An injury to the anterior cruciate ligament (ACL) is one of the most common sporting injuries in Australia—particularly in sports that involve a lot of pivoting, jumping and stopping quickly—and typically occurs in teenagers and young adults. 

This has significant implications because knee injuries are closely linked to the development of early osteoarthritis of the knee. 

Until relatively recently, the major treatment pathway in Australia and many other countries for a ruptured ACL was surgical reconstruction (ACLR). 

Physiotherapy rehabilitation was considered an adjunct to rehabilitate patients postoperatively. 

More recently, however, research has shown that the ACL can heal without surgery and that rehabilitation alone is a viable treatment option. 

‘We’ve got high quality studies showing that rehabilitation alone has as good an outcome as early surgery. 

‘Fifty per cent of people avoid the need for surgery if they try rehab first. 

‘But despite this, practice hasn’t changed in Australia,’ says Associate Professor Stephanie Filbay APAM, a physiotherapist and principal research fellow at the Centre for Health, Exercise and Sports Medicine at the University of Melbourne. 

Stephanie and her team have been at the forefront of research into the benefits and effectiveness of rehabilitation and are in the early stages of a randomised controlled trial to compare the effectiveness of their Cross Bracing Protocol (CBP) to ACL surgery in 180 people—the EMBRACE study. 

It builds on earlier studies in which 30 per cent of participants who initially received rehabilitation—whether or not they opted for delayed ACLR—had evidence of ACL healing at two years post-injury and this was associated with better clinical outcomes (Filbay et al 2022a). 

The CBP was developed in an attempt to facilitate ACL healing in people with an acute ACL rupture. 

The CBP immobilises the knee in a brace at a 90-degree angle for four weeks, then gradually increases the knee’s range of motion over the next eight weeks, removing the brace at 12 weeks. 

Supervised physiotherapy is conducted both during the bracing phase and after brace removal. 

The aim of the CBP is to bring the remnants of the torn ligament close together to facilitate bridging and tissue repair at the site of injury. 

The initial clinical study on the CBP (Filbay et al 2022b) showed that 90 per cent of patients managed using the CBP had signs of ACL healing on an MRI three months post-injury. 

At 12 months, patients reported excellent knee function and 79 per cent had returned to pre-injury sport. 

The return-to-sport rate was as high as 92 per cent in people with a thick and taut ACL heal at three months. 

The EMBRACE study, along with similar studies being conducted in New Zealand, the UK and the USA, aims to build on these findings (see breakout below). 

The results have been well received, both in Australia and overseas, spurring new avenues of research and shifting the paradigm for how ACL injuries are managed. 

‘It has created a big paradigm shift. 

‘We all believed that ACLs couldn’t heal and now, in most cases, most researchers believe that they can. 

‘That gives rise to a lot of new research opportunities because there’s so much we don’t yet know about ACL healing. 

‘For decades, people have tried to predict who will do well nonsurgically and who needs surgery. 

‘However, we haven’t had the ability to do so. 

‘Now that we understand that ACLs can heal, we’re trying to predict who’s most likely to heal and to spot earlier signs of who will benefit most from surgery.’ 

Before non-surgical management of ACL injuries becomes the norm, there are a number of barriers in the way of wider acceptance and understanding. 

‘One is societal belief—the beliefs of the public—which is fuelled by misinformation online. 

‘Studies are now showing that most information online is unbalanced and heavily favours surgery as the better treatment or as a requirement to return to sport, which isn’t supported by research. 

‘Clinicians are also exposed to that information so it’s not just consumer-facing websites. 

‘A lot of research articles use inappropriate methods and have unfounded conclusions not supported by the methods. 

‘I think it’s difficult for non-academic clinicians to decipher what research evidence they should and shouldn’t be using to inform their practice.’ 

Associate Professor Stephanie Filbay is looking for patients with ACL rupture to participate in the EMBRACE study.

Stephanie points to some of the expert consensus statements, written largely by orthopaedic surgeons and based on expert opinions rather than supporting evidence, as contributing to the misconceptions surrounding treatment options but says the messages are slowly changing. 

‘I do see a tidal wave of change, especially in Australia, largely coming from patients but also from a core group of physios, some sports doctors and some surgeons. 

‘We’re not saying that no-one should have surgery; we’re saying that we can now look toward identifying who will benefit most from surgery and who won’t require surgery and may be able to have successful outcomes nonsurgically. 

‘There are more and more surgeons coming on board with that.’ 

Current and future studies will look more closely at predicting whether a patient’s ACL injury will heal without surgery, based on the severity of the rupture and other factors. 

Stephanie is using predictive models on the data, including MRI scans from existing studies. 

‘I think we’ll see new developments in terms of early markers on MRI and that will help inform who’s better suited to a specific treatment strategy but we’re not quite there yet.’ 

