Therapeutic Exercise II (PTA 1010) - Foot and Ankle PDF

Therapeutic Exercise II PTA 1010 The Ankle and Foot  Road Map By the end of this presentation the student will be able to: Identify important aspects of the structure and function of the ankle and foot for review Implement a therapeutic exerci...

Therapeutic Exercise II PTA 1010 The Ankle and Foot  Road Map By the end of this presentation the student will be able to: Identify important aspects of the structure and function of the ankle and foot for review Implement a therapeutic exercise program to manage soft tissue and joint lesions in the ankle and foot related to stages of recovery after an inflammatory insult to the tissues Discuss the benefits and limitations of a total ankle arthroplasty versus arthrodesis of the ankle for the patient with RA Demonstrate exercise progressions to develop and improve ROM, muscle performance, and functional use of the ankle/foot and proximal LE regions 2 © Stanbridge University 2023  Anatomy and Ankle Arthrokinematics Hypomobility Post op: TAA and Tendinopathies Arthrodesis Ligamentous Shin Splints Injuries © Stanbridge University 2023 3  Bones of the Ankle & Foot A. Posterior View B. Medial C. Lateral © Stanbridge University 2023 4  Bones of the Ankle & Foot Hindfoot (Rearfoot): talus, calcaneus Midfoot: navicular, cuboid, 3 cuneiforms Forefoot: 5 metatarsals, 14 phalanges © Stanbridge University 2023 5  Anatomy Tibio-fibular Joints Superior & inferior Provide accessory motions to allow for greater motion at the ankle Distally: tibia and fibula make up the proximal surface of the talocrural joint 6 © Stanbridge University 2023  Anatomy Talocrural Joint: Supported medially by the deltoid ligament Supported laterally by the lateral collateral ligament: -Anterior talo-fibular ligament -Posterior talo-fibular ligament -Calcaneofibular ligament Arthrokinematics: (OKC) With Dorsiflexion there is an posterior glide of talus With Plantarflexion there is an anterior glide of talus 7 © Stanbridge University 2023  Medial foot DELTIOD LIGAMENT 8 © Stanbridge University 2023  Lateral Foot 9 © Stanbridge University 2023  Functional Anatomy Tri-planar motions: Supination: PF, calcaneal inversion, forefoot adduction -During WB: increased arch of the foot -Locking of the midfoot: stability in mid→ terminal stance Pronation: DF, calcaneal eversion, forefoot abduction -During WB: lowering of the arch of the foot -Unlocking of the midfoot: shock absorption in weight acceptance 10 © Stanbridge University 2023  Anatomy Transverse Tarsal Joint Talo-navicular Joint Calcaneo-cuboid Joint Participates in the tri-planar supination and pronation motions of the midfoot -abduction/adduction -inversion/eversion -dorsal/plantar gliding 11 © Stanbridge University 2023  Anatomy Intertarsal and Tarsometatarsal Joints Metatarsalphalangeal Joints Interphalangeal Joints of the toes 12 © Stanbridge University 2023  Anatomy and Ankle Arthrokinematics Hypomobility Post op: TAA and Tendinopathies Arthrodesis Ligamentous Shin Splints Injuries © Stanbridge University 2023 13  Joint Hypomobility RA, JRA OA/ DJD Trauma Joint reactions after dislocation Fracture Post-immobilization Gout (usually affects MTP of the great toe) © Stanbridge University 2021 14 © Stanbridge University 2023  Joint Hypomobility: Common Impairments & Functional Limitations Decreased joint play, capsular end feel Swelling Painful, restricted motion Muscle imbalance Muscle weakness, decreased muscle endurance Impaired balance, postural control Increased frequency of falling Painful weight bearing, gait deviations © Stanbridge University 2021 15 © Stanbridge University 2023  Joint Hypomobility: Management Acute and Subacute Phase: Education: HEP, activity modification, gait training ROM: daily PROM, AAROM Shoe wear Bracing, orthotics Assistive device Grade I, II joint mobilization Aquatic therapy Muscle setting 16 © Stanbridge University 2023  Mobility Exercises How are these two mobility exercises for DF different? 17 © Stanbridge University 2023  Joint Hypomobility: Management Subacute and Chronic Phases: Grade III, IV joint mobilization, MWM Stretching Strengthening, endurance, muscle performance exercises Balance and proprioception Cardiopulmonary Fitness 18 © Stanbridge University 2023  Mobilization with Movement: MWM To Increase PF To Increase DF 19 © Stanbridge University 2023  Review Describe what motions occur with calcaneal inversion and eversion. What is appropriate treatment options in the acute phase of ankle hypomobility and what limitations do each address? What are appropriate treatment options in the subacute phase of ankle hypomobility and what limitations do each address? 