Every year, more than 1 million total hip arthroplasties (THA) are performed worldwide. By 2030, that number is projected to exceed 2.5 million in the United States alone, driven by aging populations and rising rates of hip osteoarthritis. For most patients, the surgery itself is not the hard part, the months before and after are. A person who arrives at the operating table with strong glutes and good cardiovascular fitness recovers in a different universe from one who has spent the previous year mostly sedentary, waiting for their pain to be managed.

Hip replacement rehabilitation is no longer something that starts on day two of a hospital stay. The evidence now supports a model that starts 6–8 weeks before the surgery date, continues through a structured in-hospital period, and extends into months of outpatient or home-based work. A 2025 overview of systematic reviews in the Journal of Orthopaedic & Sports Physical Therapy (the highest-quality study design in the field) confirmed that structured pre-habilitation programs based on resistance training produce better postoperative outcomes for THA patients compared with no exercise. This article covers what that looks like in practice: what to do before surgery, what happens immediately after, and what the science says about getting back to full function.

What pre-habilitation actually does and what it does not do

Prehabilitation is physical and educational preparation before major surgery. In the context of hip replacement rehabilitation, it means starting an exercise program in the weeks before the procedure, with the goal of arriving at surgery in better muscular and cardiovascular condition than you would be without it. The concept is straightforward. The evidence, however, is more nuanced.

A 2023 systematic review published in the American Journal of Physical Medicine & Rehabilitation by Konnyu and colleagues, covering data from PubMed, Embase and Cochrane through 2021, found that a wide range of rehabilitation programs for THA do not clearly differ from each other in terms of pain, strength or quality of life at low evidence levels. This result does not mean prehabilitation does not work. It means the research field has been inconsistent in how programs are designed and measured.

A 2024 systematic review and meta-analysis in Disability and Rehabilitation by Adebero and colleagues noted high risk of bias and heterogeneity across included RCTs, which prevented firm conclusions. That is honest science. It does not mean patients should skip preparation, it means the field needs better-designed trials and more standardized protocols.

What the evidence does support is this: patients who perform resistance training, particularly targeting the hip abductors, gluteal muscles and quadriceps, before surgery arrive with a higher baseline of strength. Since recovery is measured as a return to that baseline, a higher starting point translates directly into better short-term functional outcomes.

A practical prehabilitation program for THA should include the following components:

1. Hip abductor exercises: side-lying leg raises, clamshells, resistance band abduction — 3 sets of 12–15 repetitions, 3–4 days per week.
2. Gluteal strengthening: bridges, single-leg bridges, hip thrusts with bodyweight or added load.
3. Quadriceps work: seated leg extensions, terminal knee extensions, wall sits at a pain-free range.
4. Cardiovascular base: 20–30 minutes of low-impact aerobic activity (cycling, swimming, walking) 4–5 days per week.
5. Patient education: understanding postoperative precautions, safe movement patterns, assistive device use, and what to expect during hospitalization.

A systematic review in Medicina (2022) by Widmer and colleagues analyzed 14 controlled trials on prehabilitation before THA specifically — not mixed with knee replacement — and found that exercise interventions improved postoperative physical function compared with no intervention. Education-only programs showed smaller effects. The combination of both produced the most consistent results across studies.

Patients managing diabetes or obesity face higher surgical risk during THA and other orthopedic procedures. If you or a family member falls into these categories, prehabilitation is not optional — it is the window to optimize blood glucose control, reduce inflammation, and lower the probability of wound complications.

ERAS protocols: the new standard for perioperative hip care

Enhanced Recovery After Surgery (ERAS) protocols have reshaped what the first hours and days after hip replacement look like. These are evidence-based, multimodal pathways designed to reduce surgical stress, maintain physiological function, and accelerate recovery. The ERAS Society has published 17 key recommendations for perioperative care in total hip and knee replacement — covering everything from preoperative carbohydrate loading to multimodal analgesia and early ambulation.

A 2025 systematic review published in Cureus by Aldossari and colleagues analyzed data from 7,206 patients across 6 RCTs and prospective studies (2018–2024). The ERAS group included 2,148 patients; the traditional care group included 5,058. The primary outcome was length of hospital stay — and the ERAS group consistently left the hospital sooner.

The clinical data from an RCT published in Archives of Orthopaedic and Trauma Surgery (2023) showed ERAS patients walking 252 meters by postoperative day two, compared with 120 meters in the conventional group. The difference in walking distance on day two has real consequences: less muscle atrophy, fewer thrombotic events, and faster functional independence.

One question that often comes up: does getting up the same day increase the risk of prosthetic dislocation? The evidence says no — provided patients have received clear instruction on safe movement patterns and hip precautions. This is why the education component of ERAS is not decorative. It is structural.

