Total Hip Replacement Surgery: Postoperative Care and Rehabilitation

Goal and why it matters: Moving the calf muscles during a period of reduced mobility supports circulation and reduces ankle stiffness. It does not replace prescribed clot-prevention medicine or walking.

Stage and starting criteria: From the first hours, once sensation and control have returned to the foot and the treatment team has given permission.

Equipment and environmental safety: A bed or firm chair. If you still feel dizzy or numb, perform the exercise lying down with another person present.

Starting position: Lie on your back or recline, with both lower legs supported, knees facing the ceiling, and ankles free. Do not rotate the operated leg.

1. Keep the thigh and knee relaxed.
2. Pull your toes up towards your face.
3. Then gently point them away from you.
4. Return to the starting position smoothly, without jerking or rotating the whole leg.

Range, side, and restrictions: Move both ankles only through a comfortable range. Do not force the end of range, and maintain your hip precautions.

Breathing, speed, and rhythm: Do not hold your breath; keep the up-and-down movement smooth and continuous.

Documented dose: The AAHKS home guide shows 3 sets of 10 ankle pumps with an approximately 3-second hold. Space sessions through the day as directed by your discharge plan.

Rest: Relax the legs between sets and wait for calf fatigue to settle.

Signs of correct technique and expected response: Only the ankle moves, with a mild calf stretch or muscle effort that eases soon after stopping.

Stop immediately if: you develop new calf pain or tightness, one-sided swelling, persistent numbness, shortness of breath, or chest pain.

Common mistakes: Fast, jerky movement; rotating the whole leg from the hip; pushing into pain; or holding your breath.

Easier version/regression: Reduce the range and number of repetitions, and move one ankle at a time.

Progression criteria and next stage: Smooth movement without unusual symptoms. Continue ankle pumps alongside short walking sessions, not instead of them.

Goal and why it matters: This contraction reactivates the gluteal muscles without a large joint movement so they can resume their role in standing, pelvic stability, and walking.

Stage and starting criteria: Once you are fully alert and a gentle gluteal contraction does not cause sharp pain or pull on the wound.

Equipment and environmental safety: A flat bed. Do not use a pillow or prop that places the legs in a prohibited position.

Starting position: Lie on your back with the legs in the permitted alignment and the knees comfortable. Keep the pelvis on the bed and the lower back in a natural position.

1. Relax your body and breathe normally.
2. Gently squeeze both sides of the buttocks.
3. Hold the contraction without lifting the pelvis or rotating the legs.
4. Slowly release the muscles and relax fully before the next repetition.

Range, side, and restrictions: No visible pelvic movement is needed. Both sides engage, and none of your approach-specific precautions should be broken.

Breathing, speed, and rhythm: Exhale gently as you tighten and inhale as you release. Do not hold your breath.

Documented dose: AAHKS teaches 3 sets of 10 repetitions with an approximately 5-second hold. In the first hours, begin with fewer repetitions and good form.

Rest: Release the muscle completely between repetitions and rest between sets until any cramping has gone.

Signs of correct technique and expected response: A symmetrical gluteal contraction without lifting the pelvis. Mild muscle fatigue is normal and should settle promptly.

Stop immediately if: sharp groin or surgical-site pain, persistent cramping, dizziness, or a clear increase in pain or wound drainage occurs.

Common mistakes: Holding the breath, bracing the abdomen forcefully, bridging and lifting the pelvis, or turning the toes outward.

Easier version/regression: Use a shorter, gentler contraction and fewer repetitions.

Progression criteria and next stage: Ten controlled contractions without increasing pain. Next, use the same activation during weight transfer and standing exercises.

Expected and adverse responses: Fatigue, bruising, and manageable pain are expected. Pain that keeps increasing, dizziness during a transfer, reduced sensation or movement in the foot, or any warning sign calls for stopping and assessment.

Criteria to advance: Bed and chair transfers and short walks are safe with the prescribed aid and assistance, you can follow the simple medication and exercise plan correctly, and symptoms return to baseline before the next session.

Goal and why it matters: A walker lets you practise the sequence of steps with balance and controlled loading and helps prevent a protective limp from becoming established.

Stage and starting criteria: After weight bearing has been permitted, dizziness is controlled, and you can stand with help. The treatment team selects the type of walker.

Equipment and environmental safety: A correctly adjusted walker, closed shoes, a dry floor, and a well-lit route. At first, another person should stand on the operated side.

Starting position: Stand inside the walker frame with elbows slightly bent, trunk upright, both feet in a natural alignment, and weight distributed through the hands and feet.