Recently, Stephanie and her team published two mixed-methods studies including both surveys and semi-structured interviews to understand why people choose to have surgery over managing ACL injuries non-surgically and whether physiotherapists’ understanding and beliefs match the way they practise. 

In the first study, 734 patients with ACL injuries in the previous five years were surveyed (Filbay et al 2025a) to identify their beliefs about their treatment options and the information and management advice provided to them by clinicians including GPs, specialist doctors, surgeons and physiotherapists. 

According to the study, ‘ACLR was portrayed as the best treatment option for patients by 85 per cent of orthopaedic surgeons, 65 per cent of general practitioners, 61 per cent of physiotherapists and 59 per cent of sport and exercise medicine physicians, and even more healthcare providers portrayed surgery as the best treatment to return to sport.’ 

Patients were rarely advised that similar outcomes were achievable with rehabilitation. 

General themes included patients getting mixed advice from physiotherapists, while GPs were used for referrals rather than management advice. 

Many surgeons promoted surgery as the best or only option, while consults were often rushed and patients felt poorly informed prior to surgery. 

Clinicians in general downplayed the risks and impacts of surgery. 

The second study surveyed 246 Australian physiotherapists with experience in managing acute ACL injuries (Filbay et al 2025b) and the results were mixed. 

While 60 per cent of the physiotherapists agreed that ACLR and rehabilitation alone resulted in similar outcomes, only 37 per cent regularly informed patients that the outcomes were likely to be similar. 

They believed that rehabilitation alone was underutilised as a treatment for ACL injuries but encountered barriers both to offering and to providing non-surgical options. 

Barriers included a preference for surgery based on societal beliefs, the perception that more weight was given to a surgeon’s opinion, unbalanced information provided by surgeons, patients seeing a surgeon before presenting to a physiotherapist, uncertain recovery timelines, beliefs about treatment suitability (eg, ACLR believed to be better for young, active people, not older individuals) and knowledge and experience in dealing with ACL injury management. 

The findings from these two studies have fed directly into the patient decision aid developed by Stephanie and her team to help patients with an ACL injury understand surgical and non-surgical management options so they can make an informed choice about treatment that aligns with their preferences. 

‘The decision aid has been widely used—we’ve had over 53,000 users so far. 

‘After using the decision aid, twice as many people feel that they have enough information to make a treatment choice and people are aware of the benefits and risks of treatment options. 

‘We’re now looking at trialling it in clinical practice to see what impact it has on treatment decisions and outcomes. 

‘We also plan to develop core capabilities for physiotherapists in managing ACL injuries as well as online free education for physios to see if that can reduce the gap between research evidence and current practice.’ 

The EMBRACE study 

The EMBRACE trial, led by Associate Professor Stephanie Filbay at the University of Melbourne, will compare two different treatments for ACL ruptures—the Cross Bracing Protocol (CBP) and ACL reconstruction surgery. 

The study will be conducted in Melbourne, Sydney, Brisbane, the Gold Coast and Perth. 

One hundred and eighty participants aged 16 to 40 with acute ACL ruptures will be randomly assigned to either the CBP group or the surgery group, with comprehensive follow-up over 18 months. 

‘We’ve trained a large number of physios across those cities to deliver both treatment strategies and we have a range of surgeons taking part in the trial who have agreed to perform the surgeries within eight weeks of injury. 

‘In Melbourne, we’re also offering a public hospital pathway where the surgery will be provided within eight weeks for people who aren’t insured,’ says Stephanie. 

Primary outcomes will be measured using the Knee Injury and Osteoarthritis Outcome Score, while secondary outcomes include knee function, pain, knee instability, return to sport, adverse events and health economics. 

The EMBRACE study team will provide CBP training to physiotherapists who refer eligible patients to the trial so they can become a treating clinic. 

In addition to providing CBP training, the study will fund the rehabilitation sessions for patients in the trial—23 sessions for the bracing group and 16 for the surgical group. 

The study is funded by a $1.73 million grant from the Medical Research Future Fund and additional partners, including the APA and Medibank. 

Learn to deliver the Cross Bracing Protocol 

Do you want to learn to deliver the Cross Bracing Protocol as part of your clinical practice? 

The EMBRACE Study needs your help recruiting participants with ACL rupture. 

This is the first randomised controlled trial comparing the CBP to early ACL reconstruction surgery. 

Refer a patient into the trial by directing them to the EMBRACE website or emailing our research team directly and you will have the option of: 

• becoming an EMBRACE study treating clinic and treating participants for up to 23 trial-funded physiotherapy consultations  
• accessing training modules on Cross Bracing Protocol delivery and ACL rehabilitation. 

If you live in or within two hours’ drive of Melbourne, Sydney, Brisbane, the Gold Coast or Perth, click here register your interest or visit our website to find out more. 

>> The APA is partnering with the University of Melbourne on the EMBRACE study. 

Quick links:

• References
• Embrace study website
• Patient decision aid