Anterior cruciate ligament (ACL) injuries remain one of the most challenging problems in sports medicine. Even with high-quality care, many people do not return to their previous level of sport or physical activity, and a proportion continue to experience knee symptoms that can impact their ability to participate in normal daily activities. These injuries are also associated with an increased risk of longer-term joint problems, including recurrent instability, secondary meniscal damage, and post-traumatic osteoarthritis.

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There are a range of treatments that are available to help patients who have sustained an ACL injury. As clinicians, our responsibility is to help patients make informed decisions that align with their goals, values, and circumstances. At present, many people with an ACL injury are told that surgery is required, without any real discussion about the available treatment options. This message is frequently reinforced by online information and popular websites, which often present reconstruction as the default or inevitable option. At the same time, emerging approaches such as cross-bracing may receive disproportionate attention, in part because they are novel and clinically interesting. Conversations about ACL treatment need to be realistic and individualised. It is essential to recognise that there is no single best treatment for all patients. Instead, there are several established options, each with clear benefits, limitations, and trade-offs. Patient choice, supported by clear information and clinical guidance, must sit at the centre of decision-making.

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Non-surgical management: effective for some, unpredictable for others.

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Well-structured rehabilitation without surgery (or bracing) can be an effective option for a subset of patients. This is often an option that is often not explained well to patients. This approach typically involves progressive, strength-based rehabilitation with a strong focus on quadriceps and posterior chain strength, movement quality, and neuromuscular control.

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A randomised controlled trial has compared early ACL reconstruction with a strategy of rehabilitation with the option of delayed surgery if required.^1. This study showed that around half of the patients initially managed without surgery were able to return to their desired activities (including sport) and had similar short-, medium-, and long-term patient outcomes, function and radiographic changes to those who underwent early reconstruction. It is important to highlight that, the other half of patients randomised to non-surgical care did not feel confident in their knee and ultimately proceeded to surgical reconstruction. This highlights a key issue with non-operative management. While it can work very well, it is difficult to predict in advance who will succeed. Ongoing instability episodes are not benign and are associated with a higher risk of secondary knee damage, particularly to the meniscus.

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From a clinical perspective, traditional non-surgical management can be appropriate for selected patients, particularly those with lower sporting demands or those with excellent neuromuscular control and a desire to avoid surgery. This option requires close monitoring and a willingness to reassess if confidence or stability does not improve.

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Cross-bracing protocols: emerging option with promise and uncertainty

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More recently, interest has grown in cross-bracing protocols for acute ACL rupture^2.. More recently, interest has grown in cross-bracing protocols for the acute ACL rupture. These protocols involve early immobilisation of the knee in a flexed position, followed by a structured rehabilitation programme. Early imaging studies suggest that, in some patients, this approach may allow biological healing of the ACL.

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The most compelling theoretical advantage of cross-bracing is the possibility of restoring ACL continuity.  If true healing occurs, this could, in principle, reduce some of the longer-term consequences associated with ACL deficiency and reconstruction, including altered joint mechanics and potentially post-traumatic arthritis.

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That said, cross-bracing is not suitable for everyone. Not all ACL tears appear capable of healing with this approach, and some patients fail to regain confidence or stability. There is also a real risk of treatment delay in those who ultimately require surgery, which may prolong time away from sport and work.

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At present, long-term outcome data are limited. We do not yet know whether patients' treatment with cross-bracing have a lower, similar, or higher risk of post-traumatic osteoarthritis compared with other treatment strategies. As a result, careful patient selection, shared decision-making, and close follow-up are essential when considering this option. This option is compelling for those who are interested in trying to achieve healing and those who may be more concerned about their longer-term knee health, rather than a rapid return to sport.

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Surgical reconstruction: often necessary, but not a perfect solution

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For many patients, particularly younger and more athletic individuals involved in pivoting or contact sports, surgical reconstruction remains the most reliable way to restore knee stability and a return to sporting activities.

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It is important to be clear that ACL reconstruction does not restore a normal knee. Even with excellent surgery and rehabilitation, many patients do not return to their previous level of sport, and the risk of long-term joint changes remains. Nevertheless, surgery can provide predictable mechanical stability for those with high functional demands.

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Evidence suggested that bone-patellar tendon-bone grafts are associated with a lower risk of graft failure and re-injury compared with some other graft options, particularly in young athletes³. When combined with a lateral extra-articular tenodesis or lateral ligament augmentation, the risk of re-rupture appears to be further reduced, especially in high-risk populations. This combination is generally the preferred option for athletes seeking maximum stability and a lower likelihood of repeat injury. However, it is not without trade-offs. Bone-patellar tendon-bone grafts are associated with higher rates of anterior knee pain but carry a substantially higher risk of re-injury. Some of this risk can be mitigated by adding a lateral tenodesis.

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Bringing it together: there is no single "best" option

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ACL injury management is not a one-size-fits-all decision. The best treatment is the one that aligns with the patient's goals, risk tolerance, and life context, while aiming to restore function, minimise instability, and reduce the risk of further joint damage.

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For some individuals, high-quality rehabilitation without surgery will allow a satisfactory return to activity. For others, cross-bracing may be an appropriate early option, with the understanding that outcomes are still being defined. For many young and athletic patients, surgical reconstruction remains the most reliable path, and in most cases, this will involve a bone-patellar tendon-bone graft, often combined with a lateral tenodesis.

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At Axis Sports Medicine Specialists, our role is to guide patients through these options, working closely with physiotherapists and surgeons to support informed decisions. These patients are often seen in our Acute Knee Clinic, a service designed to facilitate early access to specialist assessments, high tech imaging and surgical treatment.

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1. Frobell RB, Roos EM, Roos HP, Ranstam J, Lohmander LS.A randomized trial of treatment for acute anterior cruciate ligament tears. NEngl J Med. 2010;363(4):331-342.

2. Filbay SR, Dowsett M, Chaker Jomaa M, et alHealing ofacute anterior cruciate ligament rupture on MRI and outcomes followingnon-surgical management with the Cross Bracing ProtocolBritish Journal ofSports Medicine 2023;57:1490-1497.

3. Sim K, Rahardja R, Zhu M, Young SW. Optimal GraftChoice in Athletic Patients with Anterior Cruciate Ligament Injuries: Reviewand Clinical Insights. Open Access J Sports Med. 2022;13:55-67