1. Move the walker one short step forward and make sure it is stable.
2. Advance the operated leg without rotating it, bringing it into the middle of the frame, and place the heel down gently.
3. Bring the unaffected leg forward without stepping too far beyond the walker frame.
4. Take several small steps to turn; never pivot on a planted foot.
5. To sit, step back until you feel the chair, move your hands to the armrests, and lower yourself slowly.

Range, side, and restrictions: Keep steps short enough for the pelvis to stay level. Follow the exact weight-bearing status and any rotation or flexion restrictions on your discharge sheet.

Breathing, speed, and rhythm: Breathe freely and keep the unhurried rhythm “walker, operated leg, unaffected leg.”

Documented dose: The Mass General protocol emphasises frequent short walks and gradual increases in distance according to tolerance; it does not prescribe one daily dose for everyone. Your physiotherapy plan determines the number of sessions.

Rest: Sit down before pain changes into a limp. Begin the next session only after breathing and step quality return to baseline.

Signs of correct technique and expected response: An upright trunk, steps of nearly equal length, and toes facing forward. Mild thigh or gluteal fatigue is expected.

Stop immediately if: you develop dizziness, leg buckling, sharp pain, a sensation that the joint has shifted, shortness of breath, or a sudden loss of weight-bearing ability.

Common mistakes: Pushing the walker too far ahead, hanging through the arms, dragging the toes, taking an excessively long step, or twisting on the operated leg.

Easier version/regression: Use a shorter level route, closer supervision, and more rest. If form deteriorates, return to the previous level of support.

Progression criteria and next stage: When you walk without heavy arm support, imbalance, or an obvious limp, the physiotherapist may assess progression to a cane held in the opposite hand.

Expected and adverse responses: Fatigue and a mild rise in pain at the end of a session should settle with rest. A greater limp, pain lasting into the next morning, or increasing swelling means the route or duration was excessive.

Criteria to advance: Essential routes through the home are completed with the walker and without a near fall, transfers are controlled, and the next-day response is no worse.

Goal and why it matters: Controlled bending and straightening of the hip and knee helps reduce stiffness and makes transfers easier without placing body weight through the joint.

Stage and starting criteria: When the wound is protected, movement does not cause sharp pain, and the permitted hip-flexion range for your approach is clear. If “anterior precautions” apply to you, early heel slides may be restricted; do not begin until the instruction has been clarified.

Equipment and environmental safety: A flat bed and, if needed, a smooth bag or cloth under the heel. Forceful pulling with a strap is unnecessary.

Starting position: Lie on your back with both legs in the permitted alignment, the operated heel on the surface, and toes pointing to the ceiling.

1. Gently engage the gluteal muscles and keep the pelvis still.
2. Slowly slide the operated heel towards the buttocks.
3. Stop before pain or before crossing your specific restriction.
4. Pause briefly, then slowly slide the heel forwards along the same path.
5. Finish with the leg relaxed in a neutral alignment.

Range, side, and restrictions: Move only the operated leg and only through a comfortable permitted range. The pelvis should not rotate, and the knee should not fall inward or outward.

Breathing, speed, and rhythm: Exhale as the heel comes closer and inhale as it returns. Keep the movement slow and free of jerks.

Documented dose: AAHKS gives a pattern of 3 sets of 10 heel slides with an approximately 5-second hold. Start with less range and volume, approaching that pattern only if symptoms stay settled.

Rest: Straighten the leg and relax the muscles between sets. End the session if pain does not ease with a short rest.

Signs of correct technique and expected response: The heel slides in a straight line, with a gentle stretch at the front of the thigh or groin that does not persist.

Stop immediately if: sharp pain, painful clicking, catching, a sensation that the joint has shifted, increased wound drainage, or new numbness occurs.

Common mistakes: Pulling into pain, letting the knee fall inward, rotating the toes, lifting the pelvis, or using a jerky motion.

Easier version/regression: Reduce the range and hold, or give gentle support with the unaffected leg without moving out of the permitted alignment.

Progression criteria and next stage: Ten smooth movements without increasing pain or causing a next-day reaction. Then use this range during controlled sitting and standing.

Expected and adverse responses: A gentle stretch and brief fatigue are expected. Deep joint pain, a sense of instability, or a sustained increase in pain and swelling means reducing the range and contacting the treatment team.

Criteria to advance: Transfers and sitting are controlled within the permitted range, and exercise is tolerated without an adverse change in the wound, pain, or gait quality.

