Insurance Type Matters Most: An Analysis of Risk Factors for Poor Physical Therapy Adherence After Anterior Cruciate Ligament Reconstruction in an Urban Population

INTRODUCTION: Physical therapy (PT) after anterior cruciate ligament (ACL) reconstruction is critical for recovery. Despite this, adherence to PT protocols remains inconsistent, and although socioeconomic barriers are thought to influence PT attendance, there are a paucity of data quantifying compliance rates and the influence of these proposed barriers. METHODS: A total of 128 consecutive patients who underwent ACL reconstructions between January 2023 and December 2024 at a single urban academic medical center were studied. Three months postoperatively, patients completed a questionnaire regarding their PT compliance. Demographic, socioeconomic, and behavioral factors were collected. RESULTS: 35.9% of patients missed >15% of sessions. Reported barriers included time commitments (58.6% of respondents), transportation (50%), appointment availability (46.1%), cost (36.7%), and insurance issues (21.9%). Despite difficulties, 93.0% of patients thought PT was necessary. Government-sponsored insurance was associated with poor PT adherence (P = 0.006). By contrast, historically described barriers to healthcare access, including Area Deprivation Index (ADI) (P = 0.195), primary language other than English (P = 1.0), and lack of car ownership (P = 0.690), were not associated with poor attendance. CONCLUSION: Having state-sponsored/government-sponsored insurance is an independent risk factor for poor PT adherence, despite near unanimous strong desire of patients to attend therapy. Previously described barriers including higher ADI, primary language other than English, and not owning a car were not notable risk factors.