New in ACL Management: The Cross Bracing Protocol Explained

ACL injuries were once a surgical story; reconstruction was the only option. In more recent years, exercise-based rehabilitation emerged as a valid alternative. Now, a third option is changing the conversation – the Cross Bracing Protocol (CBP).

Designed to enhance the natural healing of the ACL, the CBP offers a structured, non-surgical pathway that may allow for ACL healing and functional recovery in select patients. For physiotherapists, this presents both a challenge and an opportunity: to identify which patients are appropriate for CBP and how to guide them through the protocol successfully.

If you want to see exactly how an expert physio guides his patient through the CBP, watch Geoff Ford’s full Case Study HERE.

Understanding ACL management options

Historically, ACL ruptures were assumed to have limited-to-no healing potential without surgical intervention. As a result, young, active individuals were often funneled into reconstruction. However, evolving research and advances in imaging have revealed that the ACL can in fact heal, leading to progress in the way we manage ACL injuries and a move away from this one-size-fits-all surgical approach. Finally, patients actually have a choice! They include:

1 – ACL reconstruction (ACLR) – the traditional approach to ACL rupture, using a graft to replace the torn ligament and promote restoration of knee stability.

2 – Exercise-based rehabilitation – focuses on strengthening, neuromuscular control and progressive return-to-sport training to enable patients to return to activity without the challenges of surgical recovery.

And the relatively new approach..

3 – The CBP – a conservative management approach with a strict range of motion (ROM) bracing protocol to promote biological healing of the ACLwithout surgery.

The idea behind the CBP

With growing evidence that the ACL can, in some cases, heal after all, the CBP aims to place the knee in a position that reduces tension on the ACL and supports the healing process. While ACL healing isn’t essential for a good outcome (as seen in successful exercise-based rehab patients with no ACL healing), some research suggests patient-reported outcomes can be better for those with a healed ACL (following exercise-based treatment), compared to those who underwent surgery or exercise-based treatment with no healing (1).

But not everyone’s a candidate for the CBP. At the moment, evidence suggests that the protocol may be most effective for people with an isolated, proximal ACL rupture. Early diagnosis is also important, as you want to start the protocol within 7-10 days of injury to promote healing. Additionally, patients need to be highly compliant and motivated, as the protocol is strict and can be challenging. While research on outcomes is still emerging, it appears that those with distal tears, multi-ligamentous injuries or meniscal/chondral damage may be less suitable for the protocol. So it’s integral to get an MRI to assess the patient’s injury, and consult with a clinician familiar with the protocol to support informed decision-making for your patient.

What your patient needs to know

When helping your patient choose the best management approach, there are a few key points to cover. First, ensure they understand what post-surgical recovery typically involves. This includes pain, the initial recovery period, and common issues like quadriceps inhibition. Second, explain that current evidence suggests there’s no disadvantage to delaying surgery. This means if they are unsure, then starting with a trial of exercise-based rehabilitation is a safe and reasonable option.

For those who are candidates for the CBP, early evidence suggests that 90% of people exhibit ACL healing on MRI at 12 weeks (2), which is exciting! But it’s important for them to know that this approach has not been explored to the same extent as other approaches, and further research is still needed. Additionally, your patient needs to understand the strict protocol before deciding, as this can be challenging for even the most motivated of patients. Being fixed in the brace can not only be frustrating, but also have implications for muscular function and recovery, particularly for the quadriceps – therefore, strong compliance to protocol-based exercise is required to maintain/regain function following the ACL injury.

Early management

So, your patient decides to go with the CBP. What’s next?

During weeks 0–4, the patient is locked at 90° and functionally non-weight bearing, using crutches or a knee scooter. While not strictly a non-weight bearing protocol, the knee position prevents weight bearing on the affected side.

Managing a patient through the CBP requires a shift in early-stage physiotherapy goals; rather than emphasising immediate range of motion, the first weeks focus heavily on restricted ROM to promote healing of the ACL. You may think you can have little influence in the first stage of rehab, but that’s incorrect! Watch Geoff explain his ‘constraints-based’ approach in this short clip from his Case Study:

Additionally, a key challenge in this first phase is to prevent/limit quadriceps atrophy – being locked in 90° flexion makes this difficult. Watch some of Geoff’s go-to phase 1 exercises in this video from his Case Study:

Wrapping up

Emerging ACL research is reshaping how we manage these injuries. For physiotherapists, this brings greater responsibility in guiding patient selection and education; ACL rupture no longer means automatic surgery followed by standard rehab. Patients now have more options!

While the CBP isn’t suitable for everyone, it offers a valuable addition to individualised care. Knowing when and how to apply the CBP allows physiotherapists to play a leading role in this evolving area of ACL rehabilitation.

If you want to know more about the innovative ACL management approach, you’re going to want see how Geoff Ford rehab’s his patient from start to finish in his excellent Case Study, watch it in full HERE.