Goal and why it matters: This practical movement improves gluteal and thigh strength and weight-transfer control for the toilet, chair, and bed, while gradually reducing reliance on the arms.

Stage and starting criteria: Once weight bearing is permitted and you can stand at a walker or counter without the leg giving way.

Equipment and environmental safety: A firm, relatively high chair with armrests, placed against a wall; keep the walker in front and another person nearby.

Starting position: Sit near the edge, feet in the permitted alignment and slightly back, the operated foot a little farther forward if needed, trunk upright, and hands on the armrests.

1. Move towards the front of the chair and plant both feet.
2. Lean the trunk slightly forward from the hips without bending beyond the permitted range.
3. Push through the armrests while engaging the gluteal and thigh muscles.
4. Once fully upright, move one hand at a time to the walker.
5. To sit, step back until you feel the chair, reach for the armrests, and lower yourself slowly.

Range, side, and restrictions: Adjust sitting depth through chair height and your precautions. Keep knees and toes facing forward, and do not let the legs cross the midline.

Breathing, speed, and rhythm: Exhale while standing and inhale while sitting; keep both directions slow and controlled.

Documented dose: The Mass General protocol progresses transfers and sit-to-stand practice according to movement quality and does not specify a fixed dose for everyone. Your physiotherapist should adjust repetitions to chair height and your ability.

Rest: Sit fully after every few repetitions and rest until breathing and form have recovered.

Signs of correct technique and expected response: Weight is shared through both feet, the pelvis stays level, and mild gluteal or thigh fatigue develops.

Stop immediately if: sharp hip pain, dizziness, leg buckling, loss of balance, or a sensation that the joint has shifted occurs.

Common mistakes: Pulling on the walker to stand, dropping into the chair, letting the knees collapse inward, twisting the trunk, or starting from a chair that is too low.

Easier version/regression: Raise the chair, reduce the range, and use more support from the arms or another person.

Progression criteria and next stage: Complete several repetitions with symmetrical weight distribution and no increase in pain or loss of control, then reduce arm support gradually.

Expected and adverse responses: Fatigue in the thigh and gluteal muscles is acceptable. Increasing pain, a greater limp, or a sudden need for more assistance is a sign to regress.

Criteria to advance: Sitting and standing are completed without dropping, twisting, or sharp pain, and walking does not deteriorate after exercise.

Goal and why it matters: A stationary bike provides repetitive low-impact movement and endurance training and can build confidence in a comfortable range of hip and knee motion.

Stage and starting criteria: After the wound has closed, the treatment team has given permission, you can mount and dismount safely, and you have enough range to turn the pedals without breaking precautions.

Equipment and environmental safety: A stable stationary bike with a high saddle and resistance near zero, plus another person during the first session. Keep the pedals and floor dry.

Starting position: Set the saddle so the knee remains slightly bent at the bottom of the pedal stroke. Keep the pelvis level on the saddle and toes facing forward.

1. Mount from the side and in the manner taught by the treatment team, then place the feet securely on the pedals.
2. Begin turning the pedals slowly without resistance.
3. If a full revolution is not comfortable, rock the pedals forwards and backwards through the permitted range.
4. Pedal evenly for a few minutes while keeping the pelvis level.
5. Before dismounting, slow down, steady the pedals, and use a support.

Range, side, and restrictions: The pelvis should not rock on the saddle or reach prohibited flexion or rotation. Add resistance only after duration is well controlled.

Breathing, speed, and rhythm: Breathe freely and use a slow, even cadence. Do not kick through a difficult point.

Documented dose: AAHKS suggests starting at about 5 minutes and gradually adding 5 minutes over the following several weeks until approximately 20 minutes is tolerated before resistance is added. Increase only when symptoms remain settled that day and the next.

Rest: Wait between sessions until pain, breathing, and walking have returned to baseline.

Signs of correct technique and expected response: A level pelvis, smooth pedal stroke, and mild muscle fatigue without a limp after dismounting.

Stop immediately if: sharp groin or hip pain, catching, dizziness, a sense of instability, increasing swelling, or clearly worse walking occurs.

Common mistakes: A low saddle, adding resistance too soon, rocking the pelvis, turning the toes, or pedalling quickly to force past a restriction.

Easier version/regression: With your physiotherapist’s guidance, raise the saddle, shorten the session, or use only short forward-and-backward arcs without a full revolution.

Progression criteria and next stage: Complete revolutions and the baseline duration without reactive pain, swelling, or limping. Increase time first and then a small amount of resistance, one variable at each stage.

