Hip Exercise Recommendations for Arthroscopic Hip Surgery
Pre-operative Exercise Program (Prehabilitation)
Begin an 8-week hip-specific exercise program before surgery to improve functional outcomes and reduce the risk of requiring inpatient rehabilitation. 1, 2
Specific Pre-operative Exercises
- Hip and trunk strengthening exercises focusing on gluteus medius and core stability, avoiding positions that could aggravate the existing hip pathology 3, 4
- Quadriceps strengthening using isometric contractions and progressive resistance training to build baseline strength 4
- Hip flexor strengthening on both operative and non-operative sides, as this demonstrates significant post-operative benefits 4
- Knee extension exercises bilaterally, which show statistically significant improvements in post-operative recovery 4
- Low-impact aerobic conditioning such as stationary cycling or aquatic exercises to maintain cardiovascular fitness without excessive joint loading 3
Evidence Supporting Prehabilitation
The strongest evidence shows that 6-8 weeks of pre-operative exercise substantially improves pre-operative functional status, increases muscle strength by 18-20%, and dramatically reduces the odds of requiring inpatient rehabilitation (adjusted odds ratio 0.27) 1, 2. A hip-specific prehabilitation program demonstrates statistically significant improvements in knee extension strength (both sides), hip flexor strength, and overall health scores post-operatively 4. Education alone without exercise has no effect on outcomes 5.
Immediate Post-operative Phase (0-4 Weeks)
Start immediate weight-bearing as tolerated with correct gait pattern, beginning isometric quadriceps exercises in the first week when pain-free. 6, 3
Week 1-2 Exercises
- Isometric quadriceps contractions and straight leg raises can be safely prescribed during the first 2 postoperative weeks, conferring advantages for faster recovery of knee range of motion without compromising stability 6, 3
- Immediate weight-bearing should only be tolerated if there is correct gait pattern (with crutches if necessary) and no pain, effusion, or increase in temperature when walking 6, 3
- Gentle hip and trunk exercises that avoid positions compromising the surgical site, focusing on muscle reactivation 3
Week 2-4 Progression
- Closed kinetic chain exercises can be performed from week 2 postoperative, including leg press exercises which can be started at 3 weeks to improve subjective knee function and functional outcomes 6, 3
- Eccentric cycle ergometer training may be initiated at 3 weeks instead of 12 weeks, resulting in greater strength gains, better daily activity level, and greater quadriceps muscle hypertrophy with beneficial effects persisting 1 year after surgery, with no effect on laxity, pain, or swelling 6
- Balance and proprioceptive training should be incorporated early to address deficits in dynamic balance and single-leg stability 3
Critical Monitoring Points
Monitor for signs of exercise intolerance including increased pain, joint effusion, or limping, adjusting intensity and duration based on individual response 3. Avoid pushing through significant pain, as this may compromise healing 3.
Mid-Phase Recovery (4-8 Weeks)
Progress to dynamic strengthening exercises for hip and trunk muscles, particularly gluteus medius, while incorporating balance training and low-impact aerobic activities. 3
Strengthening Progression
- Dynamic hip strengthening focusing on gluteus medius and other hip stabilizers using progressive resistance 3
- Both open and closed kinetic chain exercises should be used for regaining quadriceps strength, as there is no significant difference in anterior tibial laxity between these approaches 6
- Eccentric training combined with concentric exercises improves quadriceps and hamstring strength without differences between groups, though eccentric overload training does not enhance quadriceps strength gains beyond standard training 6
Functional Activities
- Low-impact aerobic activities such as stationary cycling or aquatic exercises to improve cardiovascular fitness without excessive joint loading 3
- Quality of movement monitoring during exercises, focusing on proper alignment during functional tasks like sit-to-stand and gait 3
- Neuromuscular training should be added to strength training to optimize self-reported outcome measurements and prevent altered biomechanics that could be a risk factor for reinjury 6, 3
Important Caveat
Open kinetic chain exercises might induce more anterior knee pain compared with closed kinetic chain exercises, so monitor symptoms carefully 6. Both types of exercise improve functional activities, so use both strategically 6.
Advanced Phase and Full Recovery (8-12 Weeks and Beyond)
Continue progressive resistance training for 9-12 months, progressing to functional strengthening exercises that mimic daily activities and desired recreational pursuits. 6, 3
Advanced Strengthening
- Progressive resistance training for hip and lower extremity muscles should be continued to address strength deficits, with evidence supporting continuation for 9-12 months depending on final return-to-work or play goals 6, 3
- Functional strengthening exercises that mimic daily activities and desired recreational pursuits 3
- Combination of eccentric and plyometric exercises is more effective in improving balance, functional activities, subjective knee function, and psychological readiness than eccentric or plyometric training in isolation 6
Balance and Functional Training
- More challenging balance activities and functional task training should be incorporated 3
- Neuromuscular training with attention to correct quality of movement for prevention of reinjuries 6
Outcome Monitoring
- Response to exercise should be monitored with appropriate outcome measures such as the HAGOS or IHOT questionnaires 3
- Extensive test battery for quantity and quality of movement, including at least strength testing, though there are no tests or test batteries that have been tested for construct or predictive validity for return to play 6
Long-Term Maintenance
- Physical activity should be encouraged as part of long-term management to optimize quality of life 3
- Periodic strengthening exercises should be continued to maintain hip and core muscle strength 3
Common Pitfalls to Avoid
- Failing to address specific impairments such as hip muscle weakness, altered gait mechanics, or balance deficits 3
- Discontinuing exercise program too early (before 3 months), as longer duration programs show better outcomes 3
- Not monitoring response to treatment with appropriate outcome measures can lead to suboptimal management 3
- Ignoring psychological factors such as self-efficacy, locus of control, and fear of reinjury, which influence the rehabilitation process and return to play 6