct SI alignment issues
Lumbopelvic core stability training & progression
Reassessment after 1 wk w/no Improvement:
Suggested facet jt involvement
Initiated SNAGs for L4-5 superior facet
Muscle Energy & Core Stabilization
Noted decrease in Sx & Pt. participated w/minimal pain
Ice and e-stim post activity

Facet Gliding with Spinal Movement

SNAGs Performed in a Sitting Position

Mulligans Sustained Natural Apophyseal

Glides (SNAGs):
Provide a sustained superior glide to the superior articular
facet while patient moves through painful motion
Functional technique, as the facet is bearing weight
Can be performed seated or standing
Motion must be pain-free for technique to be successful

Outcome:

Pain-free AROM restored immediately w/mobilization

Pt returned to play effectively w/decreased symptoms
Sx managed for remainder of season utilizing technique
coupled w/core strengthening w/TA emphasis

Conclusions:

Applied mobilizations released entrapped meniscoid w/in the jt

Once pain generator is released, normal function returns-->
muscle spasms resolve
Facet jt dysfunctions respond well to the Mulligan SNAG
technique

References:

Mulligan, B. R. (2004). The Lumbar Spine. In Manual Therapy: "NAGS", "SNAGS", "MWMS" etc. (5th
ed., pp. 42-53). Wellington, New Zealand: Plane View Services Ltd. (Original work published 1989)
Exelby, L. (2001, February). The Locked lumbar facet joint: intervention using mobilizations with
movement. Manual Therapy, 6(2), 116-121. doi: 10.1054/math.2001.0394