20 © Stanbridge University 2023  Anatomy and Ankle Arthrokinematics Hypomobility Post op: TAA and Tendonopathies Arthrodesis Ligamentous Shin Splints Injuries © Stanbridge University 2023 21  Joint Surgery and Postoperative Management Total ankle replacement arthroplasty Arthrodesis at the ankle and foot 22 © Stanbridge University 2023  Total Ankle Arthroplasty (TAA) Indications: Severe, persistent pain during WB, compromising function Post- traumatic DJD, OA, RA, AVN of the talus Sufficient ankle stability (ligaments intact) Flexible deformity Failure of prior conservative care, surgeries 23 © Stanbridge University 2023  Total Ankle Arthroplasty Late-Stage Arthritis 24 © Stanbridge University 2023  Total Ankle Arthroplasty (TAA) Immobilization: 0-6wks; time varies based on complexity of surgery – Check MD referral for WB and ROM restrictions Maximum protection phase: – Re-establish independent ambulation and functional mobility – Minimize atrophy of ankle and foot muscles of the operated limb Muscle setting exercises of the ankle musculature while in the immobilizer – Prevent stiffness of the operated ankle and foot 25 © Stanbridge University 2023  Total Ankle Arthroplasty (TAA) Moderate and minimum protection phases: – Achieve 100% of ROM obtained intraoperatively – Restore strength, muscular endurance and balance in the lower extremities for functional activities Low intensity high repetition open chain and closed chain exercises – Improve aerobic capacity and cardiopulmonary endurance – Resume safe level of work-related and recreational activities – Can return to low demand and, at times, moderately demanding fitness activities 26 © Stanbridge University 2023  Arthrodesis Fusion of ankle or one or more joints of the foot and toes Most used surgery for late-stage arthritis Indications: debilitating pain especially with WB, marked instability, deformity, salvage procedure after failed TAA, patients with high functional demands and pain free compensatory motion in adjacent joints Bone grafts coupled with internal fixation devices 27 © Stanbridge University 2023  Arthrodesis Management Check op report/ protocol Determine WB status Limitations/precautions dependent on joint being fused (DO NOT stretch what is fused) Stretch/Exercise surrounding joints Advance per protocol- PROM, AROM, WB activities 28 © Stanbridge University 2023  Anatomy and Ankle Arthrokinematics Hypomobility Post op: TAA and Tendinopathies Arthrodesis Ligamentous Shin Splints Injuries © Stanbridge University 2023 29  Overuse (Repetitive Trauma) Syndromes: Non-operative Management Related pathologies and etiology of symptoms Common impairments and functional limitations and disabilities Overuse syndromes: management—acute phase Overuse syndromes: management—subacute and chronic phases 30 © Stanbridge University 2023  Tendinitis vs. Tendonosis “Itis” versus “opathy”: What does this mean? -Itis -Osis Sharp localized pain with activity (a.m., Constant, dull, non-localized pain after prolonged rest) Worse with activity Pain may decrease with activity and Palpable enlargement worsen with rest Dysfunction without pain Swelling Local tenderness Warmth 31 © Stanbridge University 2023  Plantar Fascitis Function of Plantar fascia: 1. Provides ligamentous support of the longitudinal and transverse arches of the foot 2. Tightening assists with initiating swing phase of gait www.mayoclinic.org 32 © Stanbridge University 2023  Plantar Fascitis I Many histological studies have shown a lack of inflammation: corticosteroid injections won’t help Martin et al, JOSPT, 2014 -Injections can lead to fat pad atrophy & fascial rupture 33 © Stanbridge University 2023  Plantar Fascitis Predisposing factors: Lower longitudinal arch height high loading rates High arch foot with decreased pliability (Pes Cavus) 34 © Stanbridge University 2023  Plantar Fascitis Symptom Pattern for Plantar heel pain Usually worse in the morning and Early morning at beginning of the day After tissue Decreases as activity progresses warms up Worsens again with prolonged Later in day/activity weight bearing or at end of