A new approach to ACL tears - The Cross bracing protocol
ACL Tear? Have you heard of the “Cross” Bracing Protocol?
Did you know that the ACL can heal itself? After many years of professionals believing the ACL cannot heal, more recent studies and evidence suggests otherwise and there may well be an alternative treatment method that could allow you to avoid surgery.
Now this is not what all the knee surgeons out there want to hear so, often it is not an option they will offer or even discuss with patients. It’s also not a treatment protocol that everyone is aware even exists.
Firstly, what is your ACL?
ACL stands for Anterior Cruciate Ligament and it is one of the main stabilising ligaments within the knee joint. It passes in a diagonal direction from the femur (the thigh bone) to the tibia (the shin bone). Its main job is to prevent the tibia bone moving forwards in an anterior direction as well as providing rotational stability in the knee.
How is it most commonly injured?
ACL injuries are most commonly sustained during multidirectional sports and activities. A lot of the time these are non contact injuries and occur when a player or participant lands and twists the knee or has a planted foot and a rotational force acts upon the knee, for example, decelerating and changing direction when running. There is still a lot of research and further investigations being carried out as to why this type of injury occurs and if there are any factors that would increase the risk of occurrence.
Most common management of ACL injuries
Currently in Australia, 90% of ACL tears lead to surgery. They are usually repaired using a graft which can be taken from the patient, either hamstring or patella tendon, or in some cases a doner graft is used either from a parent, cadaver or animal. The process would involve drilling “tunnels” within the knee joint to screw in and attach the new graft. On average the recovery time from surgery would be 12 months of rehabilitation before returning to sport and could cost between $15,000-$20,000.
Non surgical management of an ACL tear has been much less common as only a small minority of ACL injuries heal adequately by adopting a non surgical option with rehabilitation exercises alone.
So what is the “Cross” Bracing Protocol?
Dr Mervyn Cross and his son Dr Tom Cross are both Orthopaedic Surgeons that have specialised in performing the reconstructive surgery for an ACL tear. Ironically these are the two doctors who have come up with the method that could help people avoid the very surgery that made them famous.
The Cross bracing protocol (CBP) was originally founded in 2014, since then over 700 patients have navigated or are currently navigating the cross bracing protocol to treat acute ACL injuries non surgically.
The CBP involves immobilising the knee at a certain position with the aim to reduce the gap between the two ends of the injured/torn ACL in an attempt to facilitate bridging and healing of the tissues. To bring the ends of the torn ligament closer together the bracing protocol immobilises the patients knee at a 90 degree angle for the first 4 weeks after the injury. After 4 weeks the allowed range of movement at the knee is increased at weekly increments and will be coupled with physiotherapist supervised rehabilitation exercises targeting lower limb neuromuscular control, muscle strengthening and power. Then progressing to functional training to enable return to sport and recreational activities.
In 2023 there was a study published involving 80 patients undergoing the CBP, you can find the full article in the link below.
The CBP is not for everyone, there are factors that would mean some patients are not eligible for the protocol. The method is suitable if the injury is mild to moderate which will be determined by an MRI. The patient must be within 2-3 weeks post injury (ideally 4-7days). Patients who sustained concomitant (associated) injury to other structures that would require surgical repair would be ineligible for the protocol.
What to do if you suspect you have suffered an ACL injury?
If you suspect you have sustained an ACL injury some recommended first aid would be as follows:
Rest, apply ice, compress and elevate the injured limb. The main aim of this is to contain the swelling and help with any pain in and around the joint. Resting would include keeping weight of the injured leg so using crutches if available.
See a doctor or physiotherapist as soon as possible, recommendations also suggest only seeing one practitioner for assessment of the knee.
If an ACL injury is suspected then your doctor or physio will send you for an MRI of the knee, the sooner this can be done the better ideally within the first few days. This will determine the severity of the injury. Sometimes the MRI might be accompanied by an X-ray to rule out any bone fractures.
The technical requirements to get the best images of the ACL are full sequence /double oblique sequence with slices no greater than 3mm. (To the majority this will make no sense but just in case any of you injure your knees this is what is recommended)
In regards to pain killers it is advised to avoid anti inflammatory medication as this will reduce the blood flow and swelling in the joint. Increased blood flow and swelling will assist in your recovery.
If able to then immobilisation the knee at 30-90 degrees is ideal as this is the best position for the ACL to heal.
For more detailed information on bracing you can click the link below:
If you are unsure if you have damaged your ACL or have knee pain and are unsure what to do then please book in for an assessment at Muscle Therpay Austrlia.
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