What is the optimal pre‑total hip arthroplasty exercise program for an older adult with hip osteoarthritis and limited weight‑bearing tolerance?

Pre-Hip Replacement Exercise Program

For older adults with severe hip osteoarthritis awaiting total hip arthroplasty, do not delay surgery for mandatory pre-operative physical therapy, but if exercise is pursued while awaiting surgery, implement a supervised program combining isometric hip/quadriceps strengthening, low-impact aerobic conditioning, and daily stretching. 1

Should You Delay Surgery for Exercise?

Do not mandate physical therapy as a barrier to surgery for patients already indicated for THA—postponing definitive treatment increases pain without improving postoperative outcomes. 1 The American College of Rheumatology and American Association of Hip and Knee Surgeons conditionally recommend proceeding to surgery without delay rather than requiring a trial of pre-operative physical therapy. 1

Exceptions Where Pre-Operative Exercise May Help:

• Non-ambulatory patients or those recovering from recent comorbidities (e.g., stroke) may benefit from targeted strengthening before surgery. 1
• Patients with marked lower-extremity muscular weakness may gain functional advantage from pre-operative conditioning. 1

Evidence note: One high-quality 2024 RCT demonstrated total hip replacement produced an 11.4-point greater improvement in Oxford Hip Score compared to resistance training alone (P<0.001), reinforcing that surgery should not be delayed for exercise trials in appropriate surgical candidates. 2 However, an 8-week pre-operative exercise program in a 2003 RCT showed significant improvements in strength, range of motion, and function that persisted through 24 weeks post-operatively. 3

Strength Training Components

Isometric Exercises (Primary Focus):

• Quadriceps and hip girdle muscles bilaterally: Hold contractions for 6-7 seconds, repeat 5-7 times, perform 3-5 times daily. 4
• Gluteal strengthening (gluteal squeezes): Same duration and frequency as quadriceps exercises. 4
• Intensity progression: Start at 30% of maximal voluntary contraction, progress to 75% as tolerated. 4
• Critical safety rule: Never exercise muscles to fatigue; use submaximal resistance. 4

Dynamic Strengthening (If Tolerated):

• Perform 2-4 sets of 8-12 repetitions at 60-80% of one-repetition maximum, at least 2 days per week. 4
• Focus on muscles supporting the hip joint, particularly gluteus medius and hip extensors. 1
• Choose exercises based on current joint stability and pain/inflammation levels. 1

Rationale: Isometric exercises are emphasized because they strengthen muscles without moving the painful joint through range of motion, making them better tolerated in severe osteoarthritis. 4 Dynamic exercises better mimic everyday activities but require lower pain levels. 1

Aerobic Conditioning

• Activity selection: Choose low-impact options that minimize joint loading—stationary cycling, walking on level surfaces, or aquatic exercise. 4
• Intensity target: Moderate-intensity training at 70% of maximal heart rate. 4
• Duration: 30-60 minutes per day, at least 3 days per week. 4

Both aerobic and strength training groups demonstrate significantly less pain than control groups (P<0.01) in clinical trials. 1

Flexibility and Range of Motion

• Perform daily static stretching when pain and stiffness are minimal (e.g., before bedtime). 4
• Hold each stretch for 30-60 seconds in older adults, repeating 2-4 times per muscle group. 4
• Pre-stretch preparation: Warm the joint with a warm shower or superficial moist heat before stretching. 1
• Modify or reduce range/duration if pain or joint inflammation occurs. 1

Exercise Session Structure

Every session must include three phases: 4

1. Warm-up (5-10 minutes): Low-intensity, repetitive range-of-motion exercises. 1
2. Training period: Deliver overload stimulus appropriate to targeted modality (flexibility, strength, or aerobic capacity). 1
3. Cool-down (5 minutes): Static stretching. 4, 1

Supervision Requirements

• Twelve or more directly supervised sessions are needed for significant improvement in pain and function. 4
• Exercise programs are more effective when supervised by physical therapists rather than performed independently at home. 5
• After initial instruction, patients should self-manage exercises integrated into daily routines. 4

Safety Monitoring and Red Flags

Stop or Modify Exercise If:

• Joint pain persists >1-2 hours after exercise—this indicates excessive activity requiring immediate modification. 4, 1
• Joint swelling, fatigue, or weakness develops during or after exercise. 1
• Pain occurs during activity that doesn't resolve with rest. 1

When Joints Are Inflamed:

• Decrease range of motion or duration of static holds. 4
• Reduce intensity but maintain some activity—complete rest accelerates functional decline. 6

Adjunctive Strategies

Weight Loss (If Overweight/Obese):

• Implement structured weight loss programs targeting ≥5% body weight reduction (4 kg minimum). 4
• Greater benefits occur with 10-20% weight loss. 6
• Weight loss efficacy is enhanced when combined with exercise programs. 5

Pain Management:

• Apply superficial ice or heat before exercises to reduce pain and improve tolerance. 4
• Use appropriate comfortable footwear with shock-absorbing properties. 4

Mind-Body Practices:

• Tai chi is strongly recommended for hip osteoarthritis—combines meditation, gentle movements, breathing, and relaxation. 5
• These practices may improve strength, balance, fall prevention, depression, and self-efficacy. 5

Critical Pitfalls to Avoid

1. Never delay exercise due to pain presence: Clinical trials demonstrate patients with OA pain can still achieve improvements. 4

2. Never focus solely on the affected hip: Bilateral strengthening is recommended regardless of which hip is symptomatic. 4

3. Never mandate pre-operative PT as a surgical barrier: This delays definitive treatment without improving outcomes. 1

4. Never exercise to complete fatigue: This increases injury risk and joint inflammation. 4

5. Never implement single-modality programs: Comprehensive programs combining strengthening, aerobic, and flexibility components are most effective. 4

Conflicting evidence note: One 2004 RCT found no benefit from 8-week pre-operative physiotherapy at discharge or 2-year follow-up 7, while a 2003 RCT showed significant improvements throughout 24-week post-operative follow-up 3. The difference likely reflects program intensity and supervision—the positive study used customized, supervised exercise while the negative study's intervention details were less specific. Current guidelines prioritize not delaying surgery over mandatory pre-operative exercise. 1