the day 35 © Stanbridge University 2023  Plantar Fascitis Signs and Symptoms: Sharp heel pain at origin of plantar fascia (medial tuberosity of the calcaneus) – Plantar heel pain when standing after prolonged sitting – Plantar heel pain 1st thing in the morning Decreased DF ROM Positive windlass test 36 © Stanbridge University 2023  Plantar Fascitis www.physio-pedia.com www.dltpodiatry.co.uk 37 © Stanbridge University 2023  Plantar Fascitis: Management Acute phase Reduce pain & inflammation: rest, ice, NSAID Sleep prone: feet off the bed or over large pillow Night splint A Take first few steps with the great toe up A Taping: arch of the foot, etc. A Orthotics or support sandals: always when WB Calf stretching A 38 © Stanbridge University 2023  Plantar Fascitis Management Sub-acute and Chronic Phases AROM & Stretch prior to getting out of bed -DF with great toe up Plantar fascia stretching Restore strength and flexibility (foot extrinsic and intrinsic muscles) Balance training Functional activities (Stairs, Running, plyometrics) Manual Therapy- Joint and soft tissue mob 39 © Stanbridge University 2023  Plantar Fasciitis- Evidence Martin et al, JOSPT, 2014 A Manual Therapy A Stretching A Taping A Foot orthoses A Night splints C Footwear E Education and counseling for weight loss F Therapeutic exercise and neuromuscular reeducation 40 © Stanbridge University 2023  Achilles Tendinopathy Achilles: largest & strongest tendon in the body Role in WB: decelerates ankle DF & sub-talar pronation www.dubinchiro.com 41 © Stanbridge University 2023  Achilles Tendinopathy Tendons: low metabolic rate: slower healing → initial rest period important for recovery Hypovascular zone: 5-6 cm above insertion into calcaneus (histological changes: middle aged males) Microscopic anatomy: fibers continuous www.researchgate.net with fibers of plantar fascia 42 © Stanbridge University 2023  Causes: Achilles Tendinopathy INTRINSIC FACTORS EXTRINSIC FACTORS Leg length differences Overuse Genu varus, valgus Training errors Ankle DF ROM deficits Faulty equipment, shoes Abnormal subtalar Joint motion: high Playing surfaces arch, low arch Improper recovery Decreased calf strength Repetitive, asymmetric specialized Age, Gender (M>F) training Colder temperature 43 © Stanbridge University 2023  Management 1. Identify and correct causative factors: – Structural mal-alignment (rearfoot, forefoot, 1st ray) – Training errors – Changes to footwear or terrain 2. Rest & modalities if has acute presentation 3. Stretches (support midfoot if has a low arch) 4. Passive support: orthotics, heel lift, taping, night splints 44 © Stanbridge University 2023  Management A Exercise: ECCENTRIC LOADING Sub-acute phase of healing Begin OKC, progress to CKC Heel raises on ground -DL heel raise →SL lower Heel raises off step to increase ROM and amount of eccentric load Plyometrics 45 © Stanbridge University 2023  Achilles Tendonitis- Evidence Carcia et al, JOSPT, 2010 A Eccentric Loading C Stretching C Foot orthoses C Night splints D Heel lifts F Manual therapy F Taping 46 © Stanbridge University 2023  Posterior Tibialis Tendinopathy Incidence Recent study found that tendinopathy is more common than osteoarthritis (11.8 per 1000 people vs 8.4 per 1000 persons) Common sites gluteal tendinopathy (4.22) Achilles' tendinopathy (2.35) Patellar tendinopathy (1.6) Posterior tibialis tendinopathy/ dysfunction (3.33) Plantar fasciopathy (functions like tendon) (2.44) Albers et al. Incidence and prevalence of lower extremity tendinopathy in a Dutch general practice population: a cross sectional study. BMC Musculoskeletal Disorders. Jan 2016 47 © Stanbridge University 2023  Posterior Tibialis Tendinopathy 48 © Stanbridge University 2023  Posterior Tibialis Tendinopathy Causes of overload- tensile and contractile Posterior tibialis has a major role in controlling pronation via eccentric contraction Can be overloaded with increased activity, running frequency and or speed, weight, poor footwear 49 © Stanbridge University 2023  Posterior Tibialis Tendinopathy Clinical tests/ finding: Tenderness along the posterior tibialis tendon Visible and palpable swelling along the tendon Pain or weakness with isometric contraction of ankle PF and inversion in in neutral Pain or inability to perform a single leg heel raise 50 © Stanbridge University 2023  Posterior Tibialis Tendinopathy Treatment approach: Few