ACL Cross Brace protocol

Thanks to Dr Jane Rooney for an informative lecture about their recent publication “Healing of acute anterior cruciate ligament rupture on MRI and outcomes following non-surgical management with the Cross Bracing Protocol” (Filbay, et al. 2023) which found that in select complete ACL tears up to 90% may show evidence of healing on MRI at 3 months post-injury.

They found a better potential for those patients who had a more displaced rupture (ACL tissue is within the intercondylar notch) compare to non-displaced.

Rehabilitation aims during Cross Bracing protocol.

Bracing phase: week 0- 12 weeks

⁃ Encourage optimal healing of the injure
ACL whilst minimising 1) joint stiffness/ pain 2) local and global muscle atrophy and 3) DVT risk from immobilization,

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. Non weightbearing with crutches/ wheelchair/ scooter. This is the most challenging time for patients especially if it is the car driving leg.

Week 5 the brace is then opened between 90 to 60 degrees of knee flexion to allow some movement. Still non weight bearing.

Week 6 the brace is opened further to allow movement between 90 and 45 degrees.

Weeks 7 full knee flexion and weight bearing as tolorated with crutches.

Week 8: Still full flexion allow full weight-bearing with crutches.

Week 9: -10 to flexion to limits . Still full weight-bearing with crutches.

Week 13/14: Removal of Brace. Full weight bearing

Main problems post 12:

• Joint arthrofibrosis; knee ext stiffness, PFJ stiffness/ pain

• Quads/ hamstrings/calf atrophy + plus other lower limb muscle weakness ipsilateral and contralateral leg.

• Gait disturbance especially terminal knee extension control

• Balance and neuromuscular control deficits

• cardiovascular deconditioning