Wouldn’t it be amazing if an ACL tear can heal on its own without surgery?
For sure, and there have been recent discussions about the Cross-Bracing Protocol and its impact on these injuries.
But is this too good to be true?
In this episode, we discuss the emerging cross-bracing protocol for non-operative ACL treatment, exploring its potential benefits and drawbacks. There is some skepticism about the protocol’s effectiveness, but we discuss the importance of patient selection and quality of life considerations in treatment decisions.
Good timing on this episode. I just released my brand new online course, The ACL Rehab Masterclass: A Complete Guide to Criteria-Based Rehabilitation, Testing, and Return to Sport. I teamed up with Dan Pope and Kevin Coughlin to share the exact system we use at Champion.
To view more episodes, subscribe, and ask your questions, go to mikereinold.com/askmikereinold.
#AskMikeReinold Episode 387: Can the ACL Actually Heal Without Surgery?
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Show Notes
Transcript
Mike Reinold:
Welcome back, everybody, to the latest episode of the Ask Mike Reinold Show. We are here up in Boston, Champion PT and Performance, answering your questions. Sports, PT, career advice, performance stuff, anything you want to talk about, head to mikereinold.com, click on that podcast link, and fill out the form to ask away. Let’s see, we are joined today by Anthony Videtto, Dave Tilley, Diwesh Poudyal, Brendan Gates, and Lenny Macrina. See how I’m mixing it up?
Lenny Macrina:
Hello.
Mike Reinold:
I’m zigzagging across my screen with the intros there a little bit. But yeah, we are here. No students again today, but we do have a question for you. Trying to mix up the format a little bit and see if we like it here. We’ll get another question. Next episode coming out in a couple of weeks, we’re going to go back to a good journal article review, which I don’t know, I think I’m digging. What do you guys think? You like the journal article reviews that we’re doing?
Dave Tilley:
Yeah.
Anthony Videtto:
Definitely.
Lenny Macrina:
I definitely do.
Mike Reinold:
Yeah. I feel like we like doing them, and I’ve gotten really good feedback from people listening, but keep giving us feedback. Reply to our things on social media so we can see if you like them or not. But that’s coming up next episode. This episode, we have a question from Brian from Texas.
“Mike, I’m seeing more and more people talk about non-operative ACL using the cross-bracing protocol.” I feel like if we were a real podcast, I would have a sound effect there that’d be like, tum, tum, tum. Like on that one. All right, sorry, Brian. “I’ve been a PT for a couple of decades. I have to wonder, is this the end of the road for reconstruction surgery as we know it? Or are we setting these athletes up for early onset OA?” That’s a really good question. “Or are we just setting them up to failure?”
But no, let’s talk this through here. So first off, Len, you want to introduce the crowd real quick, cross-bracing protocol. What do we know? Because I’m going to be honest with you, at Champion, we’re not seeing a ton of these here because we have so many athletic people, and I think most athletic people are scared to do this non-operative approach. So it’s kind of not our world. But Lenny, from your experience, and I know you argue… I mean, you’re active on Twitter. Can you explain the cross-bracing protocol for people?
Lenny Macrina:
I’m one of the last few PTs that are still on Twitter. Me and Dan Lorenz.
Mike Reinold:
Is that true?
Lenny Macrina:
It’s a mess.
Mike Reinold:
I’ve been off for a year.
Lenny Macrina:
I feel like I’m talking to myself out there right now, trying to share stuff. But I’ve been a little vocal on this protocol. So it’s a protocol that was developed, I believe out of Australia. I think it’s Dr. Cross. I think it’s like literally he put his name on it, and it’s immobilizing the knee. So somebody tears their ACL, and if you want to go non-op, then you are immobilized into flexion. It used to be, I think for 10 to 12 weeks. It’s down to four weeks now, and the immobilization has to happen within like the first week or so. That’s, I think, a key component of this.
The theory is that putting the knee in flexion is going to take stress off of the ACL, allow it to heal into its normal position, heal back down to the bone, and avoid a surgery. Being immobilized for four plus weeks in a position, especially flexion, comes with some negative effects, meaning blood clots can form. So you have to go on prophylactic medication to prevent that. Obviously flexion contractures, so range of motion issues, because you’re not doing anything. You’re literally immobilized in a brace for four weeks, easily, to allow that healing to occur. MRIs are what’s being used to determine healing, which obviously has some limitations. And so I think probably a repeat MRI has to be done, and obviously Lachman and stuff like that to show integrity of the ligament. And some studies out of Australia, Stephanie Filbay has shown that healing rates are high, higher than we once thought, and surgeries can often be avoided by people who do this protocol.
