Cross bracing ™ prOTOCOL

THE CROSS BRACING PROTOCOL

the decision making model

What is the Cross Bracing Protocol?

The Cross Bracing Protocol (CBP) is an innovative, non-surgical approach to managing acute ACL injuries, developed by Dr. Mervyn Cross and Dr. Tom Cross in Australia. Grounded in knee anatomy, joint biomechanics, and ligament healing physiology, the protocol aims to support natural healing of the ACL through strategic bracing and rehabilitation.

At the heart of the protocol are several key principles:

The ACL can heal. Contrary to traditional beliefs, the anterior cruciate ligament (ACL) has the potential to heal—under the right conditions.
Not all ACL injuries are equal. Research from the ACL-HEAL team suggests approximately 50% of ACL ruptures are too severe for meaningful healing. These cases may still require surgical intervention, especially for those returning to high-demand sports.
Time is critical. An acute ACL injury should be treated like a fresh wound—early intervention is essential. The ideal “window of opportunity” for initiating the Cross Bracing Protocol is within 4–10 days post-injury.
Some ACLs can heal without surgery. Partial tears and full ruptures without major displacement of ligament tissue may heal successfully with structured bracing and rehabilitation.
Healing is enhanced through knee flexion. The protocol applies the orthopedic principle of reduction—using a brace to hold the knee in flexion, which approximates the torn ligament ends and promotes tissue healing.
There is a narrow window for optimal healing. After approximately 8–14 days, involution (degeneration) of the torn ACL tissue may begin, significantly reducing the likelihood of successful healing. The protocol is generally not recommended beyond 21 days post-injury, although rare cases of healing have been observed when treatment began slightly later.
Evidence-based and growing. The initial study of 80 patients was published in the British Journal of Sports Medicine (BJSM) in 2023. Since then, over 580 patients have undertaken the Cross Bracing Protocol, with ongoing research and promising results continuing to shape its application.

***The Phases of ORKA’s Cross Bracing PROTOCOL™ Rehabilitation***

At ORKA Performance we have developed a 5 stage rehabilitation pathway that ensures you are successful at every stage. Our system has been developed to tackle every key performance indicator that is found in your testing during every block in our rehab system.

01. FOUNDATION PHASE (WEEKS 0-4)

The Foundational Phase of the Cross Bracing™ Program has the knee locked in 90° flexion within a ROM brace worn 24/7 to protect ACL approximation and optimize intrinsic healing. The athlete remains non-weight bearing (NWB) using crutches or a scooter. Physiotherapy focuses on minimizing atrophy and swelling while avoiding NSAIDs or aspiration. Weekly sessions include manual therapy at 90°, quadriceps and hamstring co-contractions, hip abduction/extension, and calf Theraband plantarflexion. The contralateral limb is strengthened with presses, curls, bridges, and core work. Upper body strength, airdyne bike and ski erg conditioning preserve global fitness. DVT mitigation protocols include calf pumps and blood thinners through Week 8.

02. TISSUE INTEGRATION (WEEKS 5-12)

During the Tissue Integration phase, brace unlocking is progressive: 60°–90° (Week 5), 45°–90° (Week 6), 30°–full flexion (Week 7), and finally unrestricted by Week 10 if tolerated. Partial weight bearing begins in Week 7, advancing to full weight-bearing as tolerated by Week 8. Anticoagulation ceases at the end of Week 8. Physiotherapy now introduces dynamic range of motion drills, wall squats (starting at 45° then 30°), bodyweight squats within brace limits, bridges, monster walks, leg press, and ROM-focused activities like heel slides. Gait retraining is introduced, along with static balance drills and exercise bike use (if >100° flexion). MRI and medical reassessment are conducted at Week 12 by the ORKA Sports Medicine team in conjunction with community partners.

03. STRENGTH CAPACITY (WEEKS 13-18)

Following brace removal in Week 13, Max Strength and force production capabilities intensify under full weight-bearing conditions. Physiotherapy emphasizes progressing hamstring and quadriceps strength with machines and functional movements such as single-leg squats, Bulgarian split squats, half-range lunges, and dynamic balance. Additional exercises include calf raises (seated/standing), single-leg press, and hamstring curls. Jogging in place, skipping, and use of cardio equipment to support reconditioning. Athletes must meet the ORKA Return-to-Run criteria before initiating straight-line running around Weeks 15–16. Manual therapy continues, and functional movement analysis is incorporated for running readiness, as they flow through ORKA's Return to Run program.

