Why a limp persists after hip replacement

A noticeable dip or lean with every step is one of the most common concerns patients raise weeks or months after hip replacement — and it has a specific mechanical cause rather than being a general sign that the body is still healing.

The pattern is called Trendelenburg gait. During normal walking, the muscles on the outer hip of the standing leg hold the pelvis level as the other foot lifts off the ground. When those muscles — the gluteus medius and gluteus minimus — cannot generate enough force quickly enough, the pelvis tilts downward toward the non-operative side with each step, producing the characteristic dip or trunk sway. A 2024 study following 89 patients at an average of 1.3 years after total hip replacement found that 27% still exhibited this pattern, with reduced eccentric contraction of the hip abductors identified as the primary determining factor.

The important distinction is that this is a muscle recruitment problem, not a sign that the replaced joint has failed or that something has gone surgically wrong. Pain does not have to be present, and the implant itself is not the issue. The gluteus medius and minimus have simply not regained the strength and activation pattern needed to stabilise the pelvis under load.

Left unaddressed, the limp can settle into a habitual movement pattern — the nervous system learns to compensate with a trunk lean rather than recruiting the abductors correctly. Correcting it earlier is consistently more straightforward than retraining an established compensation.

How your surgical approach and implant affect abductor recovery

Recovery speed after hip replacement varies between patients partly because of factors set in place before rehabilitation begins — chief among them the surgical approach used and the position of the implant.

The gluteus medius is the muscle on the outer hip that holds the pelvis level when you stand on one leg. How the surgeon accessed the hip joint determines how intact that muscle is on day one of rehabilitation. Anterolateral and direct lateral approaches require the surgeon to split or partially detach the gluteus medius to reach the joint. If that split extends more than 5 cm above the greater trochanter, the superior gluteal nerve — which runs through this area and activates the abductors — may be affected, prolonging weakness. Posterior and SPAIRE approaches leave the abductor attachment undisturbed, which is why patients who have undergone those techniques often find their hip-stabilising strength returns more quickly in the early weeks.

Implant geometry also matters. A 2025 prospective study of 174 patients found that a femoral offset reduction of more than 5 mm — a small change in the effective neck length of the femoral component — shortened the abductor lever arm enough to cap abductor strength at around 78% of normal. Patients with restored or increased offset achieved 90–92%. The difference is mechanical rather than a reflection of surgical quality.

Patients whose approach involved abductor disruption, or whose offset was not fully restored, are not starting rehabilitation from a position of failure — they are simply starting from a different biomechanical baseline, and their retraining arc will reflect that.

The exercise progression that retrains hip abductor strength

The exercise arc that corrects Trendelenburg limp follows a clear sequence: getting the abductors to fire again, teaching them to stabilise the pelvis upright, then training the exact contraction pattern that prevents the hip drop during walking.

Activation

Foundation exercises — side-lying hip abduction, clamshells, and bridging — are the starting point because they engage the gluteus medius and minimus without requiring the hip to bear full body weight. Side-lying abduction lifts the operated leg against gravity with the knee straight; clamshells rotate the top knee upward without letting the pelvis rock; bridging activates the glutes evenly from a lying position. A 2008 clinical study found that physical function correlated significantly with abductor strength at 2, 4, and 6 weeks after surgery — evidence that these foundational exercises carry measurable functional weight, even when they feel basic.

Upright control

Once weight-bearing is confident and comfortable, exercises progress to standing. Standing hip hikes — elevating the non-operative pelvis while balanced on the operated leg — introduce pelvic stability in the upright position that walking demands. Wall-supported single-leg stance follows the same principle, asking the operative hip abductors to hold level without a trunk lean for a sustained period.

Eccentric loading: the critical step

The standing pelvic drop is where retraining becomes specific. Standing on the operated leg at the edge of a step, the patient slowly lowers the non-operative foot below step height. The gluteus medius must act as a brake, controlling the descent rather than simply lifting. This eccentric lengthening under load — the muscle working as it lengthens — is the precise contraction pattern that fails in Trendelenburg gait, and it cannot be adequately trained through lifting exercises alone.

Functional integration

Resisted lateral band walking and sustained single-leg isometric stance on the operative side are progression milestones, not time-based targets. A practical criterion before adding band resistance is holding single-leg stance on the operated leg without a visible hip drop or trunk lean. Sets, repetitions, and load progression are decisions made with a physiotherapist, who can adapt the plan to individual technique and each patient's surgical starting point.

Milestones that show the limp is correcting

Knowing whether the exercises are actually working calls for concrete markers — not just a general sense of improvement.

The primary marker: a level pelvis

The clearest sign of recovering abductor control is what happens when you balance on the operated leg. Stand in front of a mirror and lift the non-operated foot off the ground. If the pelvis stays level, the gluteus medius is doing its job; if it drops toward the raised leg, the Trendelenburg pattern is still present. The same cohort study referenced earlier used this pelvic drop — or its absence — as the defining clinical indicator of whether abductor and extensor control had been regained.