The first weeks after surgery: what to expect and what to target

Total hip arthroplasty removes the damaged femoral head and acetabulum and replaces them with metal, ceramic, or polyethylene components. The hip joint is mechanically rebuilt on day one. The soft tissue — the capsule, the abductors, the iliotibial band — takes weeks to months to recover, depending on the surgical approach used.

The posterior approach is the most common globally. It provides excellent surgical visibility but requires the posterior capsule to be repaired, and traditional precautions include avoiding hip flexion beyond 90 degrees, adduction, and internal rotation for 6–12 weeks. The direct anterior approach (DAA) does not require cutting through the gluteus medius or posterior capsule, which theoretically means faster early recovery and fewer dislocation precautions — though a 2024–2025 meta-analysis comparing DAA vs. posterior approach in ERAS contexts found mixed results on longer-term outcomes.

Regardless of approach, the targets for the first 6 weeks after hip replacement rehabilitation are:

• Pain control adequate to allow active participation in physiotherapy sessions
• Full weight-bearing with assistive device (walker or crutches) by day 2–3
• Hip flexion to 90 degrees and progressive range of motion exercises
• Bed mobility: turning, bridging, transfers in and out of bed safely
• Stair negotiation before hospital discharge
• Basic ADL independence: washing, dressing lower body, sitting and standing

The JOSPT Clinical Practice Guideline on Hip Osteoarthritis (2025) recommends individualized exercise programs with dosages from 1 to 5 sessions per week, each lasting 30–120 minutes, over 5–16 weeks. Aquatic therapy, specifically pool-based exercise, improved lower extremity function and pain outcomes in multiple trials, particularly for patients with weight-bearing limitations early post-op.

For patients concerned about bone quality and long-term implant stability, the relationship between bone mass and fracture risk is relevant context: patients with better bone density going into surgery tend to achieve faster implant osseointegration and have lower periprosthetic fracture rates. If you are over 60 and have not had a DXA scan, this is the time.

Telerehabilitation: the evidence for home-based recovery

One of the most significant shifts in hip surgery recovery over the past five years is the mainstreaming of telerehabilitation. Instead of requiring patients to drive to a clinic two or three times a week, video-based remote physiotherapy delivers exercise guidance, progression monitoring, and clinical check-ins directly to the patient’s home. For many THA patients — who are often older adults managing transportation limitations — this matters enormously.

A 2023 systematic review and meta-analysis published in Disability and Rehabilitation specifically evaluated telerehabilitation after total hip replacement. The finding: internet-based telerehabilitation and face-to-face rehabilitation produced equivalent functional outcomes for THA patients. Patient compliance was actually higher in the telerehabilitation group. This is not surprising — removing travel barriers removes excuses.

A 2024 systematic review in Telemedicine and e-Health by Ouendi and colleagues searched five databases through June 2023, focusing specifically on elderly patients with hip or knee arthroplasty. The review confirmed the non-inferiority of telerehabilitation against usual care — a finding also supported by an earlier non-inferiority RCT (Nelson et al., 2020) that has since been widely replicated.

The expanded systematic review published in the International Journal of Medical Sciences (2026), synthesizing evidence from 50 RCTs and over 10,000 THA patients between 2015 and 2025, evaluated the full spectrum of rehabilitation modalities. Virtual reality (VR)-enhanced interventions and AI-driven monitoring platforms showed early promise in engagement and adherence metrics, though long-term functional outcome data remain limited. What the review does confirm clearly is that no single modality is universally superior — individualization matters.

For patients interested in what a comprehensive home program looks like after the first 6 weeks, the comparison with knee replacement rehabilitation protocols is instructive: the principles of progressive loading, aerobic baseline maintenance, and patient-reported outcome monitoring are identical. The specific muscle targets differ — hip surgery focuses more on abductors and external rotators, while knee surgery targets quadriceps and hamstrings.

Months 3 to 12: building back toward full function

The 3-to-12-month window after total hip arthroplasty is where the real work of hip replacement rehabilitation happens. Hospital stays after THA now average 1–3 days under ERAS protocols. Patients go home with a repaired joint but with abductor muscles that have been cut or stretched, surrounding tissue still healing, and gait mechanics that have been compensatory for years — sometimes decades — due to chronic hip osteoarthritis.

The meta-analysis data on abductor strength recovery (Journal of Arthroplasty, 2021) gives a useful timeline: mean strength increases of +20.2% at 4–6 months, +29.6% at 9–12 months, and +49.8% at 18–24 months — though that last figure carries wide confidence intervals. The message is that full strength recovery takes longer than most patients expect, and stopping physiotherapy at 6 weeks — which many do — leaves significant gains on the table.

A randomized controlled trial at St. Olavs University Hospital (Norway) tested maximal strength training (MST) versus standard care in 60 THA patients. MST patients showed substantially greater leg press and abduction strength at 3 months (43 kg and 3 kg above controls respectively) and at 6 months (30 kg above controls). At 12 months, the gap closed — but that 6-month advantage translated into real differences in walking speed, stair climbing, and Harris Hip Score outcomes.