Mike Reinold:
It’s crazy because I think you’ve already started to like rule in, rule out certain people. And I remember when it first came out, the period of immobilization was enormous. That’s kind of crazy. But you’re ruling out anybody that needs their knee to be anything but 90 degrees flexed for at least a month, and then you’re hoping the thing works. So like, most athletes aren’t probably going to deal with that because if it doesn’t work, you just wasted a lot of time, and you probably look awful going into the surgery.
Lenny Macrina:
I think, keep in mind that if you have a mid-substance tear, I don’t think you’re going in this protocol.
Mike Reinold:
That’s a good point.
Lenny Macrina:
This is like that proximal avulsion of somebody that shows up on an MRI like, “Oh no, wait, you have a chance.” Because there is Dr. DiFelice, I had to think of his name, Dr. DiFelice out of New York, who I’ve spoken to a couple of times, who does a repair procedure. So he doesn’t do a reconstruction, he does a repair. So he does a surgery, but to repair it back to the bone, and then an internal brace to kind of reinforce it because those proximal repairs can sometimes heal back to the bone. And I don’t want to say that’s decent evidence, but there is evidence. There is stuff out there he’s published. And so this is kind of a similar, but no surgery involved. It’s literally “position the knee to allow that ACL to heal appropriately.”
Mike Reinold:
It just seems like one of those things that we’re trying, and you’re like, “Oh, cool. It worked.” But that doesn’t mean it worked well.
Lenny Macrina:
Exciting, if possible. But man, I’m so skeptical in talking to my colleagues or your colleagues, some of our well-respected ACL therapists and even surgeons. It’s very difficult to comprehend how this could be the thing of the future. I guess on MRI you can see potential healing, but is it functionally healing? Is this allowing stability, or is it just looking like it’s healed?
Mike Reinold:
That’s a good point.
Lenny Macrina:
A paper just came out this month or last month that showed 70% retear rates in people that went through this protocol. The protocol was not used appropriately. They didn’t get some of the people into the cross-bracing protocol until weeks after the injury, versus the four to 10 days that’s traditionally utilized, but a 70% retear rate in the people that went through the cross-bracing protocol in that paper. And it’s Clinical Journal of Sports Medicine 2026. So again, some research coming out, but I’m still very skeptical. Very, very skeptical. And I am personally still recommending reconstructions for my athletes.
Mike Reinold:
Yeah. And maybe it’s just your patient population, though, too, which I think is a lot of people’s patient population that has this.
Lenny Macrina:
But if I’m choosing surgery for somebody who had a freak accident, not trying to get back to anything, but just have them work on a strengthening program and know four weeks of 90 degrees and anticoagulants, I’m choosing, “Let’s just go the traditional conservative route for that 55-year-old who doesn’t really have a high stress activity.” Why put them at 90 degrees and risk a clot?
Mike Reinold:
Len, you only have two options and you have to decide: cross-bracing protocol or allograft.
Lenny Macrina:
Allograft. I’m going allograft.
Mike Reinold:
All right. Okay. Quad tendon… No, I’m just kidding.
Lenny Macrina:
Exactly.
Mike Reinold:
All right, my question for you because… All right, so 30% of the time it works 100% of the time. That’s amazing. So, but 30% success rate. Brendan, Anthony, Dave, I know you guys have read this. I think we’ve all read this article. Of those people that were successful, how’d they deem success? What is success? How long of an outcome was it in these studies? Who wants to jump in on that? Brendan?
Brendan Gates:
Yeah, I think the follow-up in this paper exactly was two years. So they looked back two years after they had this done, and all of the people that were included in this were participating in pivoting sports, which is why I think the instability rate was so high. The ages were 16 to 40, I believe, in this paper, so definitely a more active population. I’d have to look through exactly, say, how they deemed it as successful, but that instability rate is just like absurdly high to me. And I think that the title of the paper, I think it even says, I’ll pull it up here. It says, “Unacceptably high failure rate relative to surgical stabilization.” So I mean, I’ll go through and look at the details a little bit more on the successful 30%, but that 70% is concerning.
Mike Reinold:
Yeah, for sure. What do you got, Dave?
Dave Tilley:
Yeah, I think too, I mean, we always put people in the bucket of the cutting, pivoting, 16-year-old female soccer player. It’s like the typical avatar you use, but I think people underestimate how much your knee just… Like, you want to hike, you want to move, you want to do stuff around your house. You’re putting yourself in funky positions. I can think of a couple cases of people who were in their 30s or so, and they were not super high level college people, but they were just like, “Yeah, I stepped off the curb and I felt a little whoa, and then my knee was puffy for a couple of weeks.” And I think the bigger concern is not only like, if you only classify people on “did you retear or not,” I think you’re missing a lot of quality of life and just like overall happiness with someone’s knee.
