Can the ACL Actually Heal Without Surgery? - #AMR387

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. 

• Click here to learn more about The ACL Rehab Masterclass

To see full show notes and more, head to: https://mikereinold.com/can-the-acl-actually-heal-without-surgery/

Learn our proven system for sports PTs who want to master ACL rehab, confidently progress patients, and guide athletes safely back to high-level sport.

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Transcript

Big Question On ACL Healing

SPEAKER_02 0:00

On this episode of the Ask Mike Rhinald Show, we talk about whether or not the ACL can heal without surgery. We talk about the cross-bracing protocol. The Ask Mike Reinhardt Show. Helping people feel better, move better, and perform better. Before we get to the podcast, I wanted to make sure you knew about my free online course on the introduction to performance therapy and training. If you want to learn how to get started optimizing and enhancing performance, this is the course for you. Head to microneynold.com/slash performance to sign up today. I'm back, everybody, the latest episode of the Ask Mike Reynolds Show. We are here up in Boston, champion PT Performance, answering your questions. Sports PT, career advice, performance stuff, anything you want to talk about, head to micronald.com, click on that podcast link and fill out the form to ask away. Let's see, we are joined today by Anthony Vedetto, Dave Tilley, Dewesh Podell, Brendan Gates, and Lenny McCrina. See how I'm mixing it up? I'm zigzagging across my screen with the intros there a little bit. Um, but yeah, we are here. Uh no students again today, but we do have a question for you. Um, you know, you know, trying to trying to mix up the format a little bit and see if we like it here. We get another question. Next episode coming out in a couple

Free Course And How To Submit

SPEAKER_02 1:23

weeks, we're gonna go back to a good journal article review, which I don't know. I think I'm digging. Um, what do you guys think? You like the journal article reviews that we're doing?

SPEAKER_00 1:31

Definitely.

SPEAKER_02 1:32

Yeah. I feel like we like doing them, and I've gotten really good feedback from people listening, but you know, keep giving us feedback. Like, reply to our things on social media so we we can see if you like them or not. So uh, 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 like a sound effect there. That'd be like dum dum-dum, like on that one. All right, sorry, sorry, Brian. Um, 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 that's a really good question. Or are we just setting them up to failure? But no, let's let's talk this through here. So, first off, Len, you want to introduce the crowd real quick. Cross bracing protocol. What what do we know? Because I I'm gonna be honest with you, 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

Brian’s Question From Texas

SPEAKER_02 2:39

you're active on Twitter. Um, can you uh explain the cross bracing protocol for people? I'm one of the last few PTs that are still on Twitter, me and Dan Lorenz. Um is that true?

SPEAKER_04 2:49

It's a mess. I've been off for years. I feel like I'm talking to myself out there right now, trying to share stuff. Um but I 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. Um and it's immobilizing the knee. So somebody tears their ACL, and if you want to go non-up, 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 and the immobilization has to happen within like the first week or so. That's I think a key component of this. Um, and the theory is 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 you know four plus weeks in a in a position, especially flexion, comes with some you know, negative effects, meaning um, you know, uh blood clots can and 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 you know four four weeks easily to allow that healing to

What Cross Bracing Actually Is

SPEAKER_04 4:03

occur. Uh MRIs uh are what's being used to determine healing, which obviously has you know some limitations. Um, and so I think uh probably a repeat MRI has to be done, and obviously Lochman and stuff like that to show integrity of the ligament. And some studies out of Australia, Stephanie Philbay, um has shown that you know healing rates are are high, higher than we once thought, and surgeries can often be avoided uh by by people who uh do this proceed this protocol.

SPEAKER_02 4:31

So yeah. You know, it's crazy because I I think you've already started to like rule in, rule out certain people, right? Like who's you know, and I remember when it first came out, the the period of immobilization was enormous. That's kind of crazy. But like you're ruling out anybody that um needs their knee to be anything but 90 degrees flex for at least a month. Um, and you know, and then and then you're hoping the thing works. So like most athletes aren't probably gonna deal with that because if it doesn't work, you just wasted a lot of time and you probably look awful going into the neck surgery, right? Right.

SPEAKER_04 5:05

So I think keep in mind that you know if you have a mid-substance tear, I don't think you're going in this protocol. This is like that that proximal evulsion of somebody that shows up on an MRI, they're like, oh no, wait, you can you have a chance, you know, because there is Dr. uh D. Felice, I had to think of his name, Dr. D. Felice out of New York, who I've spoken to a couple times, um, who does uh repair procedure. So he doesn't do a reconstruct, he does a repair. So repair he does a surgery, but if 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 that's you know, I don't want to say that's decent evidence, but there is evidence. There is stuff out that he's published. And um, so this is kind of a similar but no surgery involved. It's literally position the knee to allow that ACL to heal appropriately.

SPEAKER_02 5:48

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.

SPEAKER_04 5:54

Exciting, yeah, if possible, but man, I'm so skeptical. And talking to my colleagues, your colleagues, some of our well-respected ACL therapists, and even surgeons, like it it's very difficult to comprehend how this could be uh the thing of the future because it just, you know, I guess on MRI you can see potential healing, but is it uh functionally healing? Is it, you know, is it is this allowing stability or is it just looking like it's healed? Um paper just came out uh uh this month or last month um that showed 70% uh retail 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 about uh you know weeks after the injury versus the four to ten days that's traditionally utilized. Um but a 70% retail rate in the people that went through the cross bracing protocol in that paper. And it's clinical journal of sports medicine 2026. So um again, there there are some research coming out, but I'm still very skeptical, very, very skeptical. And I am personally still recommending reconstructions for my athletes.

SPEAKER_02 6:58

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.