RCT on the condition Current practice interventions Treatment for limited endurance to plantar flexors (heel raise) Plantar flexion / inversion strengthening Load management (reducing excessive training)- start with TB Eccentric loading Initially avoid strengthening into maximal DF ROM Proximal strengthening- look at the hip https://www.physio-network.com/research-reviews/ankle-foot/exercise-for-posterior-tibial- tendon-dysfunction-a-systematic-review-of-randomised-clinical-trials-and-clinical- guidelines/mjopensem.bmj.com/content/4/1/e000430 51 © Stanbridge University 2023  Review What are the most effective treatments for plantar fasciitis in the acute and subacute healing phases? What are the intrinsic and extrinsic factors that contribute to achilles tendonitis? What treatment for Achilles tendonitis has the strongest support from the literature? 52 © Stanbridge University 2023  Anatomy and Ankle Arthrokinematics Hypomobility Post op: TAA and Tendinopathies Arthrodesis Ligamentous Shin Splints Injuries © Stanbridge University 2023 53  Shin Splints Condition: pain due to periostitis along tibial border (inflammation at bone- muscle interface) ”exercise related leg pain” Medial tibial stress syndrome: pain along posteromedial border of the distal 2/3 of the tibia -Involved muscles: soleus, FDL, TP Anterior tibial stress syndrome: pain along anterolateral aspect of the shin -Involved muscles: anterior tibialis 54 © Stanbridge University 2023  Shin Splints Predisposing factors: Poor pre-season conditioning Training errors: too much, too soon Foot shape (uncompensated rearfoot, pronated position at neutral) Speed or timing of subtalar joint motion Gender (F>M) Previous injury High BMI 55 © Stanbridge University 2023  Shin Splints Common Presentation: -Pain early in exercise, then subsides -Pain with palpation of affected tissue Treatment: -Identify causes and treat accordingly -Rest -Cross train, change activities, avoid overuse -Orthotics 56 © Stanbridge University 2023  Anatomy and Ankle Arthrokinematics Hypomobility Post op: TAA and Tendinopathies Arthrodesis Ligamentous Shin Splints Injuries © Stanbridge University 2023 57  Ligamentous Injuries: Nonoperative Management Common impairments and functional limitations and disabilities Management: acute phase Management: subacute phase Management: chronic phase 58 © Stanbridge University 2023  Lateral Ankle Sprain MOI: usually PF with Inversion www.drjoeexplains.com www.youcoach.it © Stanbridge University 2023 59  Ankle Sprain: Acute treatment Radiographs Brace / Cast www.seleneparekhmd.com Rehabilitation www.thesportsphysiotherapist.com 60 © Stanbridge University 2023  SPECIAL TESTS www.Medscape.com 61 © Stanbridge University 2023  Ottawa Ankle Rules www.bmj.com 62 © Stanbridge University 2023  Physical Therapy Following Ankle Sprain Residual ROM deficits: -Limited ankle DF may increase rate of ankle injury Underestimating the severity of the injury can lead to: -Chronic Ankle Instability (CAI) -Functional Ankle Instability (FAI) 63 © Stanbridge University 2023  Chronic Ankle Instability (CAI) Occurs in 10-20% (+) of people after an acute sprain Persistent pain, swelling, recurrent sprains for > 6 mo. “Giving Way” (“functional” or “subjective” instability): - neuromuscular deficit - 17-58% of patients after ankle sprain May occur with or without true ligament laxity (“mechanical”, or “objective” laxity) 64 © Stanbridge University 2023  Neuromuscular Changes Following Ankle Sprain Decreased proprioception Arthrogenic muscle inhibition Delayed muscular reaction time (at primary site, secondary sites) Reduced Strength, Altered Muscle Sequencing Impaired Postural Control Altered Lower Limb Movement Patterns ROM deficits 65 © Stanbridge University 2023  Goals of Neuromuscular Training Following Ankle Sprain Optimize lower limb postural control and restore active stability Assist in the prevention of ankle instability and its sequela Safe return to sport/activity 66 © Stanbridge University 2023  Results of Neuromuscular Training and Rehabilitation Research has shown Less pain at 6 weeks Quicker recovery to full ROM Earlier return to activity Decreased instability at 8 weeks in those with severe injuries Fewer re-sprains 67 © Stanbridge University 2023  Phases of Rehabilitation Acute Phase Early Subacute Phase Late Subacute Phase Chronic Phase (Return-To-Sport) (*Phases often overlap*) 