What are the recommended postoperative exercises after a total hip replacement?

Recommended Exercises Post Hip Replacement

Begin immediate knee mobilization and isometric quadriceps exercises within the first postoperative week, progressing to closed kinetic chain exercises by week 2, with full weight-bearing as tolerated to optimize functional recovery and reduce hospital length of stay. 1, 2, 3

First Week: Immediate Postoperative Phase

Immediate mobilization is critical and should begin within 24 hours of surgery to prevent stiffness, reduce pain, and avoid extension deficits. 1, 2, 3

• Start sitting out of bed within 24 hours postoperatively to initiate the mobilization process. 3
• Begin walking within 48 hours after surgery, as early ambulation reduces hospital length of stay by approximately 1.8 days without increasing adverse events. 3
• Initiate isometric quadriceps exercises (static contractions, straight leg raises) in the first week if they cause no pain, as these reactivate the quadriceps muscles. 2
• Apply cryotherapy immediately after surgery and continue for the first week to reduce pain and swelling without increasing risk of complications. 2, 4
• Progress to full weight-bearing as tolerated within the first week, though this should be individualized based on surgical approach and fixation stability. 2, 3

Weeks 2-4: Early Strengthening Phase

Transition from isometric to dynamic exercises once the quadriceps is reactivated and the knee shows no effusion or increased pain. 2

• Begin closed kinetic chain exercises (leg press, squats, step-ups) from week 2 onward, as these minimize stress on the hip joint while building strength. 2
• Prioritize closed kinetic chain over open kinetic chain exercises during the first month to reduce risk of complications. 2
• Consider neuromuscular electrical stimulation (NMES) for 6-8 weeks as an adjunct to isometric exercises to re-educate voluntary quadriceps contraction and increase muscle strength. 2
• Progress from isometric to concentric and eccentric exercises when pain-free, shifting gradually to more challenging movements. 2

Weeks 4-8: Progressive Resistance Phase

Advance exercise intensity and complexity while maintaining proper form and pain-free movement. 2

• Introduce open kinetic chain exercises cautiously from week 4 onward in a restricted range of motion (90-45°), gradually expanding ROM over subsequent weeks. 2
• Continue closed kinetic chain exercises with progressive resistance to build functional strength. 2
• Implement eccentric training components for greater strength gains and muscle hypertrophy. 5
• Combine strength training with neuromuscular and motor control exercises to restore dynamic stability and prevent reinjury. 2

Beyond 8 Weeks: Return to Function

Continue rehabilitation for 9-12 months depending on functional goals, as premature discontinuation compromises optimal recovery. 2

• Add neuromuscular training to strength exercises to optimize self-reported outcomes and prevent reinjuries. 2
• Measure quadriceps and hamstring strength regularly to track progress and identify deficits. 2
• Perform comprehensive functional testing including strength tests, hop tests, and quality of movement assessments before returning to demanding activities. 2
• Aim for Limb Symmetry Index (LSI) >90% for general activities and 100% for high-demand or pivoting activities. 2

Delivery and Supervision

Supervised rehabilitation with a physiotherapist should be continued for optimal outcomes, though home-based rehabilitation may be suitable for highly motivated patients living far from therapy facilities. 1, 2

• Intensive supervised physical therapy provides better outcomes for complex cases or patients with complications. 1
• Home-based rehabilitation can be as effective as clinic-based therapy for motivated patients with uncomplicated recoveries. 1, 2

Critical Pitfalls to Avoid

• Delaying mobilization beyond the first week leads to stiffness, extension deficits, and prolonged recovery. 2, 3
• Failing to address quadriceps strength deficits significantly impacts long-term functional outcomes and increases reinjury risk. 2
• Neglecting neuromuscular training alongside strength training increases the risk of falls and functional limitations. 2
• Discontinuing rehabilitation before 9-12 months compromises optimal functional recovery and return to desired activities. 2
• Progressing too aggressively with resistance exercises before adequate muscle reactivation can cause pain, effusion, and setbacks. 2