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The Future of ACL Injury Management: Tim Cross’s Cross Bracing Protocol and Its Evolving Potential

  • 5D Physio
  • Apr 8
  • 2 min read

The Anterior Cruciate Ligament (ACL) is crucial for knee stability, and its rupture has traditionally necessitated surgical intervention. However, the Cross Bracing Protocol (CBP), developed by Drs. Mervyn and Tom Cross, offers a non-surgical alternative that facilitates natural healing of the ACL.


Understanding the Cross Bracing Protocol


The CBP involves immobilizing the knee at a 90-degree flexion angle shortly after an ACL injury. This position brings the torn ligament ends closer together, promoting healing. The protocol is structured over 12 weeks:


• Weeks 1-4: Knee braced at 90 degrees flexion.

• Week 5: Range of motion adjusted to 60-90 degrees.

• Week 6: Adjusted to 45-90 degrees.

• Week 7: Adjusted to 30 degrees to full flexion.

• Week 8: Adjusted to 20 degrees to full flexion.

• Week 9: Adjusted to 10 degrees to full flexion.

• Weeks 10-11: Unrestricted movement within the brace.

• Week 12: Brace removal.


Throughout this period, physiotherapist-supervised rehabilitation is essential to ensure proper recovery.


Efficacy and Outcomes


Clinical studies have demonstrated promising results for the CBP. In a study involving 80 patients, 90% exhibited evidence of ACL healing on MRI after three months. Furthermore, those with more significant healing reported better knee function, higher return-to-sport rates, and improved quality of life after 12 months.


Comparing the Three Main Approaches to ACL Injuries

Approach

Surgical Reconstruction

Conservative Management

Cross Bracing Protocol (CBP)

Method

Replace torn ACL with graft (usually hamstring/patellar tendon)

Physical therapy without surgery

Brace knee in 90° flexion to promote ligament healing

Healing Basis

Surgical intervention for mechanical stability

Strengthen surrounding muscles to compensate

Facilitate biological healing of torn ACL

Duration

9-12 months recovery time

Variable, often slower return to sport

12-week bracing + structured rehab

Return to Sport

80–90% return to sport, but may take 9+ months

Often slower, not always full return to pivot sports

High potential return, especially in early data

Pros

Proven long-term success, predictable outcome

No surgery, lower cost

Non-surgical healing, reduced long-term complications

Cons

Risk of complications, donor site morbidity, re-tear

Higher risk of instability, re-injury

Still emerging research, not suitable for all cases

Ideal Candidates

Athletes with high pivot demands

Lower activity individuals or partial tears

Acute, full-thickness tears with good alignment


What Lies Ahead?


The future of ACL treatment might not be one-size-fits-all, but a personalized protocol-based approach—and the Cross Bracing Protocol could be a vital third option for many patients. As more studies emerge, it will be crucial to determine which patients benefit most, and how to standardize rehab protocols following bracing.


If CBP continues to deliver on its promise, we may see a major shift in how ACL injuries are treated worldwide—away from the scalpel and toward biological healing.


Further Reading:



 
 
 

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