What pre‑operative exercise regimen is recommended for older adults with hip osteoarthritis awaiting total hip arthroplasty?

Pre-Operative Exercise for Hip Osteoarthritis Before Total Hip Arthroplasty

For older adults with severe hip osteoarthritis awaiting total hip arthroplasty, do not delay surgery for mandatory physical therapy or prehabilitation programs, as surgery provides superior outcomes and preoperative exercise does not improve post-operative results. 1, 2

Evidence Against Mandatory Preoperative Physical Therapy

The most recent high-quality evidence demonstrates that:

• Prehabilitation (6-12 weeks of tailored exercise before surgery) does not improve gait speed or any post-operative outcomes compared to usual care in patients 70 years or older. 2 This 2025 randomized controlled trial found no significant between-group differences at 3,6, or 12 months post-surgery for the primary outcome of gait speed or any secondary performance-based measures.

• The American College of Rheumatology and American Association of Hip and Knee Surgeons conditionally recommend proceeding to THA without delay over delaying arthroplasty for a trial of physical therapy. 1 Delaying surgery for physical therapy may cause increased pain due to disease severity in patients already indicated for surgery.

• Total hip replacement dramatically outperforms resistance training for severe hip osteoarthritis. 3 A 2024 randomized trial showed THR resulted in 15.9 points improvement on the Oxford Hip Score versus only 4.5 points with resistance training at 6 months (difference of 11.4 points, P<0.001).

When Preoperative Exercise May Be Considered (Not Mandatory)

While not required to delay surgery, preoperative exercise may provide modest short-term benefits in select circumstances:

• Nonambulatory patients or those recovering from medical comorbidities (e.g., stroke) that limit rehabilitation capacity may benefit from preoperative physical therapy to improve post-operative outcomes. 1

• Patients with major lower extremity muscular weakness may benefit from strengthening before surgery. 1

• Brief preoperative improvements in gait speed (0.15 m/s) and quality of life can occur with prehabilitation, but these gains disappear after surgery. 2 Both groups showed equivalent improvement 3-12 months post-surgery, indicating surgery itself is the primary therapeutic intervention.

Recommended Exercise Components (If Pursued)

If preoperative exercise is chosen for personal preference or specific clinical circumstances, the program should include: 1

Flexibility Exercises

• Perform daily static stretching when pain and stiffness are minimal. 1
• Hold terminal stretch positions for 10-30 seconds, breathing throughout each stretch. 1
• Precede stretching with warm shower or superficial moist heat application. 1
• Modify exercises to avoid pain or when the joint is inflamed by decreasing range of motion or duration. 1

Strength Training

• Use isotonic (dynamic) exercises rather than isometric exercises, as isotonic training more closely corresponds to everyday activities. 1
• Select exercises based on joint stability and degree of pain/inflammation. 1
• Exercise muscles at submaximal resistance without exercising to fatigue. 1
• Focus on strengthening muscles that support the affected hip joint. 1

Aerobic Exercise

• Include low-intensity aerobic activities to improve cardiovascular fitness and reduce disability. 1
• Both aerobic exercise and strength training groups show significantly less pain than controls (P<0.01). 1

Exercise Session Structure

• Begin with 5-10 minute warm-up of repetitive low-intensity range-of-motion exercises. 1
• Follow with the training period providing overload stimulus for flexibility, strength, or aerobic capacity. 1
• End with 5-minute cool-down involving static stretching. 1

Critical Clinical Considerations

Pre-Exercise Assessment

• Complete history and physical examination are needed before prescribing increased physical activity. 1
• Identify which functional problems are most important to the patient to guide exercise selection. 1
• Consider cardiovascular response to exercise for patients with significant risk factors, though routine exercise stress testing is not mandated for older adults without significant cardiovascular disease risk factors. 1

Warning Signs of Excessive Exercise

• Joint pain during activity 1
• Pain lasting more than 1-2 hours after exercise 1
• Swelling, fatigue, and weakness 1

Patient Education

• Involve patients in goal-setting to enhance long-term adherence. 1
• Educate patients that physical performance and disease activity vary day-to-day, requiring exercise adjustment. 1
• Reinforce that exercise does not exacerbate joint symptoms in randomized controlled trials. 1

Common Pitfalls to Avoid

• Do not mandate physical therapy as a barrier to surgery for patients already indicated for THA. 1 This delays definitive treatment and may worsen pain without improving post-operative outcomes.

• Do not confuse prehabilitation with post-operative rehabilitation. 1 The 2023 AAOS guidelines recommend either formal PT or unsupervised home exercise after THA (moderate-strength recommendation based on high-quality evidence), but this is distinct from preoperative exercise requirements.

• Do not delay surgery for patients with acute OA flares. 1 Consider glucocorticoid injection for immediate pain relief, but be aware of increased infection risk if surgery occurs within 3 months of intra-articular injection.

• Recognize that 21% of patients assigned to resistance training in trials ultimately undergo THR within 6 months anyway. 3 This highlights that exercise cannot replace surgery for severe disease.