68 © Stanbridge University 2023  Acute Phase: Goals Joint Protection Promote Healing Analgesic Effects Antiphlogisic Effects Reduction in Swelling 69 © Stanbridge University 2023  Acute Phase PRICE: -Protection -Rest -Ice -Compression -Elevation NSAIDS: associated with improved pain control, function, swelling, return to activity (adults) 70 © Stanbridge University 2023  Acute Phase Early Weight Bearing and External Support (boots and A strapping techniques): ✓ allows for early NWB exercises, but protects from further stress ✓ decrease residual symptoms ✓ expedite recovery ✓ decreased % with ankle instability ✓ decreased % with ROM loss ✓ time frame highly variable in the literature: 10 days – 6 weeks 71 © Stanbridge University 2023  Acute Phase Semi-rigid braces, lace-up braces, bandages, tape: A -decreased pain, swelling, instability, prevention of recurrent sprain Semi-rigid & lace up braces are more effective than tape or elastic bandage for time to return to sport and decreased incidences of instability 72 © Stanbridge University 2023  Acute Phase Immobilization in Plaster Cast: Reserved for the worst cases due to risk of local irritation, joint stiffness, muscle atrophy, loss of proprioception Considerations: age of the patient, ability to adhere/comply to instructions if not casted, etc. 73 © Stanbridge University 2023  Acute Phase Manual Therapy: B – Lymphatic drainage – Active and Passive soft tissue and joint mobilization (pain free) – Anterior to posterior talar joint mobilization A Therapeutic Exercise (Acute stage appropriate exercises) 74 © Stanbridge University 2023  Early Subacute Phase: ROM A Manual Therapy: immediate improvements in ROM, decreased pain, swelling – Joint mobilization: earlier full ROM into DF, greater increases in stride speed ROM exercises: – Start in the sagittal plane→ progress to multi-planar motion C Initiate balance and strength training: - within guidelines of tissue healing & objective findings - within patient’s tolerance 75 © Stanbridge University 2023  Early Subacute Phase: Strength Training Manual Resistance: -perceived as less traumatic by client -proprioceptive and verbal feedback Exercise contra-lateral ankle and surrounding joints – (can facilitate improvements in injured ankle due to cross over effect) 76 © Stanbridge University 2023  Early Subacute Phase: Strength Training OKC training with resistive bands Proximal muscle strength training: - studies show decreased gluteus maximus muscle activity in severe ankle sprains - address muscle strength deficits that may have contributed to abnormal movement strategies 77 © Stanbridge University 2023  Early Subacute Phase C Balance Training Severe cases: may have to initiate on CL limb through cross-over effect, can get improvements in latency of muscle activation AND/OR Start Seated: single plane tilt board exercises → multi- planar positions 78 © Stanbridge University 2023  Early Phase: Balance Training C Balance Training (Continued): Double leg balance: -modify BOS -progression: unstable surfaces Single leg balance 79 © Stanbridge University 2023  Early Subacute Phase: Functional Training Gait training: with or without an assistive device and/or immobilizer Body Weight Supported Treadmill (BWST) 80 © Stanbridge University 2023  Late Subacute Phase: Goals Reduce proprioceptive deficits Increase strength and endurance Promote neuromuscular performance training 81 © Stanbridge University 2023  Late Subacute Phase: Strength Training Focus is on entire lower quarter and core stability Individualize the program: train the specific movement patterns needed for the particular sport requirements Strong ankle evertors are not enough: inadequate time for pre- activation to prevent forced inversion 82 © Stanbridge University 2023  Late Subacute Phase: Balance Training Single leg balance training: Visual system Unstable surfaces Concentration on an alternative task: athlete must be able to focus on alternative activities without a decrease in postural performance 83 © Stanbridge University 2023  Late Subacute Phase: Balance Training External perturbation: changes in muscular co-contraction, improved muscle recruitment and activation, accelerated anticipatory reactions By end of phase: Balance abilities are task specific and must be retrained relative to their sport 84 © Stanbridge University 2023  Late Subacute Phase: Functional Training