Why entering surgery with stronger hips changes long-term outcomes

Pre-operative exercise before hip replacement does more than ease the first few days in hospital — research suggests it shapes how independently a patient lives two years later. A widely cited longitudinal study by Fortin and colleagues found that patients with low preoperative hip function were five times more likely to need ongoing assistance with everyday activities at 24 months post-surgery than those who entered the operating theatre in better physical condition. That is a long-horizon consequence, not simply a question of discharge speed.

The stakes have sharpened because NHS hospitals have become considerably more efficient. Mean length of stay for primary total hip replacement fell from seven days in 2004 to around four days in 2021, following the adoption of Enhanced Recovery After Surgery (ERAS) protocols. Patients now need to meet mobility and self-care criteria faster than previous generations of hip replacement recipients did — and those who arrive at surgery already able to walk with an aid, transfer safely, and manage basic tasks have a meaningful head start.

The hip joint depends on four muscle groups working in coordination: the gluteals, lateral rotators, adductors, and iliopsoas. Weakness in any of these limits early post-operative mobility and, if left unaddressed, can persist well into recovery. Prehabilitation reframes the pre-surgical period as preparation for the recovery process itself — building the physical reserves that translate into walking further, regaining independence sooner, and reducing the likelihood of needing additional rehabilitation support down the line.

The strength milestones that predict a smoother recovery

Three categories of physical readiness recur most consistently across hip prehabilitation studies — and they are concrete enough to discuss with a physiotherapist before surgery.

Hip abductor and gluteal strength

This is the highest-priority target. The gluteus medius and minimus control pelvic stability during single-leg weight-bearing; when they are weak, the pelvis drops to the opposite side with each step — the pattern clinicians call a Trendelenburg gait, and patients often describe as a hip-drop limp. Abductor weakness is one of the most common functional impairments following total hip replacement, and it directly predicts gait disturbance and delayed recovery. Research into targeted gluteus medius and minimus rehabilitation found that systematic training shifted hip abductor strength from approximately 3.4 to 5.3 kgf alongside an improvement in gait speed from 0.55 to 0.73 m/s — even in the early post-operative phase. That data illustrates what structured gluteal work can achieve, though individual results vary. A practical pre-surgical benchmark is the ability to perform a side-lying leg raise and a standing hip abduction against light resistance with control.

Quadriceps strength

Holding a straight leg raise for five seconds without the knee buckling is a standard pre-surgical target. Quadriceps strength underpins safe transfers, stair negotiation, and the ability to rise from a hospital bed — all tasks that appear in the first 24 hours after surgery.

Functional sit-to-stand

Rising from a standard-height chair without pushing off with the arms maps directly onto early post-operative mobility criteria. Patients who can do this comfortably before surgery tend to manage hospital transfers more safely and progress to walking aids sooner.

Exercise volume and precise loading parameters matter less than actually reaching these functional thresholds — evidence does not support a single optimal dose, so the focus should be on milestone attainment and consistent adherence.

How clinicians measure prehab readiness and progress

Physiotherapists tracking hip prehabilitation progress typically draw on a small set of practical tests — and two of them are most directly tied to surgical readiness, while the others map the broader arc of recovery before and after the operation.

The Timed Up and Go (TUG) test and the Chair Stand Test sit at the top of that hierarchy. The TUG asks a patient to rise from a chair, walk three metres, turn around, return, and sit down again — capturing the full sequence of balance, coordination, and confidence that safe early discharge depends on. The Chair Stand Test counts how many times a patient can sit and stand from a standard chair in 30 seconds, providing a direct read on lower-limb power and functional independence. Together, these two tests reflect the physical demands of the first day or two after surgery.

Gait speed — measured over a short timed walk — adds a simple whole-limb benchmark: it reflects how well the lower-limb muscles and nervous system are working together, without needing special equipment.

The 6-Minute Walk Test (6MWT) steps back further, measuring how far a patient can walk at a comfortable pace in six minutes — relevant to cardiovascular fitness and the walking capacity needed before discharge is considered.

HOOS (Hip disability and Osteoarthritis Outcome Score) shifts to the patient's own perspective, covering pain, daily function, and quality of life across several subscales.

Because the same tests are used after surgery, scores taken during prehabilitation become a personal baseline — a reference point for tracking how far recovery has progressed, not a threshold a patient must hit to proceed.

What the evidence genuinely shows — and where uncertainty remains

The evidence base for hip prehabilitation has strengthened considerably in recent years, though a careful reading of it shows both meaningful gains and important limits.

On the positive side, a 2025 overview published in JOSPT pooled findings from 19 THA randomised controlled trials (1,110 patients) and concluded that structured, resistance-training-led prehabilitation reduces complication rates and improves strength, objective function, quality of life, and self-reported function after surgery. A large 2023 systematic review adds moderate-certainty evidence that prehabilitation specifically improves hip abductor strength and health-related quality of life before surgery — two outcomes that directly connect to the milestones described earlier in this article.

The picture becomes more nuanced over time. The 2025 AktivA® randomised trial — 98 patients aged 70 or older, following a 6–12 week tailored programme — found meaningful pre-surgical improvements in gait speed (+0.15 m/s) and HOOS quality-of-life scores. At the three-month post-surgery primary endpoint, however, no significant between-group difference was found. Surgery itself appears to level outcomes across groups over the medium term, and the JOSPT overview confirms this pattern: benefits are real but largely concentrated in the first six post-operative months and attenuate thereafter.

