An anterior cruciate ligament (ACL) injury can be a major setback for athletes, affecting mobility and performance. However, not every ACL injury requires surgical intervention. For those opting for a conservative approach, the Cross Bracing Protocol offers a structured path to recovery without undergoing surgery.
Understanding the Cross Bracing Protocol
The Cross Bracing Protocol is designed to support the knee through a carefully controlled range of motion, providing stability while allowing for healing and strengthening. This approach is particularly beneficial for athletes who wish to avoid surgery or for those whose injuries are suitable for conservative management. In a study by Filbay et al. (2023), they found that 90% (72 out of 80) patients that underwent this bracing protocol showed signs of healing of the torn ACL (ends had started merging back together) at the 3 month mark.
Phases of the Cross Bracing Protocol
Weeks 1-4:
Objective: Minimise movement to protect the injured ACL and initiate healing.
Bracing: Athletes wear a knee brace full-time, including during sleep and daily activities, to restrict movement and provide support.
Range of Motion: The brace is locked at 90 degrees flexion for the first 4 weeks, with patients unable to weight bear and to use crutches.
Physiotherapy: Manual therapy to assist in symptom relief and muscle stimulator work and exercises to prevent muscle atrophy/wasting.
Rehab Exercises:
Theraband exercises for the calf, hip and groin
Quadricep and hamstring co-contraction work (+/- muscle stimulation machine)
Glute bridges
Isometric lateral hip and groin exercises
Advanced Rehab Exercises (if coping)
Isometric wall sit progressions
Isometric hamstring curls
Other isometric progressions with brace on.
Other: Upper body gym, seated ski erg, arm crank, boxing etc.
Week 5-6:
Objective: Maintain as muscle muscle size as possible and adhere to range of motion restrictions.
Bracing: Week 5 (60-90 degrees), week 6 (45-90 degrees).
Physiotherapy: Manual therapy to assist in symptom relief and muscle stimulator work and exercises to prevent muscle atrophy/wasting.
Rehab Exercises:
Quadricep and hamstring co-contraction work in restricted range.
Continue with banded calf, groin and lateral hip exercises.
Weight shifts
Wall squats/ holds to available range.
Bodyweight squats within limits.
Double leg leg press.
Hamstring & glute bridges
Advanced Exercises (if coping):
Single leg leg press in available range
Goblet squats
Hamstring curls in range
Single leg bridges
Other: Upper body gym, standing ski erg, arm crank, boxing etc.
Week 7-8:
Objective: Introduce weight-bearing, minimise muscle atrophy, adhere to range restrictions and maximise ACL remodelling.
Bracing: week 7 (30-full flexion, WBAT), week 8 (20-full flexion, WBAT).
Physiotherapy: Manual therapy to assist in symptom relief, muscle stimulator work to prevent muscle atrophy/wasting and gait retraining.
Rehab Exercises:
As prior +
Start on a stationary bike
Weighted squats
Hamstring curls
Calf raise variations
Advanced Exercises:
SL hamstring curls
Deadlifts
Lunges
SL balance on a stable surface
Weighted calf raises
Other: Upper body gym, cycle/bike, standing ski erg, arm crank, boxing etc.
Week 9:
Objective: Increase knee range, maximise lower limb strength, balance and ACL remodelling.
Bracing: week 9 (10-full flexion, WBAT).
Physiotherapy: Manual therapy to assist in symptom relief, muscle stimulator work to prevent muscle atrophy/wasting and gait retraining.
Rehab Exercises:
Knee range of motion drills
Leg press
Weighted squats and lunges
Calf raise variations (weighted)
Bridges (biasing glutes or hamstrings)
Balance and proprioception drills
Advanced Exercises:
Advanced balance exercises on unstable surfaces.
Other: Upper body gym, standing ski erg, arm crank, boxing etc.
Week 10-12:
Objective: Increase knee range, maximise lower limb strength, balance and ACL remodelling.
Bracing: week 10-12 (full range, brace off for sleep WBAT)
Physiotherapy: Manual therapy to assist in symptom relief, muscle stimulator work to prevent muscle atrophy/wasting and gait retraining.
Rehab Exercises:
Progress all sagittal plane strength exercises (up, down, forward and back).
Dynamic balance exercises.
Get as strong as possible.
Other: Upper body gym, cycle/bike, standing ski erg, arm crank, boxing etc.
END OF WEEK 12: Follow-up MRI, specialist doctor review and physical testing
Week 13-16:
Objective: Maximise lower limb strength, balance and preparedness for running.
Physiotherapy: Weekly/fortnightly reviews for testing, treatment and program progression.
Rehab Exercises:
Progress all sagittal plane strength exercises (up, down, forward and back).
Dynamic balance exercises.
Get as strong as possible.
Continue low-level plyometric progressions to build capacity of knee to withstand jogging loads.
Other: Upper body gym, cycle/bike, standing ski erg, arm crank, boxing etc.
Progression Criteria to Power Phase & Running: as per Game Time ACL protocol
Week 17-26:
Objective: Maximise lower limb strength, rate of force development, balance and straight line running.
Physiotherapy: fortnightly/4-weekly reviews for testing, treatment and program progression.
Rehab Exercises/ Focus:
Get as strong as possible in the gym.
Introduce frontal plane (side to side) movements in the gym and low-level hops/jumps as well.
Introduce and progress straight line running, working on mechanics and components of running. Running may start with long, slow runs and build to more "speed" sessions working up to 80-90% max speed.
Continue plyometric progressions (moderate to difficult) to maximise power and rate of force production of the lower limb.
Progression Criteria For Return To Training Phase: as per Game Time ACL protocol
Month 7-9/12:
Objective: Maximise lower limb strength, power, balance, straight line running and agility.
Physiotherapy: fortnightly/4-weekly reviews for testing, treatment and program progression.
Rehab Exercises/ Focus:
Get as strong and powerful as possible in the gym.
Progress to 100% straight line running, change of direction and agility drills.
Return and progression of skills-based drills at training.
Maximise fitness and conditioning.
Work on any weaknesses at the knee or anywhere else.
Progression Criteria For Discharge: as per Game Time ACL protocol
Benefits of the Cross Bracing Protocol
Non-Invasive: Offers a non-surgical option for managing ACL injuries, reducing recovery time and surgical risks
Quicker: There's no wait time to get surgery then start the timer on a return to sport. Just get your knee in the brace asap! If you go publicly in Australia, you will wait a minimum of 6 weeks (usually 2-3 months).
Cheaper: Surgery isn't cheap if you're paying for it!
Considerations for Athletes
Professional Guidance: Regular assessments by a physiotherapist or healthcare professional are essential to ensure the protocol is appropriately adjusted and progress is on track.
Commitment to Rehabilitation: Success with the Cross Bracing Protocol requires dedication to the rehabilitation process, including adherence to bracing and exercise regimens. There is nothing worse than spending 3 months in a brace to need surgery anyway due to not sticking to the bracing protocol.
Monitoring and Adjustments: Be attentive to any signs of discomfort or instability, and communicate with healthcare providers to make necessary adjustments.
Conclusion
The Cross Bracing Protocol provides a viable path for athletes seeking conservative management of ACL injuries. By focusing on restoring the integrity of the original ligament, stability, this approach aims to restore knee function and support a successful return to sport in less time and not requiring an operation. As with any rehabilitation journey, collaboration with healthcare professionals and a commitment to the process are key to achieving optimal outcomes.
References:
Filbay SR, Dowsett M, Chaker Jomaa M, et al. (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,57,1490-1497.
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