Plyometric Activities: Un-weighted positions (BWST, leg shuttles) Double leg → Single leg Forward hopping, lateral hopping, lateral shuffles, carioca, running, cutting, agility drills Endurance Training: fatigue → delayed proprioceptive input →slower reaction time 85 © Stanbridge University 2023  Chronic Phase (Return to Sport) A comprehensive training program incorporating sport or skill-specific exercise, as well as strengthening and neuromuscular training, has been the most successful in allowing for a safe return to sport 86 © Stanbridge University 2023  Chronic Phase (Return to Sport) Controlled → un-controlled situations Coordinate care with athletic trainer and coaches May still require use of a brace during sport if not able to perform tasks safely, or if in a high-risk sport 87 © Stanbridge University 2023  Ankle Sprain- Evidence Martin et al, JOSPT, 2013 Acute Phase – A Early weight bearing with support –B Manual therapy –A Therapeutic exercises Subacute/Chronic Phases – A Manual therapy –C Therapeutic exercise and activities –C Sport related activity training 88 © Stanbridge University 2023  Ankle Sprain- Evidence Meta-analysis of 194 articles January 2009- September 2016 89 © Stanbridge University 2023  90 © Stanbridge University 2023  91 © Stanbridge University 2023  92 © Stanbridge University 2023  93 © Stanbridge University 2023  Review What are the two types of shin splints and what overuse motions would cause each type to occur? Why is proprioception affected after an ankle sprain? What is the best intervention for an ankle sprain in the acute phase of tissue healing? Subacute phase? 94 © Stanbridge University 2023  EXERCISES FOR THE FOOT & ANKLE 95 © Stanbridge University 2023  Flexibility and Strengthening Exercises Gastrocnemius Stretch Resisted ankle DF Towel roll to allow the calcaneus to follow arc of motion 96 © Stanbridge University 2023  Strengthening Exercises Inversion Eversion Place a ball between and squeeze with knees to prevent hip abd./ add. 97 © Stanbridge University 2023  Calf Strengthening Exercises Weight Bearing Progressions: Double leg Up with 2 legs, transition weight to one, lower on one Single leg www.HEP2go.com 98 © Stanbridge University 2023  Single Leg Balance (L) With: Opposite hip flexion Opposite hip horizontal adduction www.HEP2go.com © Stanbridge University 2023 99  Balance Exercises (single leg) www.jospt.org 100 © Stanbridge University 2023  Steamboats www.skimble.com 101 © Stanbridge University 2023  Steamboats: SL balance with opposite hip adduction 102 © Stanbridge University 2023  Steamboats: SLB with opposite hip abduction 103 © Stanbridge University 2023  Steamboats: SLB with opposite hip extension 104 © Stanbridge University 2023  Steamboats: SLB with opposite hip flexion 105 © Stanbridge University 2023  SL balance: unstable surface www.anklesprainmanagement.weebly.com 106 © Stanbridge University 2023  SL balance with sport cord perturbation www.stack.com www.jospt.org 107 © Stanbridge University 2023  Dynamic Stability: Resisted lateral stepping with squat www.athletico.com 108 © Stanbridge University 2023  Step Up with SL balance: Dynamic stability www.HEP2go.com 109 © Stanbridge University 2023  Resisted Lateral Shuffle www.popworkouts.com www.stack.com 110 © Stanbridge University 2023  Lateral Hop: Single Limb Stability www.girlsgonesporty.com 111 © Stanbridge University 2023  Lateral Bounding www.crossroadsoffitness.com www.fitnessfound.blogspot.com 112 © Stanbridge University 2023  Lateral Lunge to SL balance www.magazine.nasm.org 113 © Stanbridge University 2023  SAID Principle Create balance exercises that mimic the load in at the ankle in the sport or activity www.jospt.org 114 © Stanbridge University 2023  Road Map At this point the student should be able to: Identify important aspects of the structure and function of the ankle and foot for review. Implement a therapeutic exercise program to manage soft tissue and joint lesions in the ankle and foot related to stages of recovery after an inflammatory insult to the tissues. 115 © Stanbridge University 2023  Road Map Discuss the benefits and limitations of a total ankle arthroplasty versus arthrodesis of the ankle for the patient with RA. Demonstrate exercise progressions to develop and improve ROM, muscle performance, and functional use of the ankle/foot and proximal LE regions. 116 © Stanbridge University 2023