Healing with CBP After ACL Tear

Previous common belief among clinicians and researchers was that after tearing your anterior cruciate ligament (ACL), chances are you will need reconstuctive surgery. Especially if it affects your activities of daily living like climbing stairs, squatting etc. More so if you wish to return to sports.

Well, latest research shows that one may not need surgical intervention to achieve healing after all. The following paper (Filbay et al, 2023) showed excellent results with the Cross Bracing Protocol (CBP) in patients who tore their ACL. 72 out of 80 participants (90 percent) with a total tear of their ACL at baseline had MRI signs of ACL healing (a continuous ACL) after only 3 months.

Of the 8 participants whose ACL's did not heal, 6 had attached to the lateral wall ± PCL (post cruciate ligament), with MRI evidence after 3 months.

The subjects studied were between 10-58 years old who saw a sports doctor in private practice in Sydney, Australia and followed up from 2016-2021 with MRI confirming acute ACL rupture. They were all managed with the CBP.

The CBP aims to reduce the gap distance between the torn ACL remnants by immobilizing the knee at 90 degrees flexion (or bending) for 4 weeks in a knee brace after acute rupture. This to facilitate bridging of tissue and healing between the torn/ ruptured bits. The subjects also used crutches (or wheelchair, i-walker etc) for up to 8 weeks. After 4 weeks the range of motion is increased weekly whilst the subjects underwent physiotherapist-supervised rehabilitation. 

Previous published research by Filbay et al (2023) support current findings. The KANON (Knee Anterior Cruciate Nonsurgical versus Surgical treatment) trial found at least 30 percent of participants (16 out of 54 participants) with ACL ruptures had signs of  healing (shown on MRI) with conservative management. (Note:  In the KANON trial, subjects with ACL tears had better outcomes when randomized to rehabilitation and optional delayed ACL reconstruction or early surgery and rehabilitation).

The high rate of healing observed after 3 months on MRI suggests that this CRP can be conducive to ACL healing. It is also heartening to note that patients with other associated injuries at baseline became asymptomatic after the CBP.

But it is not known whether a continous ACL observed on MRI demonstrates restoration of pre injury ACL function. 14 percent (11 patients) had re-ruptured their ACL at time of follow up. This rate of reinjury is comparable with re-injury rates following ACL surgery. 90 percent of these re-ruptures occur after return to high risk sports.

Note that data from this study was collected in the course of clinical practice rather than in a research setting so some adaptations were made to the CBP over time. The study design also did not allow comparison of outcomes with people managed with surgery or rehabilitation alone. 

Looking at the protocol in detail (supplementary detail in appendix 1), one would need to wear a knee brace for 12 weeks while using crutches for up to 10 weeks. Some would definitely choose that considering the potential for positive outcomes. 

Results from the KANON trial and the CBP clearly suggest that there may be more ACL healing than what was commonly known. I would add that larger randomized cohorts with longer follow up duration will add more weight to this protocol. Take collagen at the same time to help with further healing.

References

Filbay SR, Roemer FW, Lohmander LS et al (2023). Evidence Of ACL Healing On MRI Following ACL Rupture Treated With Rehabilitation Alone May Be Associated With Better Patient-Reported Outcomes: A Secondary Analysis Fom The KANON Trial. BJSM. 57: 91-99. DOI: 10.1136/bjsports-2022-105473. *

Filbay SR, Dowsett M, Chaket JM et al (2023). Healing Of Acute Anterior Cruciate Ligament Rupture On MRI And Outcomes Following Non-Surgical Management With The Cross Bracing protocol. DOI: 10.1136/bjsports-2023-106931

*Some of the authors from this study like Frobell and Roemer first investigated ACL healing with papers published back in 2013. You can read more from our other blog.

My Patient Was Told He "Just" Tore His Lateral Meniscus

Maybe it's not so obvious from just the picture above. But when I looked at my patient's legs, they were the first clue I received that perhaps there was something more than meets the eye.

He had gone on a skiing holiday in Whistler in March earlier this year and suffered a fall. After being brought to the physiotherapy clinic on site, they just gave him a knee brace and told him that he tore his lateral meniscus and that it will recover in a month or two. He actually felt fine after a few days of resting and thought he recovered fully after returning to New York where he's studying.

Two months later, when he tried to play tennis once, his right knee "gave way" and he had a very sharp pain for a few seconds. That actually subsided quite quickly too. Similarly on another occasion when he had a kick around game of football with his friends, his knee collapsed again.

He then mentioned that he wasn't confident about running, playing sport with his knee since even it seems to him that he'd recovered.

From what he told me, I immediately suspected he'd tore his Anterior Cruciate Ligament (ACL). Not wanting to "scare" him at first, I didn't say anything to my patient I went through all the ligament and joint testing thoroughly.

