ACL Cross Bracing Protocol: Everything you need to know
MRI images demonstrating MRI evidence of ACL healing for five participants. ACL, anterior cruciate ligament; ACLOAS, Anterior Cruciate Ligament OsteoArthritis Score.
The ACL Cross Bracing protocol is an non-surgical bracing program that is designed to increase the probability of healing of the anterior cruciate ligament in complete ACL tears (rupture, full thickness tear).
A recent publication (Filbay, et al. 2023) found that in select complete ACL tears up to 90% may show evidence of healing on MRI at 3 months post-injury, and up to 79% may return to pre-injury sport within 12 months post-injury. Participants reported an average Lysholm Score of 95/100 at 12 months post injury which indicates excellent knee function. For reference, Carey et al. (2009) found the average Lysholm Score post operatively to be between 85-95/100 at 2-6 years post-op.
Here’s everything you need to know about the Cross Bracing Protocol.
The protocol is a 12 week graduated 24/7 bracing program that needs to be implemented within the first 4 weeks post-injury.
It involves an initial period of 6 weeks of non-weight bearing with crutches or a mobility scooter in a range of motion knee brace.
Weeks 1-4 the knee is locked at 90 degrees of flexion 24/7.
Week 5 the brace is then opened between 90 to 60 degrees of knee flexion to allow some movement.
Week 6 the brace is opened further to allow movement between 90 and 45 degrees.
Weeks 7 - 8 allow partial weight bearing with crutches.
Week 7 is restricted between 30 degrees to full flexion.
Week 8 is restricted between 20 degrees to full flexion.
Week 9 onward allows full weight bearing.
Week 9 is restricted between 10 to full flexion.
Weeks 10 - 12 allow full range of motion and weight bearing in the brace
Following week 12 the brace is removed and rehabilitation is continued.
Graduated supervised rehabilitation exercise and therapeutic physiotherapy treatment for both the injured and non-injured limb, as well as the upper body is continued throughout the entire bracing period.
Medical anticoagulants are required to be taken throughout the first 8 weeks of bracing to reduce the risk of deep vein thrombosis, this needs to be overseen by a sports doctor.
Does the Cross Bracing Protocol guarantee ACL healing?
Unfortunately not, despite very high rates of healing, we cannot guarantee everyone will heal anatomically.
Can my ACL heal without the Cross Bracing Protocol?
Yes, the ACL can heal other full weight-bearing bracing protocols which have good healing rates with up to 80-90% of patients showing signs of healing on MRI (Ihara, 2017; Jacobi, 2016). Up to >1 in 3 ACLs can potentially heal with rehabilitation alone and no bracing (Filbay, 2022).
How do I know if I am eligible for the Cross Bracing Protocol?
A complete physiotherapy assessment, review of your MRI, and medical assessment is required before determining your eligibility for the protocol.
Can I expect a great outcome from just doing the Cross Bracing Protocol?
No, a key component is the completion of a specific and supervised exercise program both during and after the bracing protocol to ensure safety during the bracing period, and resolution of full function. Each phase of rehabilitation requires completion of specific criteria to permit you to progress to the next phase and eventually return to sport.
What if I don’t want to be non-weight bearing?
There are other rehabilitation and bracing protocols that allow weight bearing that you may be eligible for.
What if I have a meniscus tear or other ligament injury?
49% of the participants in Filbay et al. (2023) had a meniscus tear, 50% had a medial collateral ligament tear, and 39% had a posterior lateral corner tear.
Can this allow a return to competitive sport?
Yes! 66% of participants in the Filbay et al. (2023) study participated in competitive or professional sport and 79% of all participants returned to pre-injury sport?
What are my chances of re-injury following the Cross Bracing Protocol?
Re-injury within 12 months (14%) is on par with global re-injury rates of ACL tears.
What if it’s been longer than 4 weeks since my injury?
Unfortunately the Cross Bracing Protocol may not be for you, however there still could be a possibility for your ACL to heal and you may be eligible for other protocols.
What are the benefits?
High probability of ACL healing
Avoid unnecessary surgery
High chance of returning to sport
Most meniscus tears become asymptomatic
What are the risks?
DVT
Muscle atrophy
Pain and discomfort from the brace
Flexion contracture
Contralateral limb overuse injuries
To find out if you are eligible, or to discuss your options further please book an online consultation.
Filbay, S. R., Dowsett, M., Jomaa, M. C., Rooney, J., Sabharwal, R., Lucas, P., ... & 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.
Filbay, S., Roemer, F., Lohmander, S., Turkiewicz, A., Roos, E. M., Frobell, R., & Englund, M. (2022). Spontaneous healing of the ruptured anterior cruciate ligament: Observations from the KANON trial. Osteoarthritis and Cartilage, 30, S21-S22.
Carey JL, Dunn WR, Dahm DL, Zeger SL, Spindler KP. A systematic review of anterior cruciate ligament reconstruction with autograft compared with allograft. J Bone Joint Surg Am. 2009 Sep;91(9):2242-50. doi: 10.2106/JBJS.I.00610. PMID: 19724004; PMCID: PMC2730860.
Ihara H, Kawano T. Influence of Age on Healing Capacity of Acute Tears of the Anterior Cruciate Ligament Based on Magnetic Resonance Imaging Assessment. J Comput Assist Tomogr. 2017 Mar/Apr;41(2):206-211. doi: 10.1097/RCT.0000000000000515. PMID: 28045756; PMCID: PMC5359784.
Jacobi M, Reischl N, Rönn K, Magnusson RA, Gautier E, Jakob RP. Healing of the Acutely Injured Anterior Cruciate Ligament: Functional Treatment with the ACL-Jack, a Dynamic Posterior Drawer Brace. Adv Orthop. 2016;2016:1609067. doi: 10.1155/2016/1609067. Epub 2016 Dec 7. PMID: 28053787; PMCID: PMC5174171.
