Ischaemic digital ulcers lead to significant pain and functional limitations of the hands in patients with SSc . Our study investigated the effectiveness of an innovative and easy to perform rehabilitation protocol for the management of patients with IDUs secondary to SSc, including therapeutic US and manual therapy. In the literature there are no similar studies evaluating this intervention strategy in the management of IDUs.
Therapeutic US reduces inflammation of tissues and improves cell proliferation, collagen production, neoangiogenesis and fibrinolysis [12, 13]. Low US frequencies can reduce bacterial counts on wounds through selective destruction of bacterial biofilm .
The McMennel method prevents the development of deformity of the claws, resulting in an improvement in hands’ mobility, and improves hand muscles’ extrinsic strength in order to decrease pain and joint stiffness .
The mobilization technique of pompage allows reaching the optimal elongation of the collagen fibers that form the fascia, obtaining the recovery of the physiological lengths of this structure, as well as having analgesic effects, and promotes local blood circulation ..
Therapeutic US combined with hand rehabilitation using manual therapies (the McMennel method, connective tissue massage, pompage) has proven to be safe in this population, as it is free of side effects, and it might be included among the conservative approaches to SSc patients with IDUs as ancillary intervention to the recommended pharmacological therapies . Furthermore, the painless and short duration of US technique promotes greater compliance , as demonstrated by treatment adherence and persistence.
The treatment and prevention of IDUs is an important component in the management of patients with SSc. The European League against Rheumatism (EULAR) guidelines recommend only pharmacological approaches as gold standard for treating active digital ulcers in patients with SSc, such as intravenous iloprost. However, repeated infusions of this drug require patient hospitalisation and are associated with serious adverse effects (i.e., headache, flushing, nausea, vomiting, jaw pain, myalgia) . There are multiple topical treatments proposed for IDUs in the literature , although no consensus about this therapeutic option has been reached. The application of topical hydrocolloid and occlusive substances may be useful to protect the affected skin and to prevent the outbreak of further ulcers .
Ozone therapy has been shown to be useful in promoting IDUs healing in patients with SSc, through induction of VEGF and release of oxygen stimulating antioxidant enzymes .
Lipofilling is a minimally invasive method that can induce improvement or healing in SSc-related IDUs that are resistant to other traditional therapeutic approaches. It is a technique widely used in cosmetic (anti-ageing), surgery, but also for the treatment of post-surgical scars and radiotherapy-induced lesions. The method consists of taking fat tissue from the patient (liposuction) and re-injecting it into a different body region .
Debridement of IDUs has shown a reduction in ulcer-related pain and improved healing of the tissues involved, although no standardised protocols are available .
Physical modalities have been also proposed to treat IDUs in SSc patients. In this population, application of extracorporeal shock wave therapy (ESWT) has been shown to be well tolerated, repeatable, painless, and effective. It results in improvement of digital ulcers, skin elasticity and general well-being, however beneficial effects tend to reduce over time 
Recently, the local administration of a vasodilator (i.e., treprostinil) through iontophoresis has been proposed. This treatment increases the blood flow of the skin in the leg and foot compared to a placebo. Despite some minor local adverse events (e.g., erythema or burns), related to iontophoresis, this procedure has been shown to be safe and effective in the treatment of digital ulcers in patients with systemic sclerosis .
Promising results are obtained by using botulinum toxin type A (BTX-A) injections for treating chronic and refractory IDUs. The authors state that treatment with BTX-A is a minimally invasive method that resulted in a significant reduction in perceived pain, with an average duration of effect for 8 months, and a reduction in the intake of vasodilator medicines. Hand function and grip strength also showed significant improvements .
Although few studies support rehabilitative interventions for patients with SSc, these approaches are widely used in clinical practice. In agreement with our results, Bongi et al., demonstrated the effectiveness of the combination of connective tissue massage and the McMennel method on pain, joint mobility, and hand function . Horváth et al. also support the effectiveness of physiotherapy in the treatment of IDUs from SSc .
The strength of the study is the originality of the proposed treatment, as the combination of therapeutic US and of manual therapy has never been studied in patients with SSc-related IDUs. Moreover, also considering that digital ulcers heal over time even without interventions, our population consisted of patients complaining of IDU persistence for several months.
The main limitations of the study are the sample size, the study design (pre-post study), and the lack of a control group. Another limitation of this study is the lack of a long-term evaluation of the benefits obtained in terms of healing and prevention of ulcers. On the other side, it must be considered the difficulty in finding participants as SSc is a rare disease.. The results obtained might open a future line of research that should be implemented through randomized controlled trials. In the future, we would improve the study design to carry out a more reliable investigation including the comparison of treatment effects with a control group.