In the last post, I introduced the new research highlights that would be happening from time to time on The PT Page. I told you you wouldn’t have to wait long!
I saw this ACL research mentioned so much on socials and even had it recommended to me by a coworker I figured it deserved the first research highlight! These research posts will not be analyzing sample sizes or statistical methods of the study. It’s also not meant to be in lieu of actually reading it. They will give a brief summary of the study and the findings. The rest will be elaborating on results, interesting talking points either not mentioned or not fully flushed out in the discussion section of the article, and influence and/or integration into practice. Here is your first research feature! Full article linked below!
Stephanie R Filbay, Matthew Dowsett, Mohammad Chaker Jomaaa, Jane Rooney, Rohan Sabharwal, Phil Lucas, Andrew Van Den Heever, James Kazaglis, Justin Merlino, Mick Moran, Maggie Allwright, Donald E K Kuah, RA Durie, Greg Roger, Mervyn Cross, Tom Cross
The Rundown
Alright, so what did Filbay and colleagues do? They took 80 patients with acute ACL injuries and treated them conservatively with a Cross Bracing Protocol (CBP). They measured ACL healing with MRIs at 3 and 6 months then quantified it using the ACL OsteoArthritis Score (ACLOAS). Patient reported outcomes were measured using the Lysholm scale and ACL QOL scale around 12 months post-injury. They also measured knee laxity using Lachman’s test (3 months) or Pivot-shift test (6 months) and return to sport after 12 months.
Results of the study showed 90% of patients’ ACL tears were healing after 3 months. It also showed if you were a grade I on the ACLOAS at 3 months your overall outcomes were better in terms of self-reported measures, knee laxity, and return to sport.
The ACL OsteoArthritis Score (ACLOAS)
I just wanted to make a quick note on the ACLOAS as it’s important for digesting the results. I personally was not familiar with this prior to the article. The scale uses grades from 0-3 to quantify the quality or healing of the ACL. The grades are as follows:
0 = normal ligament, no injury
1 = thickened ligament and/or ill-defined, but intact
2 = thinned, stretched, but still intact
3 = absent, ruptured
If we look back at the results of the 3 month MRI if they had grade I – continuous ligament that was thickened, their self-reported outcome measures, laxity, and return to sport was better compared to those that had a grade II or III at 3 months. It’s also important to note that all the test subjects started off as grade III, complete ruptures. So 90% of patients went from a complete rupture to a ligament that was not only continuous, but also thickened within the first 3 months of the cross bracing protocol.
What the Heck is Cross Bracing?
I was not familiar or completely understood the term “cross bracing” prior to reading the article. At first I thought maybe it was a special kind of brace, but it’s your standard brace with flexion/extension stops. This cross bracing protocol specifically locked the patients into 90° of flexion. I couldn’t help but find this funny since after ACLR it’s the exact opposite with the patient’s knee locked in extension.
The Protocol
The patients were in 90° flexion for 4 weeks and then gradually progressed out. The article contains a very comprehensive week by week protocol for this progression with stage-appropriate therapy exercises, conditions for advancement to the next phase, and goals of the current phase or week. I was really impressed with the detail of their protocol as it included all the parts of ACLR protocols. It gave a good idea how this could be an alternative to ACLR. It also would make it very easy to integrate into practice.
My first initial concern with this protocol was the formation of knee flexion contracture. Surprisingly, only 11 out of 80 subjects demoed any kind of contracture AND they all got full ROM within 3 weeks with appropriate exercises. Oftentimes I tend to view flexion as easier to get back versus extension, but these numbers calmed my worries.
My second concern was how fast does this protocol move out of flexion to increase weight-bearing and wean off assistive devices? This happens fairly quickly with ACLR. I figured there’s no way the patient returns to sport as fast considering unrestricted ROM and full weight bearing is delayed with cross bracing until week 9! I was wrong though. Much like ACLR, the authors recommended full return to sport around 9-12 months. They acknowledged this could change depending on patient performance and how quickly they meet stage progression criteria. The protocol also says you can return to sport-specific training around 5 months with the next phase being return to play. This coincides with a possible return to play at 6 months as those with ACLR are able to do.
Time to return to play will be an important factor to our patients when making decisions about their care. Cross-bracing allows comparable return to sport time as ACLR overall, IF the patient lands in the 90% that shows healing at 3 months. If not, then they’ve been stuck with their leg bent for a month and have to get surgery anyway. Given this, it’s important to discuss who cross bracing might be for and who it might not.
Cross Bracing – Is It for Everyone?
Let’s start by discussing who the researchers ruled in or out from the beginning. First of all, the study only used acute ACL tears that presented to the clinic within 1 month of injury. This study solely focused on acute ACL rehab. However, I would be interested in a study using cross bracing for patients after a failed ACLR somewhere down the line. The researchers also ruled out those with other injuries that would require surgery such as unstable bucket-handle meniscus tears. Lastly, medical history including PE and/or DVT deemed a patient ineligible to participate in the study.
