Practical Advice – Daily Tips For The Cross Bracing Protocol (CBP)

Your movement, and ability to bear weight, will be limited while on the Cross Bracing Protocol (CBP). Here are some practical tips to help you manage better, and to optimise your healing.

Remember that you ALWAYS need to keep your knee at the correct angle, without straightening your leg beyond the range allowed in the CBP. If your knee is extended beyond the angle allowed, you may potentially undo healing of your ACL that may have been achieved.  

Things to consider​

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Crutches used for the first 8 weeks of the CBP

Crutches

You won’t be able to put weight onto your injured leg for at least 8 weeks, so you will need crutches, or other mobility aids, to help you move around.

  • Ensure your crutches are correctly fitted by your physiotherapist. The preferred crutches are the forearm ones (Canadian crutches), however underarm crutches may be better suited to those with less upper body strength, or for people lacking confidence with the use of crutches.
  • If you develop wrist pain after prolonged use of your crutches, your physiotherapist may be able to tape your wrists for additional support. Massaging your forearms can also help, in addition to padding the handles to provide cushioning.
  • Stairs can be difficult to navigate, so you may want to practice with your physiotherapist.

 

Tip: when going upstairs, your non-injured leg should go up first, then the crutches should follow. When going downstairs, the crutches should go first, followed by your non-injured leg.

Knee rover scooter and iWalk

Other mobility aids

If you need to travel distances, or find crutches uncomfortable, there are other mobility aids available.

  • The iWalk can be used from the first day you start the CBP. 
  • Many patients also recommend the “Knee Rover”.
  • Neither of these mobility aids will compromise ACL healing.
  • Other mobility aids include wheelchairs and motorised carts. Talk with your doctor or physiotherapist about what may suit you best.

Minimise risk of falling

If you fall and twist your knee during your recovery, you could damage some of the ACL healing that has occurred.

  • Take extra caution when using crutches on wet surfaces and in poorly lit environments.
  • Try to avoid large crowds so you can reduce the risk of people bumping into you.
  • Be extremely careful if you choose to drink alcohol during your CBP period, as this may increase your risk of a fall.
  • In the first 8-weeks of the CBP you will be taking anti-coagulation (blood thinning) medication. If you fall while taking this medication, this may lead to increased bleeding and bruising, so be extra careful.
  • You will be able to walk without crutches after week 8, however your brace will remain on with increased range of movement allowed. You will need to take extra care during this time as your knee will be stiff, and your leg muscles may have wasted. Special care should be taken when on stairs.
  • Wear shoes that have good support, fit well and have good grip.
  • Take care in the bathroom and shower to avoid slipping on wet tiles.

Sleeping

It might take some time for your to work out the most comfortable sleeping position while in a brace

  • Pillows can help increase your sleeping comfort:
    • If on your back, use a couple of pillows under your knees.
    • If on your side, use 1 or 2 pillows between your knees.
    • If on your stomach, use a couple of pillows under your shin, as shin discomfort from wearing the brace, especially when sleeping, is common.
  • Consider gravity when finding your most comfortable position. If your foot is lower than your knee, the brace will typically fall towards your foot and cause pressure against your shin. So, if sleeping on your side, make sure your foot and knee are aligned (the lower limb is parallel to the ground).

 

Tip: sleeping on the same side as your injured knee can often be the most comfortable position, with a pillow in between your legs.

Muscle cramps

You may experience muscle cramps during your bracing period, as the muscles are held in a shortened position. Night-time cramps are common

  • If you have a cramp in your hamstring, please DO NOT straighten your knee, as this will compromise your ACL healing.
  • If you have a cramp in your calf, you can stretch your calf out by bending your ankle so your toes come up towards you.
  • Make sure you are well hydrated to minimise muscle cramping, in addition to taking a daily magnesium supplement 30 minutes before sleeping. Please see the nutritional advice recommended for the CBP.
  • If you are cramping regularly, please consult your Doctor or Physiotherapist.

 

Tip: you can take the brace off to massage your leg, however make sure you maintain the angle of your knee according to what CBP stage you are up to.

Available in your local hardware store

Bathing

One of your trickiest times in the day will be when showering or bathing

  • You may want to sit down on a plastic chair in the shower so you can safely take your brace off to wash your leg. ALWAYS keep your knee at the specified angle. As soon as you are dry, put your brace back on.
  • Many patients have found the Estilo shower tool, available at your local hardware store, safe and functional.
  • Be careful not to slip on the wet tiles in your bathroom.

Tip: if you choose to keep the brace on whilst showering, cover the brace with a large garbage bag and tape the ends. This will protect the brace, and its padding, and is better for your skin underneath.

Skin irritation– wearing althetic pants under the brace can help

Skin protection

By making sure your brace fits well, you will minimise the risk of damage to your skin underneath

  • If the brace is compressing at the hinge at the side of your knee, or if the straps are too tight, you may damage your skin underneath, creating compression sores, so it’s important to make sure the brace fits well and is regularly adjusted.
  • If the bottom strap/bar of the brace is causing discomfort, insert some 3mm Poron foam underneath a calf sleeve or long compression sock to cushion this area. Thicker foam is not necessarily better!
  • If you wear your knee brace while bathing (or swimming), ensure that the brace is dried off afterwards (hairdryers are useful), as well as drying your skin underneath.
  • Your physiotherapist can help you with strategies to maximise the comfort of your brace. Contact them as soon as any issues arise as it’s best to fix any problems early.

 

Tip: wearing a knee sleeve, long compression sock or calf sleeve underneath your brace can help protect your skin. Alternatively, you can wear waist to ankle athletic pants, which can protect your skin as well as provide improved circulation and lymphatic drainage. Just be careful to maintain your knee angle when taking garments on and off.  

Wall squats can help maintain muscle strength

Muscle wasting

Muscle wasting (atrophy) will start within the first few days of wearing the brace, however there are steps you can take to minimise loss of muscle

  • Remember your priority is to maximise your ACL healing – your muscle strength will return during rehabilitation. However, to minimise muscle wasting, complete the isometric exercises (muscle contractions) that your physiotherapist prescribes.
  • Your excercises will involve both legs, which is of particular benefit during your recovery. In recent neural pathway studies, it was found that training the uninjured side of your body has been shown to increased recovery on the injured side (by 15 to 20%).
  • Collagen supplementation can potentially help reduce muscle atrophy and may improve your ACL healing. 10 grams of collagen taken 30 minutes before your physiotherapy or exercise session is recommended.

Tip: your physiotherapist can show you isometric “wall squats”. These maintain the 90 degree knee flexion as you sit against a wall, and can be completed from day 1 of the CBP, as often as you like.

Brace-free time

If you are in a controlled envioronment, and can maintain the required bend in your knee, you can enjoy some brace-free time

  • In order to massage your leg (self-massage or by another), or to moisturise your skin, you can take your brace off under very controlled conditions.
  • It’s important that you do not move around without your brace on. Remember, the 90-degree flexion angle MUST be maintained at all times in the first 4 weeks.

 

Tip: while sitting at your computer, watching television or reading a book on your couch, this would be optimal time to enjoy some brace-free time while ensuring your knee remains at the required angle.

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References

  1. Andrushko JW et al. Unilateral strength training leads to muscle-specific sparing effects during opposite homologous limb immobilization. J Appl Physiol (1985). 2018 Apr 1;124(4):866-876
  2. Khatri M et al. The effects of collagen peptide supplementation on body composition, collagen synthesis, and recovery from joint injury and exercise: a systematic review. Amino Acids. 2021 Oct;53(10):1493-1506

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