Progressive milestones

Several functional markers signal forward progress alongside pelvic levelling:

• Single-leg stance duration: progressing from a brief, wobbly hold to a sustained upright balance on the operated side without trunk lean or visible hip drop
• Gait symmetry: step length and pelvic height becoming equal on both sides; the shoulder no longer dips toward the operated hip with each step
• Walking speed: comfortable pace returning as compensatory patterns reduce and the gait cycle normalises

Making improvement visible

The brain often adapts so completely to a lopsided gait that the pattern stops feeling abnormal — which is why visual feedback matters. Walking beside a mirror, or alongside a physiotherapist, provides real-time information that cuts through this adaptation and lets the brain correct what it has come to accept. A contralateral cane — held in the hand opposite the operated hip — can temporarily reduce the load on the recovering abductors, helping to interrupt the trunk-lean habit while strength consolidates. If you are working with a physiotherapist, ask about inertial sensor gait tools, which can detect subtle pelvic shifts that mirror observation or unaided assessment may miss.

If these markers are not improving after several weeks of consistent, structured effort, further clinical assessment is appropriate — not a sign of personal failure. Persistent limp can reflect upstream factors such as incomplete abductor recovery or implant geometry, and warrants evaluation rather than simply more of the same exercises.

When nerve involvement slows abductor recovery

Sometimes, consistent effort with the exercises simply does not produce the expected gains — and the reason may not be muscular at all.

The superior gluteal nerve carries the activation signal to the gluteus medius and minimus. During certain surgical approaches, particularly anterolateral and direct lateral techniques, the nerve can experience traction or compression without sustaining obvious structural damage. The conductivity of the nerve is reduced, and the muscles receive a weaker or slower signal even though the tissue itself has healed. The result is abductor weakness that seems disproportionate to the effort being put into rehabilitation.

This neurogenic component is easy to miss. Patients are often told to keep working through the exercises, when in fact the limiting factor is upstream of the muscle entirely.

Early evidence suggests that addressing the nerve directly may help. A 2025 case series of eight patients, assessed on day 14 after hip replacement, found that a single session of ultrasound-guided SGN-targeted manual therapy combined with visual feedback exercise improved abductor strength from 3.4 to 5.3 kgf, gait speed from 0.55 to 0.73 m/s, and walking pain from 3.6 to 1.5 on a standard scale. The study was small, and this approach is not a standard recommendation for all patients — but it points to nerve involvement as an identifiable, assessable cause of slow progress rather than an unexplained plateau.

A physiotherapist experienced in hip rehabilitation can assess whether a neurogenic contribution is plausible and whether nerve-targeted techniques are appropriate for an individual patient.

Realistic expectations and when to seek a review

Four to twelve weeks of consistent, structured retraining is a realistic window for meaningful improvement — but progress toward the shorter end depends on factors set before rehabilitation begins. Patients who had a muscle-sparing approach such as SPAIRE or a standard posterior technique typically start with better-preserved abductor tissue and tend to gain pelvic control earlier. Those whose surgery involved splitting the gluteus medius, or whose femoral offset was reduced by more than 5 mm, face a larger initial deficit and may need a more extended programme. Age, pre-operative abductor strength, and rehabilitation adherence interact with these surgical variables; no single factor alone determines the trajectory.

When a persistent limp warrants reassessment

The clearest clinical prompt for review is when the Trendelenburg dip is not progressively reducing despite several weeks of structured effort, or when the limp is worsening rather than plateauing. Abductor repair failure, implant offset mismatch, and ongoing superior gluteal nerve dysfunction are all identifiable, assessable causes — and distinguishing between them changes the treatment direction. Continuing the same exercises in the hope that more time will resolve a structural problem is unlikely to help, and patients should not assume that nothing further can be done.

Patient satisfaction after hip replacement remains high even when some asymmetry persists. In published data on patients treated for chronic abductor insufficiency, all said they would undergo the procedure again, despite a persisting Trendelenburg pattern in the majority. Restoring confidence and reducing compensatory effort in walking are clinically valid goals alongside gait symmetry.

Lincolnshire Hip accepts patients without referral for hip assessment — including post-replacement gait concerns — at Sleaford and Grantham.

1. [1] Trendelenburg gait after total hip arthroplasty due to reduced muscle contraction of the hip abductors and extensors. (2024). https://doi.org/10.1016/j.jor.2024.07.020 https://doi.org/10.1016/j.jor.2024.07.020
2. [2] Correlation of Global Femoral Offset Changes with Abductor Strength in Total Hip Arthroplasty Patients. (2025). https://doi.org/10.32553/ijmbs.v9i5.3133 https://doi.org/10.32553/ijmbs.v9i5.3133
3. [3] Immediate Effects of Ultrasound-Guided Superior Gluteal Nerve-Targeted Manual Therapy and Exercise on Hip Abductor Strength, Gait Speed, and Pain in Early Postoperative THA. (2025). https://doi.org/10.7759/cureus.94708 https://doi.org/10.7759/cureus.94708
4. [4] Poster 82: A Comprehensive 6-Phase Prehabilitation and Rehabilitation Program for Patients Undergoing Endoscopic Repair of Full-Thickness Gluteus Medius and/or Minimus Tears. (2025). https://doi.org/10.1177/2325967125s00188 https://doi.org/10.1177/2325967125s00188