People want their knee to be not a limiting factor when they go out on the weekends, when they walk for a long time. And I think people who have, for a range of issues, if they have these kind of alternative versions of surgery, they just sometimes don’t have great feeling knees. It’s not even about their retear rate is high, but maybe they get instability, they have a meniscus thing, they have like a fat pad irritation, they have a chronic, just like swollen, cranky knee. They can’t go for long walks in the city with their family. And I think that’s probably a quality of life thing you have to consider, is like, sure, maybe you didn’t have a massive retear or long-term structural damage, but maybe that person’s not exactly happy with the way their knee is the rest of their life.
Mike Reinold:
Yeah. I would even add, Dave, too, the happiness of the first two to three months. In the rehab process, not even just long-term satisfaction with their knee, but how brutal were the first few months? I think that’s something to keep in mind with that, too. I don’t know. I think with anything else we talk about when you have a new procedure like this, the number one thing we do is… It’s this new procedure. We tried on a lot of people. We have to identify who’s the right person for this because we all kind of chuckle about this because we’re all working with athletes and stuff. But I don’t know, maybe if my mom tore her ACL? I mean, I don’t know. I mean, that’s a bad example. She’s not young. But somebody out there… We have to identify who is the right person to potentially try this.
And then what I would like to see is, to Lenny’s point, I want to see a study comparing non-operative treatment where we actually rehab the person versus immobilizing them, and see what the difference in long-term outcomes is, even with an ACL deficient knee. I mean, how many people here know somebody that doesn’t have an ACL and they’re fine. I think we all do. I know PTs that don’t have ACLs that they tore, and they never had it fixed, and they’re fine. We have a friend that just had two total knee replacements, which is a consequence of not having ACLs, but he didn’t have ACLs for a very long time and he was fine, other than the OA.
And it’s funny, Brian from Texas actually said, “Are we setting these athletes up for early onset OA?” I mean, maybe that would be the next thing to look at, is, do these people have more OA down the road than if you did a traditional reconstruction? I don’t think we know the answer to that yet.
So I’d say cross-bracing… It’s interesting. I think it’s intriguing that we’re at the point where maybe these things aren’t all surgical candidates, but gosh, the future’s different. There’s going to be different ways that we can do this, right? Different ways that we can potentially like… I don’t know, there’s new procedures, stem cells, I don’t know, all this stuff that’s coming out that we probably have a better thing in the future than just “let’s immobilize and hope this thing heals itself.” I don’t know. Good ending? What do you think, Brendan?
Brendan Gates:
Just one thing on the OA. I think maybe if it’s an isolated ACL rupture, that’s one thing, but we know that meniscus injuries can have some impact on OA long term. So if this is an ACL rupture with some sort of meniscus pathology, at that point, do you just punt on this idea completely and just go right back to surgery? I wonder your guys’ thoughts on that.
Mike Reinold:
Yeah. I mean, if you need multiple procedures for stuff, if you need to work on your meniscus, I would imagine. I don’t know. What do you think, Dave?
Dave Tilley:
Yeah, I mean, I agree. I think the long tail of what you’re choosing in the beginning makes a huge ripple effect, and down the road, between the healing stuff, the timelines. And I’m just thinking in my mind about if you’re immobilized for four weeks when you come into PT, the last thing we’re thinking about is strengthening and trying to get you in good shape to do things that are fun and upright. It’s going to take so long to get your motion back and to get you going and to get you in a place where your knee is just happy and not a cranky, angry knee from being stiff.
So that’s what I was thinking about when I think Lenny was mentioning… It’s like, man, four weeks of immobilize, how long is that going to take to get to a normal pain-free walking gait pattern? Let alone you’re strengthening, you’re doing a traditional… That’s got to be two to three months before you can load somebody really well. And I don’t mean to laugh, but that’s at least three months of hard work in the clinic before you’re even talking about getting somebody back into a fun strengthening program.
Mike Reinold:
Agree. Agree. All right. Well, yeah, cross-brace protocol. What a good episode.
Stay tuned. Future episode here. But yeah, no, I mean, very interesting stuff. But anyway, good question, Brian. I think a lot of people are probably going to hear about this. I don’t know if we’re seeing it as much as we’re hearing about it. I know there’s a lot of people excited about the concept of this on social media, but conceptually is nice, but functionally is a little bit different too. So keep your eyes out for that. I mean, hopefully we get better and better at this, but for now, I don’t know, I think we’re cautious.
So appreciate the question there, Brian. Thanks so much. If you have a question like that, head to mikereinold.com, click on that podcast link and be sure to subscribe so you get future updates. Thanks so much.