A realistic progressive program from month 3 through month 12 includes:

• Progressive resistance training: increase load on abductors and gluteals every 2–3 weeks using the 2-rep reserve principle.
• Gait retraining: work with a physiotherapist on Trendelenburg pattern correction, step length symmetry, and heel-to-toe mechanics.
• Balance and proprioception: single-leg stance progression, unstable surface training, obstacle navigation.
• Aerobic reconditioning: cycling is the most joint-friendly option; swimming and hydrotherapy are excellent alternatives for load-sensitive patients. Walking distance targets: 1 km by week 6, 3 km by month 3, 5+ km by month 6.
• Return to occupational and recreational activities: driving (typically cleared at 4–6 weeks for right-hip surgery), golf (month 3–4), light hiking (month 4–6), higher-impact sports (month 6–12 depending on bone integration).

Patients managing osteoporosis or fragility fracture history require special attention during this phase. Load management is more conservative, balance training is more intensive, and fall prevention becomes an explicit therapeutic target. The implant itself is not the vulnerability — periprosthetic fracture risk rises sharply in patients with compromised bone density who fall during the first year.

One area where evidence is growing — though not yet definitive — is the role of regenerative interventions such as stem cell therapy and PRP in managing soft tissue recovery around joint replacements. Current applications remain investigational in this context, but mechanistic plausibility is high for patients with delayed tissue healing or chronic postoperative pain.

Patient-reported outcomes are the standard benchmark for THA success. The two most widely used instruments are the Harris Hip Score (HHS) and the Hip Disability and Osteoarthritis Outcome Score (HOOS). The HHS scores pain, function, range of motion, and deformity out of 100. A score of 80–100 is considered good to excellent. Most patients reach that range by 6 months with consistent rehabilitation. The HOOS breaks outcomes into subscales — symptoms, pain, ADLs, sport and recreation and quality of life — which makes it more sensitive to functional nuances that the HHS misses.

What the evidence tells patients and clinicians

Hip replacement rehabilitation is not a passive process that happens to patients, it is an active process that patients do, with clinical support. The research from the past five years is consistent on a few key points: the pre-surgical period is an opportunity, not dead time; same-day mobilization under ERAS protocols is safe and effective; the abductor muscles are the functional keystone of THA recovery and must be targeted explicitly before and after surgery; tele-rehabilitation delivers equivalent outcomes to clinic-based care with better compliance; and full strength recovery takes 12–24 months, not 6 weeks.

For patients preparing for hip replacement rehabilitation, the practical implication is this: the 6–8 weeks before your surgery date are not waiting time. They are training time. Every set of hip abductions you complete in that window deposits capacity into the recovery account your body will draw from after the procedure.

For clinicians, the data from the 2025 JOSPT overview and the expanded 50-study synthesis from 2026 point toward individualized, multimodal programs — combining resistance training, aerobic conditioning, patient education and outcome monitoring, as the evidence-based standard. The 18.6% mean abductor strength deficit that patients arrive with at surgery is not a fixed number. It is a target.

References

1. Structured Prehabilitation on THA and TKA Outcomes. J Orthop Sports Phys Ther. 2025. doi:10.2519/jospt.2025.13075
2. Konnyu KJ, Thoma LM, Cao W, et al. Rehabilitation for total hip arthroplasty: a systematic review. Am J Phys Med Rehabil. 2023;102(1):11-18. doi:10.1097/PHM.0000000000002007
3. Adebero T, Omana H, Somerville L, Lanting B, Hunter SW. Effectiveness of prehabilitation on outcomes following total knee and hip arthroplasty for osteoarthritis: a systematic review and meta-analysis of randomized controlled trials. Disabil Rehabil. 2024;46(24):5771-5790. doi:10.1080/09638288.2024.2313128
4. Widmer P, Oesch P, Bachmann S. Effect of prehabilitation in form of exercise and/or education in patients undergoing total hip arthroplasty on postoperative outcomes — a systematic review. Medicina. 2022;58(6):742. doi:10.3390/medicina58060742
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8. Ouendi N, Avril E, Dervaux B, Pudlo P, Wallard L. Effectiveness of telerehabilitation programs in elderly with hip or knee arthroplasty: a systematic review. Telemed J E Health. 2024;30(6):1507-21. doi:10.1089/tmj.2023.0622
9. Hip Pain and Mobility Deficits — Hip Osteoarthritis: Revision 2025 CPG. J Orthop Sports Phys Ther. 2025;55(11):CPG1-CPG31. doi:10.2519/jospt.2025.0301
10. 10.Expanded systematic review: rehabilitation for total hip arthroplasty (50 RCTs, 10,000+ patients, 2015–2025). Int J Med Sci. 2026.