Clinicians should recommend patients with high energy lower extremity trauma injuries participate in a rehabilitation program (e.g. PT, OT, behavioral health) to improve psychological and functional outcomes.
Limb Salvage or Early Amputation
This guideline was produced in collaboration with METRC, with funding provided by the US Department of Defense. Endorsed by: AOFAS, OTA



Available evidence demonstrates the importance of psychosocial factors (e.g. anxiety, depression, Self-efficacy) on outcomes (O’Toole 2008, MacKenzie 2005) and indicates improvement through structured behavioral health intervention could improve outcomes. Further, improved psychosocial adjustment is associated with greater physical mobility. (Wen 2018)

Available evidence suggests a beneficial effect of physical therapy after severe high energy lower-extremity trauma. Individuals whose legs were salvaged after limb-threatening trauma to the lower limb, and had an unmet need for physical therapist directed care as determined by a physical therapist, have decreased odds of improvement in multiple domains of care as compared to patients whose needs were met (Castillo 2008).

In military service members, a structured clinical pathway including multi-disciplinary rehabilitative care (e.g. PT, OT, behavioral health) and a custom carbon fiber dynamic orthosis yielded significant improvements in physical mobility, patient reported outcomes and return to work (duty) following limb trauma. (Blair 2014, Potter 2018, Hsu 2017)


The benefits of participation in a structured rehabilitation program (e.g. PT, OT, behavioral health) following high energy lower extremity traumatic injury are improved psychological and functional outcomes. Physical or psychological risks associated with receiving care from a qualified provider are limited. Participation in a structured rehabilitation program requires both transportation and dedicated time. Risks associated with an inability to access rehabilitative care include decreased functional and psychological outcomes.


Priority outcomes include pain, the ability to complete essential activities of daily living, psychosocial state, the ability to return to full employment and the ability to participate in activities in the community.


The financial cost and resource utilization associated with participation in therapist driven structured rehabilitative programs are outweighed by benefits in improved physical mobility, function, participation and psychosocial state. Logistical concerns and costs for individuals with limited resources are a primary consideration.




Moderate (Dependent on payor status, policy and patient resources)


Additional studies examining the specific association between the type (e.g. PT, OT, behavioral health interventions) and volume of care (number and duration) and resulting outcomes are needed. These data would help optimize the care pathway following traumatic limb injury, particularly in the context of multi-system or multi-limb injury, community reintegration/participation and training to use prosthetic and/or orthotic devices.


Additional Rationale References:
1. Hsu, J.R., Owens, J.G., DeSanto, J., et. al. Patient Response to an Integrated Orthotic and Rehabilitation Initiative for Traumatic Injuries: The PRIORITI-MTF Study. J Orthop Trauma 2017; 31:S56-S62.
2. Potter, B.K., Sheu, R.G., Stinner, D., et. al. Multisite Evaluation of a Custom Energy-Storing Carbon Fiber Orthosis for Patients with Residual Disability After Lower-Limb Trauma. J Bone Joint Surg Am. 2018; 100(20): 1781-1789.