Expected and adverse responses: Brief fatigue and a gentle stretch are expected. Persistent pain, increased limping, or swelling that does not settle by the next morning means the volume was too high.

Criteria for entering month 2: The wound is settled, basic tasks and routes through the home are safe, the appropriate walking aid is being used, and month-1 exercises are tolerated without a meaningful reaction lasting into the next day.

Goal and why it matters: Strengthens the buttock and back-of-thigh muscles that steady the hip when you stand and walk.

Stage and starting criteria: From week four, if lying face down is comfortable and the wound is closed. If lying on your front still hurts, postpone this one and tell your care team.

Equipment and environmental safety: A firm bed or mat and a thin pillow under the hips; keep the floor clear so getting up from lying face down is safe.

Starting position: Face down, a thin pillow under the hips, both legs in their natural line and toes pointing down; head and neck relaxed.

1. Gently tighten the buttock on the operated side so the pelvis is set before anything moves.
2. Keep the knee straight and lift the operated leg only a few centimetres off the bed.
3. Hold there for one or two seconds without arching the back or letting the pelvis rotate.
4. Lower the leg slowly and under control.
5. Let the muscles release completely before the next repetition.

Range, side, and restrictions: Only the operated leg, and only as high as the pelvis can stay on the bed; the leg does not cross the midline and does not rotate inward. Lifting higher moves the work from the buttock to the lower back.

Breathing, speed, and rhythm: Breathe out as the leg lifts and in as it lowers; never hold your breath and never swing the leg up.

Documented dose: 10 repetitions, twice a day.

Rest: Take a few slow breaths between sets and let the buttock release; if the lower back starts to grip, end the session there.

Signs of correct technique and expected response: You feel the work in the buttock and back of the thigh, not in the lower back, and the pelvis stays flat on the bed throughout.

Stop immediately if: Back pain, sharp groin pain, or a feeling of instability in the hip.

Common mistakes: Arching the back to lift higher, bending the knee, twisting the pelvis to one side, and lifting the shoulders at the same time.

Easier version/regression: Reduce the lift to a couple of centimetres, or simply tighten the buttock without lifting at all until lying face down feels easier.

Progression criteria and next stage: Ten smooth repetitions with no back pain and no next-day reaction; then lengthen the hold rather than raising the leg higher.

Expected and adverse responses: Mild buttock fatigue is expected; back pain, groin pain or a sense of the joint shifting is not — stop and raise it with your care team.

Goal and why it matters: Retrains the stepping pattern and wakes the front-of-thigh muscles without any weight through the joint.

Stage and starting criteria: From week four, strictly within your hip flexion limit. If a specific restriction was written for you, that is the limit — not a general number.

Equipment and environmental safety: A flat bed or mat; if lifting is hard, rest your hands beside you and use them only for steadiness.

Starting position: On your back, knees bent, both feet flat, feet hip-width apart and the lower back in its natural position.

1. Engage the abdominal muscles very gently so the pelvis cannot twist as you move.
2. Lift one foot slightly, keeping the knee no higher than hip level.
3. Pause for a moment, then lower the foot along the same path.
4. Settle both feet fully on the bed before starting the other leg.
5. Repeat with the other leg, keeping the rhythm even.

Range, side, and restrictions: The knee never rises above hip level and the thigh never crosses the midline; if lifting forces more hip flexion, reduce the range rather than the restriction.

Breathing, speed, and rhythm: Breathe out as the foot lifts and in as it lowers; keep the pace slow and deliberate.

Documented dose: 10 repetitions each leg, twice a day.

Rest: Between sets, let both feet rest on the bed until the pull at the front of the thigh settles.

Signs of correct technique and expected response: The leg lifts lightly without help from your hands and the pelvis stays level as you change sides; you feel a mild pull at the front of the thigh.

Stop immediately if: If lifting the leg forces the hip past its permitted angle, or you feel a clunk or sudden pain.

Common mistakes: Drawing the knee up towards the chest, letting the pelvis tip to one side, holding the breath, and pulling the thigh up with a hand.

Easier version/regression: Slide the heel a few centimetres instead of lifting, or halve the range so the pelvis stays completely still.

Progression criteria and next stage: Ten repetitions per leg with a level pelvis and no next-day reaction; then carry the same pattern into standing with support.

Expected and adverse responses: Brief fatigue at the front of the thigh is expected; groin pain, a painful clunk or a catching sensation means stop and contact your care team.