What is the best course of treatment for a 60-year-old male with a history of anterior cruciate ligament (ACL) surgery, who never received physical therapy (PT), and is now requesting a knee brace for left knee support?

Treatment Recommendation for Post-ACL Surgery Patient Without Prior Physical Therapy

This 60-year-old male should be referred immediately to supervised physical therapy rather than simply being provided a knee brace, as postoperative functional bracing is not recommended for routine use after ACL reconstruction, and the lack of prior rehabilitation represents a critical gap in his recovery that must be addressed to optimize knee function and prevent long-term complications. 1

Why a Knee Brace Alone is Insufficient

Evidence Against Routine Bracing

• Multiple high-quality guidelines consistently recommend against routine postoperative functional knee bracing after ACL reconstruction 1
• The New Zealand Guidelines Group, Danish Orthopaedic Association, MOON group, and American Academy of Orthopaedic Surgeons all state that postoperative knee braces should not be used routinely 1
• Functional knee orthoses do not confer clinical benefit in patients who received primary isolated ACL reconstruction 2
• Bracing may only be considered according to patient preferences or if there are associated ligament injuries, which is not the standard scenario 1

The Critical Missing Element: Physical Therapy

• The absence of postoperative physical therapy represents a major deficit in this patient's care that likely explains his current need for external support 1
• Supervised rehabilitation should be leading in decision-making after ACL surgery, with the physical therapist guiding the recovery process 1
• Even though this patient is now years post-surgery, initiating a structured rehabilitation program can still address persistent deficits in strength, proprioception, and functional stability 1, 2

Recommended Treatment Algorithm

Step 1: Comprehensive Functional Assessment

Before prescribing any intervention, evaluate:

• Quadriceps and hamstring strength deficits (compare to contralateral side; >20% deficit significantly impacts outcomes) 1
• Range of motion limitations (particularly extension deficit, which is a major risk factor for poor outcomes) 1
• Knee stability using Lachman, pivot shift, and anterior drawer tests 1
• Patient-reported outcomes using validated tools like IKDC subjective score or KOOS 1
• Functional performance with single-leg hop testing and activity-specific assessments 1

Step 2: Initiate Supervised Physical Therapy

• Refer to a physical therapist experienced in ACL rehabilitation for a structured program focusing on deficits identified in assessment 1, 2
• The program should include:
  • Quadriceps strengthening exercises (both open and closed kinetic chain exercises) 1, 2
  • Balance and proprioception training to improve functional stability 3
  • Neuromuscular re-education training in addition to muscle strengthening 1
  • Functional exercises tailored to his daily activity demands 3

Step 3: Consider Brace Only If Specific Criteria Met

A functional knee brace may be considered only if:

• The patient experiences significant functional instability during daily activities despite adequate rehabilitation efforts 3
• There is documented instability on physical examination after completing an appropriate trial of physical therapy 3
• The brace serves as an adjunct to, not a replacement for, ongoing therapeutic exercises 3

Step 4: Transition to Self-Directed Program

• After initial supervised therapy demonstrates improvement in strength and stability, a self-directed exercise program may be appropriate 3
• The goal is improving functional stability and reducing any pain or instability symptoms 3
• Regular follow-up to assess functional stability, pain levels, and ability to perform daily activities 3

Why This Matters for Long-Term Outcomes

Impact on Morbidity and Quality of Life

• At age 60, this patient's activity levels may be lower than younger individuals, making ACL deficiency potentially better tolerated 3
• However, inadequate rehabilitation increases the risk of:
  • Persistent quadriceps weakness and functional limitations 1
  • Increased risk of subsequent meniscal tears and cartilage damage 2
  • Progressive development of knee osteoarthritis 2
  • Reduced quality of life due to activity limitations 1

The Window for Intervention Remains Open

• While optimal rehabilitation occurs in the 9-12 months post-surgery, initiating a structured program even years later can still address persistent deficits 1
• Supervised rehabilitation focusing on strength, proprioception, and functional training can improve outcomes even in delayed presentations 1, 3
• Weight control and appropriate activity modification remain important modifiable risk factors for osteoarthritis progression 3

Common Pitfalls to Avoid

• Do not simply provide a brace without addressing the underlying functional deficits that likely stem from absent postoperative rehabilitation 1
• Avoid underestimating the importance of supervised rehabilitation even in this delayed presentation 3
• Do not assume that because surgery occurred years ago, rehabilitation is no longer beneficial 1, 3
• Failing to assess and address modifiable risk factors such as quadriceps weakness and proprioceptive deficits 3
• Unnecessary reliance on passive interventions (like bracing alone) when active rehabilitation is the evidence-based approach 1

Documentation and Follow-Up

• Document the patient's current functional limitations, strength deficits, and stability concerns 1
• Provide clear communication to the physical therapist about the patient's history, including the absence of prior postoperative rehabilitation 1
• Schedule follow-up to monitor progress with rehabilitation and reassess the need for any assistive devices 3
• Monitor for development of new symptoms that might warrant further evaluation 3