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  • Writer's pictureJay Kasthuriarachchi

Managing ACL Injuries Using The Cross Bracing Protocol

Updated: Oct 16, 2023

Sustaining an ACL injury can be scary and overwhelming. There has been varying opinions on whether someone should get surgery or trial conservative treatment. Previous to this debate, conservative treatment was never even considered! Recent emerging evidence has challenged traditional thoughts and showed high promise with conservative treatment. The ACL was once believed to have limited healing capacity. However, anatomical studies have demonstrated that the ACL actually has rich blood supply.

The ‘Cross Bracing Protocol’ was developed by Dr Tom Cross with the idea of allowing the ACL to heal by reducing the distance between where the ligament has torn and where it should attach. This distance is the shortest when the knee is in 90-135 degrees of knee flexion. Therefore, the goal is to immobilize the knee at 90degrees for the first 4 weeks after an acute ACL rupture in attempt to facilitate bridging of tissue and healing between the ruptured ACL remnants.

Is the Cross Bracing Protocol For You?

  • Patients of all ages

  • Must be within 1 month of acute ACL rupture - confirmed on MRI

  • Must be functionally independent and capable of managing a period of knee immobilization

  • Must not have evidence of structural concomitant injuries that need surgical intervention (eg. unstable bucket-handle meniscal tear)

  • Must not have Deep Vein Thrombosis or Pulmonary Embolism

Here's a summarized version of the cross bracing protocol:

  1. Purpose: The primary goal of cross bracing is to protect the healing ACL and surrounding structures while promoting a safe and controlled range of motion during the initial recovery period.

  2. Timing: Cross bracing is typically used in the early stages of rehabilitation, immediately after an ACL injury or post-surgery, when the knee is still healing and is vulnerable to further damage. Generally speaking the patient is non weight bearing for the first 6 weeks, partial weight bearing for 7 - 9 weeks, weight bearing as tolerated as it is weaned off after that

  3. At 13 weeks an MRI is redone to check the ACL's healing

  4. Brace Type: The knee brace used for cross bracing is designed to limit excessive movements that might stress the healing ACL. It is usually a hinged brace that allows controlled flexion and extension of the knee while restricting side-to-side movements.

  5. Physical Therapy: Cross bracing is often used in conjunction with physical therapy. The physical therapist will guide the patient through exercises to strengthen the surrounding muscles, improve flexibility, and restore knee function, once the initial phase has been completed

  6. Gradual Removal: As the knee heals and the patient's strength and stability improve, the use of the brace may be gradually reduced. This is usually done under the guidance of the healthcare team.

Does it work?

In a recent trial, 90% off patients were shown to have some sort of healing at the 3 month mark, with a re- injury rate of 14%, which is comparable to ACL surgery


It's important to note that the cross bracing protocol is just one aspect of ACL injury rehabilitation. Each patient's treatment plan may vary based on the extent of the injury, individual factors, and the preferences of the healthcare team. Patients should always follow their healthcare provider's instructions and consult with them regularly throughout the recovery process.

Want to learn more about ACL injuries? Check out our new ACL specific website here

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