Management of ACL tears – A third option, Ligament healing?

Since I graduated university as a physiotherapist in the late 1990’s, I have been taught that complete ACL ruptures don’t naturally heal because they tear through their blood supply and the ligament endings are too far apart to join back together naturally.

This conventional “wisdom” has really been unquestioned until recently, where studies have shown that, yes, at three months, complete ruptures do not heal, but this is a very different story when the knee is examined again at 2 years.  At the 2-year mark, 30% of ACL ruptures treated conservatively will show signs of healing (Filbay et al, 2023).

Since 2014, Dr Tom Cross and his father, Mr Mervyn Cross (retired orthopedic surgeon) have been working on a bracing protocol (Cross-bracing protocol (CBP)), which is aimed to facilitate primary healing of the ACL after rupture, with exciting and potentially game changing results.

The idea is simple.  As early as possible after the ACL is torn (within the first 7-10 days, but no later than 21 days after the injury), brace the knee at 90 degrees, where the ligament is at its shortest, the ends potentially crossover and it has the greatest potential to heal.  The knee is kept in this position for 4 weeks, then the knee is gradually extended out to straight within the brace over a period of 8 weeks (12 weeks in total).

The initial results are very exciting.  At the 3-month mark:

• 50% of patients treated with cross bracing show a healing, normal sized ACL that is thickened, with 92% returning to sport at the 12-month mark
• 40% of patients treated with cross bracing showed healing, but the ACL was lengthened and thinner.  However, of these participants, 64% returned to sport

This is compared to only 55% of people who have an ACL reconstruction returning to sport and of these only half will return to the previous level of sporting activity (~27%)

Th additional benefit of the CBP is that concurrent meniscal injuries, which are extremely common with an ACL tear (39% of females and 49% of males), also healed during this time without further intervention required.

Although it is still early days in the CBP trials and there are no long-term studies, it appears that there is an additional potential pathway if you have an ACL rupture.

References:

Filbay SR, Dowsett M, Jomaa MC, Rooney J, Sabharwal R, Lucas P, Van Den Heever A, Kazaglis J, Merlino J,Moran M, Allwright M, Kuah DEK, Durie R, Roger G, Cross M, Cross T (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 No. 0 P.1–8.

Filbay SR, Roemer FW, Lohmander LS, et al (2023) Evidence of ACL healing on MRI following ACL rupture treated with rehabilitation alone may be associated with better patient-reported outcomes: a secondary analysis from the KANON trial. British Journal of Sports Medicine No. 57. P.91–9.

Webster A (2023) Bend the knee: the game changing procedure for athletes with ACL injuries.  The Sydney Morning Herald.  30^th June 2023.

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