Psychological readiness is a genuine clinical factor, not a soft add-on. Systematic review evidence links preoperative depression, anxiety, and low self-efficacy independently to worse post-THA pain and poorer functional outcomes — which is why an international expert panel in 2025 recommended that prehab programmes address anxiety management alongside physical targets.

What remains unresolved is how much prehab is enough. No meta-regression has identified an optimal duration, frequency, or loading dose. Programme adherence and reaching functional thresholds appear to matter more than the precise specification of sets and repetitions.

What a hip replacement prehab programme should include

Resistance training sits at the core of any well-designed prehabilitation programme — and within that, the hip abductors, gluteals, and quadriceps are the priority targets. Exercises such as side-lying hip abductions, standing hip abductions against light resistance, and repeated sit-to-stand repetitions directly build the strength behind the leg-raise and chair-rise benchmarks that predict a smoother early discharge. Straight leg raises, bodyweight squats to a raised surface, and step-ups are typical quadriceps exercises at this stage.

Balance and range-of-motion work sit alongside resistance training. Single-leg stance practice — even briefly, holding a worktop for safety — begins to train the Trendelenburg control that matters from the first post-operative day. Light cardiovascular exercise such as walking, static cycling, or swimming adds general conditioning without loading the joint excessively, and a 2025 international consensus of 17 clinicians includes cardiovascular fitness as a recommended prehab component alongside muscle strength, hip range of motion, and proprioception.

Home preparation is practical prehabilitation, and patients often underestimate it. Fitting a raised toilet seat, checking grab-rail positions, removing loose rugs, and practising with a walking frame or elbow crutches before admission reduce both the physical and cognitive demands of the first 48 hours at home.

Typical prehab programmes in trials last six to twelve weeks. What matters most is consistently reaching the functional milestones — abductor strength, the ability to stand from a chair without using arms, and steady gait — rather than adhering to a precise loading prescription. The evidence does not favour one specific set-and-rep scheme over another; adherence and milestone attainment are what count. Preparing mentally and managing anxiety about surgery form part of genuine readiness alongside the physical work.

Getting prehab support before hip replacement in the UK

Fewer than half of the 29 NHS hospitals surveyed in a 2025 national audit offered a dedicated prehabilitation programme for hip replacement patients — funding and staffing were the primary barriers. That gap makes self-advocacy a practical necessity rather than an optional extra.

The most direct step is to ask a GP or orthopaedic team explicitly for a pre-operative physiotherapy referral, rather than waiting to see whether one is offered. Making that request three to six months before planned surgery allows enough time to complete a structured programme and reach the functional milestones that matter at admission. When attending that appointment, framing goals around the specific targets covered in this article — abductor strength, chair-rise ability, and walking endurance — helps a physiotherapist prioritise work with a clear surgical endpoint in mind.

Patients who are not offered an NHS physiotherapy referral, or who prefer an earlier specialist hip assessment, can access community or private pathways without a long wait. Lincolnshire Hip is part of the MSK Doctors group and accepts patients without a GP referral for hip assessment, with clinics in Sleaford and Grantham for patients across Lincolnshire and the surrounding area.

1. [1] Prehabilitation for Patients With FAI Syndrome Who Will Have Hip Arthroscopy: Report From an International Consensus Meeting. (2025). https://doi.org/10.2519/josptopen.2025.0166 https://doi.org/10.2519/josptopen.2025.0166
2. [2] The bumpy road to recovery: older adults' experiences during the first year after hip replacement surgery — a longitudinal qualitative study. (2025). https://doi.org/10.1186/s12877-025-06155-6 https://doi.org/10.1186/s12877-025-06155-6
3. [3] The effect of prehabilitation for older patients awaiting total hip replacement. A randomized controlled trial with long-term follow up. (2025). https://doi.org/10.1186/s12891-025-08468-4 https://doi.org/10.1186/s12891-025-08468-4
4. [4] Systematic review: preoperative psychological factors and total hip arthroplasty outcomes. (2022). https://doi.org/10.1186/s13018-022-03355-3 https://doi.org/10.1186/s13018-022-03355-3
5. [5] The Effects of Structured Prehabilitation on Postoperative Outcomes Following Total Hip and Total Knee Arthroplasty: An Overview of Systematic Reviews and Meta-analyses of RCTs. (2025). https://doi.org/10.2519/jospt.2025.13075 https://doi.org/10.2519/jospt.2025.13075
6. [6] Comparison of Abductor Muscle Strength and Harris Hip Score after Total Hip Arthroplasty. (2025). https://doi.org/10.55095/achot2025/009 https://doi.org/10.55095/achot2025/009
7. [7] Immediate Effects of Superior Gluteal Nerve-Targeted Manual Therapy and Exercise on Hip Abductor Strength, Gait Speed, and Pain in Early Postoperative THA: A Case Series. (2025). https://doi.org/10.7759/cureus.94708 https://doi.org/10.7759/cureus.94708
8. [8] Pre-operative education and prehabilitation provision for patients undergoing hip and knee replacement: a national survey of current NHS practice. (2025). https://doi.org/10.1186/s12891-025-08637-5 https://doi.org/10.1186/s12891-025-08637-5