What is the Cross Bracing Protocol? Non-surgical management of ACL rupture

An ACL rupture refers to a tear or injury to the Anterior Cruciate Ligament (ACL), one of the major ligaments in your knee. The ACL is crucial for maintaining stability in the knee joint, especially during activities that involve twisting or changing direction quickly. When an ACL rupture occurs, it often happens during sports or activities that involve sudden stops, changes in direction, or jumping, such as netball, basketball, rugby and football to name a few. It typically causes significant pain, swelling, and instability in the knee. In our previous blog, we explored how you can reduce the risk of sustaining an ACL injury. In this blog we explore the innovative conservative management program that helps to facilitate healing of the ACL.

Cross-Bracing Protocol (CBP)

Historically, the common belief was that if you rupture your ACL, surgery was necessary to regain function. ACL tears often required surgical intervention followed by extensive rehabilitation to restore strength and stability. Whilst effective, this approach involves a prolonged recovery period and isn't always suitable for everyone. However, recent research indicates that for specific types of ACL ruptures, there’s an alternative approach which can lead to ACL healing via the Cross Bracing Protocol. This new alternative to surgery is promising for many individuals who do not want to undergo surgery.

What is the cross-bracing protocol?

The CBP involves applying a range of motion knee brace, ideally within the first 10 days post injury, and immobilising the knee at 90 degrees for the first 4 weeks for 24 hrs/day in an attempt to facilitate bridging of tissue and healing between the ruptured ACL remnants (Filbay et al, 2023).
90 degrees of knee flexion is the position that most closely approximates the two ends of the torn ACL. The brace is then adjusted at weekly increments to allow a progressive increase in range of motion. The first 6 weeks should be non-weight bearing on the affected leg (i.e on crutches or knee scooter).

• WEEK 16: Open chain seated leg extensions

• WEEK 17: Graded running program

• WEEK 20: Agility

• 6 MONTHS: Return to training

• 12 MONTHS: Return to play (Filbay et al, 2023)

Is It Right for You?

While the Cross Bracing Protocol shows promise, its suitability depends on several factors, including the extent and type of the ACL injury, meniscal pathology overall knee stability, and individual goals. Consultation with a sports medicine physician or orthopedic specialist is crucial to determine the best course of action based on your specific circumstances.

Considerations

• DVT risk due to immobilisation for prolonged period. Risk mitigated with medication (blood-thinners) and exercises (ankle pumps, quads and hamstring co-contractions, hip abduction and extension) (Filbay et al, 2023).

• Practicality (showering, sleeping, getting in/out of car)

• Pressure related issues due to wearing the brace 24/7 – ensure proper positioning/fitting

• Risk of muscle loss and knee contracture due to maintaining knee flexion for extended period (Perlstein, 2023)

• Contralateral limb overuse injuries

The stats ACL healing on 3-month MRI (from Filbay et al, 2023):

• 90% participants with complete discontinuity of the ACL at baseline had signs of ACL healing (ACL continuity)

• 50% had a continuous thickened ACL heal

• 40% had a continuous but thinned or elongated ACL heal

• 10% had a non-anatomical or non-heal

Why Physio?

The Cross Bracing Protocol is coupled together with physiotherapist-supervised rehabilitation targeting lower limb neuromuscular control, muscle strengthening and power, and functional training to enable return-to-sport and recreational activities.

At Back to Bounce Sports Physiotherapy, we can offer a structured and supervised rehabilitation program in accordance with the CBP guidelines, and ensure criteria are met to safely return to sport. We guide you through a specific program designed for you and the goals and sports you are aiming to return to.

Conclusion

Innovative approaches like the Cross Bracing Protocol are revolutionizing ACL injury management, offering athletes a viable alternative to traditional surgical intervention. By combining advanced bracing technology with targeted rehabilitation strategies, this protocol supports natural healing and facilitates a safe return to sports participation.
It is essential to remain cautious as the protocol is still in its early stages, and its potential long-term effects and drawbacks need further investigation. Some patients despite achieving ACL healing do end up with laxity of their ACL and reduced knee function, however reduced knee function is an established and widely understood side effect of an ACL injury, with or without surgery. However, the benefits and patient outcomes based on the early research of the CBP are currently very positive (Perlstein, 2023).

At Back to Bounce Sports Physiotherapy, we endeavour to keep people moving and feeling confident with movement. We specialise in ACL rehabilitation and injury prevention and utilise VALD technology to help guide treatment and return to sport plans. If you would like to make an appointment to gain a plan for your physiotherapy management of your ACL, you can book online or call our team on (07)53781571.

References

Filbay, S. R., Rooney, J., & Cross, T. (2023). The Cross Bracing Protocol - A Novel Non-surgical Intervention to Facilitate ACL Healing. ASPETAR Sports Medicine Journal, 12.

Filbay, S. R., Dowsett, M., Chaker Jomaa, M., Rooney, J., Sabharwal, R., Lucas, P., Van Den Heever, A., Kazaglis, J., Merlino, J., Moran, M., Allwright, M., Kuah, D. E. K., Durie, R., Roger, G., Cross, M., & Cross, T.. (2023). Healing of acute anterior cruciate ligament rupture on MRI and outcomes following non-surgical management with the Cross Bracing Protocol. British Journal of Sports Medicine, 57(23), 1490–1497. https://doi.org/10.1136/bjsports-2023-106931

Perlstein, K. (2023, July 25). Cross Bracing ACL Rehabilitation Protocol: Our Take. Orthotics plus Melbourne. https://orthoticsplus.com.au/articles/cross-bracing-acl-rehabilitation-protocol-our-take/#:~:text=The%20Cross%20Bracing%20Protocol%20involves%20immobilising%20the%20le