SPEAKER_04 7:03

But um But

Risks And Who It Fits

SPEAKER_04 7:05

I uh I if I'm choosing um if I'm choosing surgery or somebody who had a freak accident, not trying to get back to anything, but just have them work on a strengthening program and no four weeks of 90 degrees and anticoagulants. I'm choosing let's just go the traditional, you know, conservative route for that 55-year-old who doesn't really have a high stress, you know, uh activity, you know. Why put them at 90 degrees and risk a clot?

SPEAKER_02 7:32

Len, you have you have only have two options and you have to decide crop cross-bracing protocol or allograft. Alligraphed. I'm going allograft. All right, okay. Quad tendon? No, I'm just kidding. Exactly. Um I my question for you, because all right, so 30% of the time it works 100% of the time. That's amazing. So, but 30%, 30% success rate, Brendan, Anthony, Dave, I know you guys have read this. I think we've all read this article. Um, of those people that were successful, how'd they deem success? Like what what what is success? You know, like uh how long of an outcome was was it in these studies? You know, who who wants to jump in on that? Brendan?

SPEAKER_03 8:14

Yeah, I think the follow-up in this uh paper exactly was two years. So they looked back two years after they had this done. Um 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. Um the ages were 16 to 40, I believe, in this paper. Um, so definitely a more active population. Um I have to look through exactly to say how they deemed it as successful. Um, but that instability rate is just like absurdly high to me. Uh 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, uh I'll go through and look at the details a little bit more on the successful 30%, but that 70% is concerning.

SPEAKER_00 9:00

Yeah. Yeah, for sure. What do you got, Dave? Yeah, I think too, I mean, we always put people in the bucket of like the cutting, pivoting, 16-year-old female soccer player, right? It's like the typical avatar you use, but like 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. Like you're you're putting yourself in funky positions. Like 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 like I felt a little whoa. And then like my knee was puffy for a couple of weeks. And I think the bigger concern is not only like the if you only classify people on did you retain 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 like kind of alternative versions of surgery, they just sometimes don't have great feeling knees. It's not even about their retail rate is high, but they maybe they get instability, they have a meniscus thing, they have like a fat pad irritation, they have a chronic, just like swollen,

New Data And Failure Rates

SPEAKER_00 9:55

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 retail or long-term structural damage, but like maybe that person's not exactly happy with the way their knee is the rest of their life, you know?

SPEAKER_02 10:09

Yeah, I would even add, Dave, too, I the happiness of the first two to three months, right? Like in the rehab process, not even just long-term satisfaction with their knee, but like how brutal were the first few months. You know, I I I think that's something to like kind of keep in mind with that too. So, you know, I I don't know. I I think like I with anything else we talk about when you have like a new procedure like this, the number one thing we do is like it's this new procedure. We try it 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 like my mom tore ACL, I mean, I don't know, maybe that's a bad example. She's not young, but like you know, like I it's somebody out there, like 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, right? I mean, how many people here, I mean, know somebody that doesn't have an ACL and they're fine? I think we all do, right? I know, I know PTs that don't have ACLs that they tore and they never had a fix and they're fine. Uh, we have a friend that just had total two total knee replacements, so which is a consequence of not having ACLs, but he didn't have ACLs for a very long time and he was fine, you know, other than the the OA. And you know, it's funny, Brian from Texas actually said, are we setting these athletes up for early onset OA? I mean, maybe. Um, 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

Quality Of Life Over “Success”

SPEAKER_02 11:40

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, you know, aren't all surgical candidates, but gosh, the future's different, right? There's gonna be different ways that we can do this, right? Different ways that we can potentially like uh, you know, uh I don't know. There's there's new procedures, stem cells, I don't know, all these 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, right? I don't know. Good good ending. What do you think, Brandon?

SPEAKER_03 12:11

Uh just one thing on the the OA, you know, I think maybe if it's uh an isolated ACL rupture, um that's one thing, but we know that uh meniscus injuries can have some impact on OA long term. So if this is an ACL rupture with some sort of meniscus pathology, you know, at that point do you just punt on this idea completely and just go right back to surgery? Um, I I wonder your guys' thoughts on that.

SPEAKER_02 12:37

Yeah, I mean if you have if you need multiple procedures for stuff, right? If you need like to work on your meniscus, I would imagine, right? I don't know. What do you what do you think, Dave?

SPEAKER_00 12:45

Yeah, I I mean, I agree. I think like the the long tail of what you're choosing in the beginning makes a huge ripple effect and like down the road, right? Between the time like the healing stuff, the timelines, like, and I'm just thinking in my mind about like if you're immobilized for four weeks when you come into PT, the last thing we're thinking about is like strengthening and trying to get you like in good shape to do things that are fun and upright, right? Like it's gonna 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, like that's what I was thinking about when when um I think Lenny was mentioning is like, man, four weeks of immobilize, how long is that gonna take to get to a normal, pain-free walking gait pattern? Let alone you're strengthening, you're doing a traditional, like that's gotta be two to three months before you can load somebody

OA Meniscus And Future Options

SPEAKER_00 13:30

really well. And I don't mean to laugh, but like that's at least three months of hard work in the clinic before you're even talking about getting somebody back into like a fun strengthening program.

SPEAKER_02 13:38

Agree, agree. So all right, well, yeah, cross braids protocol. Good up. BC517 coming out soon. Stay tuned, future episode here. But yeah, no, I mean, yeah, very interesting stuff. But anyway, good question, Brian. Um, I think a lot of people are probably gonna 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 he's nice, but functionally is like 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 I don't know. I think we're cautious. So uh appreciate the question there, Brian. Uh, thanks so much. If you have a question like that, head to microneel.com, click on that podcast link, and be sure to subscribe so you get future updates. Thanks so much.