After checking his patellofemoral and tibia femoral joints, I did the Lachman's test, Reverse Pivot Shift test and the Anterior Drawer Test for the knee and they were all positive. (I seldom get a positive result for the Anterior Drawer Test but for him there was pain and a big difference in laxity compared to his other leg).

My patient was very shocked when I told him that he'd torn his ACL based on my assessment findings. He wasn't very convinced at first until I explained to him what I found based on his history, the positive orthopedic tests (and the fact that the physiotherapist in Whistler didn't actually examine him). Later he added that no wonder his knee never felt quite right after the skiing trip and now he knew the reason for it.

From my patient

He later went to see his general practitioner doctor and got a referral for a MRI scan and he later messaged me the result as you can see in the picture above.

After some consideration, he decided to do his ACL reconstruction yesterday in Singapore instead doing it elsewhere. Here's the picture he sent me upon discharge from hospital today.

Picture from my patient

It's not the the first time I have a patient who tore his ACL but the previous doctor/ medical practitioner/ physiotherapist they went to first missed it.

Please make sure whoever you see for your knee pain assesses your knee thoroughly.

Fear Is Your Biggest Enemy When You're Injured

Now that's gotta hurt (Picture from Ang Kee Meng)

Are you recovering from an injury or recuperating from a surgery? Fear plays an enormous role when you're recovering from an injury, especially a long term injury.

Trust me I've had 3 knee surgeries on my right knee. For a few years after my 3rd knee operation I was paranoid about the slightest pain in my right knee. I made sure I only ran on grass (less impact or so I thought), read every single published article on articular cartilage injuries (my condition) and did lots of deep water running.

I remember every time if someone on the bus or MRT stood too close to me (let alone bump into my knee) I'll give the person a dirty look and move away.

So I'm pleased to share that I'm not the only paranoid athlete/ person around. Researchers suggest fear can determine whether or not an athlete makes a full recovery. Some athletes even have "post traumatic stress" back to the moment they got injured.

In a group of patients recovering from an anterior cruciate reconstruction (ACL) reconstruction, strength of muscles around the knees, functional range of movement, level of activity and intensity of pain were measured over the course of their recovery. Researchers also measure levels of kinesiophobia, pain related fear of movement,

The most common reason for not having a full recovery was the fear of getting injured again. These athletes did not have higher levels of pain than others in the study, they were just plain scared.

The researchers concluded that their results show that physical impairments may contribute to initial functional deficits whereas psychological factors (or fear) may contribute to longer term functional deficits in patients who are still fearful of re-injury. This fear and/ or lack of confidence may be a barrier to future sports participation.

Addressing your fear, alongside the physical injury is critical for your recovery.

Oh, by the way I forgot to mention that I've also fractured my skull before and had a compression fracture in my lumbar spine as well.

Come see us in either of our clinics if you're struggling to recover from your injuries/ surgery from fear, lack of confidence or other physical reasons.


Reference

Lentz TA, Zeppieri G Jr, George, SZ et al (2015). Comparison Of Physical Impairment, Functional, And Psychosocial Measures Based On Fear Of Reinjury/ Lack of Confidence And Return-To-Sport Status After ACL Reconstruction. AJSM. 43(2): 345-353. DOI: 10.1177/0363546514559707.

After Rupturing His Patella Tendon .....

Nice leather seats ....

This is how Ronald Susilo came to our clinic after surgery to re-attach his patella tendon - his wife drove him while he sat in the back seat. Besides rupturing his patella tendon, he also tore his ACL and his meniscus.

With the Floss band

Last Saturday (20/02/16)  you saw him struggling to turn the pedals a full round while on the stationary bike. Only with the Floss band he managed to go one full round albeit with lots of shouting (in pain of course)!

On Monday (22/2/16), we went to the pool for hydrotherapy. 

And yesterday he saw his surgeon for a review. His surgeon told him "good progress". Little did the surgeon know he couldn't bend his knee more than 60 degrees last Saturday!

Today we got him on the Bongo board. Yes, both side to side and front and back. A board developed to challenge even professional athletes.

Check this out!

Holding on for dear life

What I'm trying to say is we didn't achieved this progress just because of the Floss band. Yes maybe the Floss band did kick start his rehab last Saturday by allowing him to turn the stationary bike pedals a full round. He began to believe in himself after that.

We did lots of other things along the way too, (I've left out the other rehab details of course, come talk to me if you wanna know). 

Use your Floss band as part of the treatment strategies you have to treat your patients. It's not a magic bullet. It's certainly not the only treatment aid/ tool you should be using.

To Jane Fong, Danny Ho, Sven Kruse and Sanctband, thank you for introducing to me the Floss band. It's definitely a tool I use in my bag of tools to treat my patients.

Ronald Susilo going down stairs