Article Text

Healing of acute anterior cruciate ligament rupture on MRI and outcomes following non-surgical management with the Cross Bracing Protocol
  1. Stephanie R Filbay1,
  2. Matthew Dowsett2,
  3. Mohammad Chaker Jomaa3,
  4. Jane Rooney4,
  5. Rohan Sabharwal5,
  6. Phil Lucas5,
  7. Andrew Van Den Heever5,
  8. James Kazaglis6,
  9. Justin Merlino6,
  10. Mick Moran6,
  11. Maggie Allwright7,
  12. Donald E K Kuah8,
  13. Ra Durie9,
  14. Greg Roger10,11,
  15. Mervyn Cross12,
  16. Tom Cross12
  1. 1 Department of Physiotherapy, The University of Melbourne, Melbourne, Victoria, Australia
  2. 2 School of Medicine, Sydney Campus, The University of Notre Dame Australia, Darlinghurst, New South Wales, Australia
  3. 3 School of Public Health, University of Sydney Medical School, Sydney, New South Wales, Australia
  4. 4 Lifecare Prahran Sports Medicine Centre, Melbourne, Victoria, Australia
  5. 5 PRP Diagnostic Imaging, Sydney, New South Wales, Australia
  6. 6 Stadium Sports Physiotherapy, Sydney, New South Wales, Australia
  7. 7 Northern Beaches Hospital, Sydney, New South Wales, Australia
  8. 8 New South Wales Institute of Sports, Sydney, New South Wales, Australia
  9. 9 Sportsmed Manawatu, Palmerston North, New Zealand
  10. 10 The University of Sydney School of Biomedical Engineering, Darlington, New South Wales, Australia
  11. 11 Vestech Medical Pty Ltd, Sydney, New South Wales, Australia
  12. 12 The Stadium Sports Medicine Clinic, Sydney, New South Wales, Australia
  1. Correspondence to Dr Stephanie R Filbay, Department of Physiotherapy, The University of Melbourne, Melbourne, VIC 3010, Australia; stephanie.filbay{at}


Objective Investigate MRI evidence of anterior cruciate ligament (ACL) healing, patient-reported outcomes and knee laxity in patients with acute ACL rupture managed non-surgically with the Cross Bracing Protocol (CBP).

Methods Eighty consecutive patients within 4 weeks of ACL rupture were managed with CBP (knee immobilisation at 90° flexion in brace for 4 weeks, followed by progressive increases in range-of-motion until brace removal at 12 weeks, and physiotherapist-supervised goal-oriented rehabilitation). MRIs (3 months and 6 months) were graded using the ACL OsteoArthritis Score (ACLOAS) by three radiologists. Mann-Whitney U tests compared Lysholm Scale and ACL quality of life (ACLQOL) scores evaluated at median (IQR) of 12 months (7–16 months) post-injury, and χ2 tests compared knee laxity (3-month Lachman’s test and 6-month Pivot-shift test), and return-to-sport at 12 months between groups (ACLOAS grades 0–1 (continuous±thickened ligament and/or high intraligamentous signal) versus ACLOAS grades 2–3 (continuous but thinned/elongated or complete discontinuity)).

Results Participants were aged 26±10 years at injury, 39% were female, 49% had concomitant meniscal injury. At 3 months, 90% (n=72) had evidence of ACL healing (ACLOAS grade 1: 50%; grade 2: 40%; grade 3: 10%). Participants with ACLOAS grade 1 reported better Lysholm Scale (median (IQR): 98 (94–100) vs 94 (85–100)) and ACLQOL (89 (76–96) vs 70 (64–82)) scores, compared with ACLOAS grades 2–3. More participants with ACLOAS grade 1 had normal 3-month knee laxity (100% vs 40%) and returned to pre-injury sport (92% vs 64%), compared with participants with an ACLOAS grades 2–3. Eleven patients (14%) re-injured their ACL.

Conclusion After management of acute ACL rupture with the CBP, 90% of patients had evidence of healing on 3-month MRI (continuity of the ACL). More ACL healing on 3-month MRI was associated with better outcomes. Longer-term follow-up and clinical trials are needed to inform clinical practice.

  • Anterior Cruciate Ligament
  • Rehabilitation
  • Knee injuries
  • Physical Therapy
  • Orthopedics

Data availability statement

Data are available upon reasonable request.

This is an open access article distributed in accordance with the Creative Commons Attribution 4.0 Unported (CC BY 4.0) license, which permits others to copy, redistribute, remix, transform and build upon this work for any purpose, provided the original work is properly cited, a link to the licence is given, and indication of whether changes were made. See:

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Data availability statement

Data are available upon reasonable request.

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  • Contributors SRF applied for ethics approval, designed the study, ran the analysis, drafted and revised the manuscript, created all figures and tables, and is the study guarantor. MC conceived the Cross Bracing Protocol (CBP). TC led the development/refinement of the CBP and management of patients, collected all data, contributed to interpretation of findings and manuscript revision. RS, PL and AVDH graded all MRIs. MD, MCJ and MA assisted with data collection. MCJ, JR, JK, JM, MM, DEKK, RD and GR managed patients in clinical practice and contributed to the refinement of the CBP and rehabilitation protocol. All authors provided input and approved the final version of the manuscript.

  • Funding This study was funded through an NHMRC Investigator Grant awarded to SRF (1194428).

  • Competing interests SRF served on the Osteoarthritis Research Society International (OARSI) Board of Directors in 2022-2023, and received funding (for travel and accommodation) to attend two board meetings. MA received reimbursement to attend and speak at Smith and Nephew symposium at The Combined TOSSM & APKASS conference in Thailand, October 2022. TC has formed a non-financial relationship with Bauerfeind, Germany, and Bauerfeind, Australia, to select a knee brace that optimises patient comfort and compliance. This relationship has had no impact on the completion of this study. After the completion of this study, Bauerfeind, Germany, donated 100 braces to TC for use in clinical practice. Donated braces were not used with participants in this study.

  • Patient and public involvement Patients and/or the public were involved in the design, or conduct, or reporting, or dissemination plans of this research. Refer to the Methods section for further details.

  • Provenance and peer review Not commissioned; externally peer reviewed.

  • Supplemental material This content has been supplied by the author(s). It has not been vetted by BMJ Publishing Group Limited (BMJ) and may not have been peer-reviewed. Any opinions or recommendations discussed are solely those of the author(s) and are not endorsed by BMJ. BMJ disclaims all liability and responsibility arising from any reliance placed on the content. Where the content includes any translated material, BMJ does not warrant the accuracy and reliability of the translations (including but not limited to local regulations, clinical guidelines, terminology, drug names and drug dosages), and is not responsible for any error and/or omissions arising from translation and adaptation or otherwise.