Like I said, anyone with an unstable bucket-handle meniscus tear or other injury that would NEED surgery were excluded from the study. However, almost half the subjects did have meniscus tears in addition to the ACL that did not need surgery. The cross-bracing protocol just about damn near fixed all of them. Now they didn’t quantify or specifically measure meniscus healing, but by the end of the study an impressive 97% of patients with meniscal injuries were asymptomatic.
If anything, another study should be considered using cross-bracing as a possible choice for conservative management of meniscus injury. I would be interested to see more longitudinal results as far as if participants stayed asymptomatic with long-term return to activities and sports. I would also really love to see how this cross bracing protocol would fare with an unhappy triad injury. Results have already shown promising for the ACL and meniscus so why not throw the MCL in there as well?
Now is a good time to talk about the 8 patients who showed no healing in the ACL. The idea of cross bracing is that staying in flexion reduces the distance between the ACL’s origin and insertion. The hope is that by reducing this gap, bridging may occur and allow the ACL to heal. The article speculates presentations where there is a large gap between ACL remnants or where they fall out of a certain area might not respond to cross bracing as well as others.
This leads to several follow-up questions. How far is too far and how do we quantify this? Would this require the formation of another scale kind of like the ACLOAS? Also how would we or other physicians get that info? I personally have never seen imaging reports that quantified distance between remnants of ligaments or described in detail where they laid. Not that it can’t be done, but I don’t think it’s something radiologists are used to reporting on. I believe in order to integrate this the referring physician, PT or other, would have to specifically ask for this info. Has anyone ever seen this info in an imaging report? Let us all know in the comments.
The Re-tear Rate
Now time to address the elephant in the room, re-tear rate. So in this study 14% (11 patients) re-injured their ACL. All injuries happened during sport or high intensity activity. Patients who with ACLOAS grade I at 3 months, their re-tears were due to high speed and/or contact injuries. The researchers acknowledge the 14% is comparable to ACLR re-tear rates with the vast majority also occurring as a result of high intensity sport and/or collisions.
So the re-tear rate isn’t awesome for conservative or non-conservative treatment. So what works?! Surgeons look at new operative techniques or research which ones typically get the best outcomes. We need to look at it from a rehab lens and begin asking ourselves what we can do better when it comes to adequately preparing patients for return to sport.
We have lots of tools and tests such as the LSI, quad to hamstring ratios, and comparisons to the non-injured leg that supposedly all indicate readiness for return to sport. Are they accurate enough though? Re-tear rates for both conservative and non-conservative treatment suggest it might not be. How are we addressing the needs of athletes to withstand the high-impact, explosive, and/or high intensity movements that commonly cause re-injury? I know one trend I’ve seen is training not just to control knee valgus but IN it. Personally I’m a big fan of this. It’s inevitable that at some point our athletes are going to go into or get knocked into a knee valgus or tibial rotation. We need to make sure they can tolerate these positions and/or adjust accordingly.
Anyone taken a great ACL rehab CEU or have some good drills they use to bulletproof the ACLs of their athletes? Drop em’ in the comments and share with the group!
Implementation and Integration into Practice
While the protocol from the researchers is in my opinion, stellar, implementation of conservative treatment for ACL rehab still has its barriers. I think the biggest one we’re all likely thinking of is getting surgeons to go along with this idea. The Washington Post actually wrote about the findings of this study as well. They got a couple surgeons’ viewpoints on the cross-bracing protocol who pretty much scoffed at the idea, but I remain hopeful. I tried to do some digging to see what the overall pulse on conservative ACL treatment was with MDs. I didn’t get a very clear picture, but many orthopedic websites mentioned conservative treatment for ACLs as an option. Now I’m not sure how often these doctors actually use conservative treatment, but a girl can dream right?
The results of this study suggest cross-bracing as a good option for someone returning to low to moderate exercise. None of the re-tears were from just normal weight-lifting, running, yoga, swimming, etc. So just your regular active person could rehab the ACL without a costly and painful surgery. You would hope orthopedic and sports medicine MDs would be open to this idea at least for a certain patient population if further research continues to support it. Anyone know what the consensus is among these physicians?
The other thing we have to ask ourselves is what do we think of it? I think there’s definitely some good stuff here! But is there enough yet that if a patient asked me if I thought they should go conservative or get surgery that I’d have a great answer? Honestly, I’d probably have a typical annoying PT “it depends” response. As more research comes out and available to the public it will be important we have informed opinions on this. What would you say? Are there certain situations you would consider conservative over reconstruction that wasn’t mentioned in this post or in the study itself?
This study definitely left some doors open for further research. Excitingly, it’s already in the works. The article by the Washington Post reported Filbay plans to continue this research in the near future so we’ll definitely be looking forward to that. Hats off to all the researchers involved in the study. I don’t think I’ve seen any PT study mentioned so much in the media and on social networks. This is the kind of exposure we need!
So there’s your first research highlight! I asked you a few questions in the comments that I’m genuinely curious about. If you have some insight please share! Discuss and share your thoughts and ideas in the comments section as well! Got an article you find interesting and would like to see discussed on The PT Page? Send it my way through the contact page or DM on Instagram @the_pt_page! As always, subscribe to get the latest posts directly to your inbox!
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