Non-Surgical Management of ACL Injuries: Updating Conservative Care

Typically, when an individual tears their ACL, they undergo surgery to reconstruct the ligament. A significantly smaller population opts to not have surgery and go without an ACL. 

But, what if there was another option? 

What if the ACL could heal through rehab without surgery? 

That crucial question is currently being explored and we are here for it! So let’s talk about the “Cross Bracing Protocol.”

Current ACL Landscape

Anterior cruciate ligament (“ACL”) tears of the knee are, unfortunately, extremely common. Currently, the immediate recommendation following confirmation of an ACL tear is to have surgery to reconstruct the ligament. This is done with use of a tissue graft (typically your own patellar tendon, hamstring tendon, or quad tendon, or a cadaver graft). Which graft is used is another topic of conversation - but in short - using your own quad or patellar tendon seems to be the strongest and thus is utilized in younger, more active people, while cadaver grafts are used with an older population as initial phases of recovery are easier and they are not as reliant on the strength of the graft.

While that is the typical course of action, some people opt to NOT have surgery following an ACL tear - leading to the question, can we function without an ACL?  

Currently, when people choose to not have surgery, they will go through rehabilitation and find out if they become a “coper” or a “non-coper”.  

• A coper is identified as an individual who restores normal level of function with an ACL-deficient knee. They no longer have an ACL, but their body does not seem to miss it.

• A non-coper is identified as an individual with an ACL-deficient knee that does not restore function and continues to feel instability of the knee.  These individuals typically will go on to have ACL reconstructive surgery.

Rehabilitation for an individual who wants to find out if they are a coper or non-coper is multi-factorial, as any rehab program is: build the leg muscles (e.g., quad, hamstring, gluts, calves, etc), build back balance, build back function, build back fitness; see how far you can get to restore normal function, and you’ll have your answer if your body can cope or not.

A Non-Surgical Way of the Future? Enter the Cross Bracing Protocol

Unwilling to settle for the current landscape, yet another crucial question is currently being investigated: can the ACL heal itself without surgery?

The Research

In 2019, the ACL-heal project commenced. This is an on-going research project with positive results. At the heart of this project, Dr. Tom Cross and Dr. Stephanie Filbay are amongst the lead individuals working on a bracing protocol with individuals who have torn their ACL — the “Cross Bracing Protocol.” The research done thus far using this protocol has shown that over 90% of the qualifying ACLs can HEAL themselves when given the opportunity to do so. The researchers have been able to identify patterns on MRI that show how likely the bracing protocol is to work. This is tremendous, as the way we have recommended treatment prior to this has been — “your ACL won’t heal and we’ll find out if your body can handle that or not.”

The research is building in this area, but the Cross Bracing Protocol is here and it looks like it will be entering the game with a bang! This protocol involves a period of time that the knee is braced/immobilized to 90 degrees of bend (flexion).  Anatomically, this is where the ends of the ACL can actually communicate best, allowing them to start to heal together. The theory is that of reduction; just as fractures are treated. If you put the ends of the bone close together and cast them, they will communicate and heal the fracture. This same theory is now being applied to the ACL.

The Protocol

The Cross Bracing Protocol is 12 weeks in length (for the brace). The initial 4 weeks are immobilized at 90 degrees, the following 8 weeks the brace is given more motion every 1-2 weeks until reaching full range of motion. At 12 weeks, the individual has another MRI to show the level of healing of the ACL. Once allowed full range of motion, rehabilitation would continue to restore back to the previous level of function. Rehab remains likely to be 9-12 months long, but without surgery, rehab is performed all while the brace is on to minimize loss of muscle and fitness.

Key Considerations

There are certain things to take into account when adopting the bracing protocol, including: (1) is the person a candidate, which is based on MRI findings, the type of ACL tear, as well as if there are other tissues injured; (2) can the individual get on an prophylactic anticoagulant (due to risk of blood clots associated with being immobilized); and (3) are they at high risk for a blood clot.  

Another important factor is TIME — time to diagnosis, time to get them braced. For bracing? The earlier, the better (once the person can reach 90 degrees on their own). This means the individual needs to: (1) get to a clinician for evaluation (PT/urgent care/physician), and (2) get an MRI scheduled and results, as soon as possible! The window for bracing is 14 days.  After 14 days, the protocol is not recommended.

If an ACL tear is suspected, the individual can be braced 90-30 degrees while awaiting results, and should try to spend most of their time at 90 degrees (sitting around, etc). Some people are even trying hybrid versions of the bracing so they can function (e.g., bracing 90-30 when driving so they can still be independent, but then spend the rest of the day at 90).

Conservative care for ACL injuries is soon to be a hot topic and an exciting option for those at any level — elite athletes to those living a seemingly “normal” daily life — who wish to avoid surgery and heal the ACL.   

Want to Know More?

I had the honor to connect directly to Dr. Tom Cross who is and will continue to help navigate these cases as the research builds. If you are considering conservative care, it is likely that many physicians and PTs will not know of this protocol simply because the work will not be published until later in 2023, but the data is ready and coming! 

If you find yourself having questions about the process, this blog and or the research / data, please feel free to contact me at alison@suarezphysicaltherapy.com.