Lumbar Facet Dysfunction & the Use of Mulligan’s SNAG Technique: A Case Report Bedard, R, Lazenby, T, Millspaugh, R & Geisler, P (2009). Athletic Training Education Program Department of Exercise and Sport Sciences

Background:   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:   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

Uniqueness:  Use of a weight bearing manual mobilization technique that

incorporates movement, while the mobilization force is applied to restore facet joint mechanics

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

SNAGs Performed in a Sitting Position

L4-5 Lumbar Spine Facet Joint

Facet Gliding with Spinal Movement

Facet Joint Function:   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

Mulligan’s 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

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

Facet Joint Anatomy

  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

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