04. TRANSITION TO CHAOS (WEEKS 19-24+)

The Transition to Chaos Phase reintroduces high-velocity and reactive elements in preparation for sport, including power development The athlete will transition from closed, controlled environments to more variable and reactive settings. With the brace no longer required, athletes progress through structured exposures—beginning with deceleration and controlled linear mechanics, then layering in unanticipated tasks like reactive cuts, agility sequences, and jump-landing variability. Emphasis is placed on rate of force development in unpredictable conditions, reactivity (auditory/visual cues), and perceptual-cognitive demands like pattern recognition and anticipation. Physiotherapy includes multidirectional drills, SL landings under fatigue, decel-reaccel tasks, and dual-task constraints (e.g., passing/catching during movement). Athletes are progressed from movement control and force expression through to chaotic sport-specific scenarios—ensuring physical and cognitive resilience under pressure.

05. RETURN TO SPORT (MONTHS 9-12+)

We've reached the culmination of your rehab journey at ORKA Performance, and within your Cross Bracing™ journey. This stage prepares the athlete for full integration into high-speed, high-load, and high-context environments. Clearance is based on robust return to sport criteria, alongside demonstrated robustness during chaos-based drills. The focus shifts from purely physical readiness to “return to performance”—where decision-making, skill execution under fatigue, and position-specific chaos are tested. Integrated field sessions replicate real match tempo and intensity, layering chaotic variables such as opposition pressure, time constraints, and reactive transitions. Load monitoring, neuromuscular testing, and communication with sport coaches guide return-to-play progressions. The athlete isn’t just cleared to participate—they’re prepared to perform at pre-injury levels or better, with injury risk mitigation strategies actively embedded. The return to sport is criteria-based, typically falling between 9–12 months post-injury, in the context of no complications.

THE STAKEHOLDERS

POTENTIAL

PATIENT COSTS INCURRED

TOTAL POTENTIAL INCURRED COSTS: $6,935.66-$10,297.66

Cross Bracing Protocol™

Developed by Dr. Tom Cross, Sports and Exercise Medicine Physician

For more information, visit www.healACL.com

This document is based on the principles of the Cross Bracing Protocol™, a trademarked approach by Dr. Tom Cross. All rights to the original protocol, including associated resources and infographics, remain with the original creator. This adaptation is for informational purposes within the Canadian context.

FAQs

Frequently Asked Questions

What is the Cross Bracing Protocol?

The Cross Bracing Protocol (CBP) is a structured, non-operative treatment for complete ACL tears developed by Drs. Merv and Tom Cross. It involves using a knee brace locked at 90° for 4 weeks, followed by gradual unlocking over the next 8 weeks, combined with targeted physiotherapy to facilitate natural healing of the ligament.

Who is eligible for the Cross Bracing Protocol?

Patients with recent (within 4 weeks) complete ACL tears and specific MRI characteristics indicating good healing potential are eligible. A medical assessment is required to determine suitability.

How does the brace change over time?

Weeks 1–4: Locked at 90°, non-weight bearing

Week 5: Unlocked to 60°–90°

Week 6: Unlocked to 45°–90°

Week 7: Unlocked to 30°–120°, partial weight bearing

Week 8: Unlocked to 20°–120°, full weight bearing

Week 9: Unlocked to 10°–120°Weeks 10–11: Full ROM brace, removed during sleep

Week 12: Brace removed; MRI and medical review follow

What physiotherapy and exercises are involved?

Exercises are tailored to each stage. Early rehab includes quad/hamstring co-contractions, calf pumps, hip strengthening, and core work. As the brace unlocks, patients progress to squats, leg press, bridges, ROM drills, bike, balance, and later agility, jumping, and running drills. Physiotherapy is supervised weekly.

What are the success rates?

Studies show that around 90% of patients have MRI-confirmed ACL healing after 3 months using this protocol, with two-thirds returning to competitive sport within 12 months. Functional scores are comparable to surgical outcomes.

Can ACLs heal without surgery or bracing?

Some ACL tears may heal with rehab alone, but cross bracing improves the likelihood of ligament approximation and healing, especially in the right patient cohort. Some tears are not appropriate for the program, and this is determined by the medical team in consultation with the radiologist and surgical specialist.

What are the benefits and risks?

Benefits: High healing potential, avoids surgery, strong return-to-sport rates.

Risks: Brace discomfort, muscle atrophy, DVT risk (managed with anticoagulants), and not all patients are eligible.

Is this the right option for me?

Only a specialist can determine that. MRI results, injury timing, lifestyle, and goals all factor in. If you're within 4 weeks of injury, get assessed promptly.

What happens after the brace is removed?

Rehab continues with strengthening, agility, and return-to-sport progression. Running typically resumes around Weeks 16–17, light training at Week 20, and full return to sport between 9–12 months, with regular testing and imaging.