What hip replacement prehabilitation actually involves

Prehabilitation — 'prehab' for short — is structured exercise and education undertaken in the weeks before total hip arthroplasty (THA) to improve physical readiness ahead of surgery. The aim is to reach the operating table in better condition than a passive wait would allow: stronger muscles, better cardiovascular fitness, and a clearer sense of what recovery demands.

The hip joint depends on four major muscle groups — the gluteal, lateral rotator, adductor, and iliopsoas groups — to maintain stability and movement quality. When these muscles have weakened through months or years of hip osteoarthritis, surgery begins from a lower functional baseline. Prehab is the opportunity to recover some of that lost ground before the procedure rather than entirely afterwards.

One important distinction: education alone — information leaflets, videos, or group talks without supervised exercise — has not been shown to produce meaningful functional improvement in hip replacement patients. Exercise is the active ingredient. Evidence from a 2025 JOSPT overview of THA trials confirms that structured, exercise-based programmes improve strength, function, and quality of life around the time of surgery, though the magnitude of benefit beyond six months is less certain.

Prehab is best understood as physical preparedness and risk reduction, not a guarantee of a faster or uncomplicated recovery.

The hip exercises recommended before surgery

Six exercises form the clinical core of most NHS-aligned hip replacement prehab protocols. Perform each one to two times daily, aiming for 10–20 repetitions unless a hold time is specified. Stop any movement that causes sharp or increasing pain and discuss it with your physiotherapist or surgical team before continuing.

Ankle pumps. Lying or sitting, flex and point the foot repeatedly in a smooth, controlled rhythm. This keeps circulation moving through the lower limb and activates the calf pump — particularly useful during periods of reduced mobility before surgery.

Quadriceps sets. Lying flat, press the back of the knee gently down into the bed and tighten the thigh muscle. Hold for five seconds, then release. This maintains the strength of the quadriceps, which support the hip during standing and early walking after surgery.

Gluteal squeezes. Lying flat or standing, squeeze both buttock muscles firmly and hold for five seconds. The gluteal group — the primary hip abductor and extensor muscles — is typically one of the first to weaken with hip osteoarthritis, so direct activation here pays dividends in early post-operative gait.

Heel slides. Lying flat with legs extended, slide one heel slowly towards the buttock by bending the hip and knee, keeping the kneecap pointing upward. Slide back to the start. This preserves hip flexion range without placing compressive load through the joint.

Lying and standing hip abduction. Lying on your back, slide one leg out to the side and return it; progress to standing hip abduction, lifting the leg out against gravity while holding a stable surface for balance. Both variations target the gluteal and hip abductor muscles directly.

Mini-squats. Stand with feet hip-width apart and lower slowly, bending at the hip and knee simultaneously. The hips must not drop below knee level — limit the movement to 45 degrees of hip and knee flexion. This is a hard ceiling, not a guideline: exceeding it risks impingement and pain flare in a joint already affected by osteoarthritis.

Cardio and whole-chain conditioning before hip replacement

Hip osteoarthritis rarely confines its effects to the hip joint alone. Secondary lower back stiffness, altered gait mechanics, and progressive weakening of the muscles running from the hip to the foot are common by the time patients reach the surgical waiting list. A 2025 international expert consensus on hip prehabilitation reinforces this point explicitly: proprioception and cardiovascular fitness belong alongside strength work in any structured programme — conditioning the whole lower-limb kinetic chain, not only the hip muscles in isolation, is what produces meaningful preoperative readiness.

Cardiovascular fitness also matters for a practical surgical reason: greater aerobic capacity is associated with better tolerance of general anaesthesia and improved capacity to drive early recovery. The goal before hip replacement is not peak athletic conditioning — it is maintaining a functional baseline that has often eroded during months of reduced activity.

Three low-impact modalities are consistently endorsed for patients awaiting THA:

• Walking is the most accessible option. Begin on flat ground and progress to gentle inclines as comfort allows; the variable terrain lightly challenges proprioception as well as cardiovascular output. Do not push through hip pain to achieve distance.
• Swimming and aquatic therapy reduce compressive load through the hip joint while preserving cardiovascular work and hip mobility — a useful combination when weight-bearing exercise is poorly tolerated.
• Stationary cycling maintains aerobic fitness and hip range of motion with minimal joint impact; seat height should be set so the hip never flexes beyond a comfortable, pain-free arc.

For all three, intensity is secondary to consistency. Short, regular sessions that respect the hip's current limits are more productive than infrequent, effortful ones.

Movements and activities to avoid before hip replacement

Restrictions during prehab are not about caution for its own sake — they protect a joint that is already structurally compromised and cannot absorb excessive load safely.

High-impact activities — running, jumping, tennis, contact sports. Each footstrike or sudden change of direction transmits forces through the hip joint that a healthy cartilage surface handles easily but a degenerating one cannot. These activities should be set aside entirely during the prehab period.

Deep squats beyond 45 degrees of hip flexion. Descending below the point where the thigh is parallel to the floor increases intra-articular pressure sharply and risks bony impingement. The 45-degree limit stated in the previous section is a hard ceiling regardless of a patient's previous fitness level.

Leg crossing and extreme hip rotation. Both movements stress the joint capsule and the structures around the femoral head at a time when they are already inflamed or structurally compromised.

Any exercise producing sharp, new, or progressively worsening pain. Pain during prehab is a stop signal, not a metric to push through. A pre-surgical hip should not be loaded into pain; doing so risks flare-ups that interrupt the programme and may increase surgical complexity. Stop the movement immediately and report it to the surgical team before resuming any exercise.

The overriding principle is this: if an activity loads or rotates the hip beyond its current comfortable range, it belongs in the post-recovery phase — not the pre-operative one.

How long prehab benefits actually last

Widmer and colleagues' 2022 systematic review of 14 studies found consistent postoperative improvements across four clinically meaningful measures: the six-minute walk test, the Timed Up and Go, chair-rise, and stair climbing — precisely the functional milestones that determine how quickly a patient moves through early hip replacement recovery. Crucially, no harmful effects were reported in any included study.

The 2025 JOSPT overview of systematic reviews (19 THA RCTs, 1,110 patients) confirmed this picture and added an important time qualifier: postoperative gains from prehabilitation are clearest within the first six months after surgery and become harder to detect beyond that point. A meta-analysis of 48 RCTs (Punnoose et al., 2023) similarly found moderate-certainty evidence for pre-operative improvements in HRQOL and hip abductor strength, but limited evidence that these advantages persist well into the post-operative year.

A 2025 Norwegian RCT of 98 patients aged 70 and over sharpens the picture further. Six to twelve weeks of tailored prehabilitation produced significant pre-operative gains in gait speed (+0.15 m/s) and quality of life. At the three-month post-surgery follow-up, however, both the prehabilitation and usual-care groups had converged: no significant between-group difference remained. This does not mean the pre-operative gains were worthless — patients who arrived at surgery stronger and more mobile recovered from a better starting point — but it does suggest prehab's clearest contribution is to pre-operative wellbeing, physical readiness, and early recovery acceleration rather than to durable long-term superiority over patients who did no structured preparation.

What remains unresolved is the optimal programme length, exercise frequency, and resistance-training load. Given that variation, individual physiotherapy assessment is the most reliable way to set a programme that matches a patient's pre-operative hip pain level and functional baseline.

Getting prehab support when it is not offered locally

Fewer than half of NHS hospitals in England currently offer structured prehabilitation to patients waiting for hip replacement. A 2025 national survey of 29 hospitals found that only 14 provided a formal programme, with funding gaps, staffing shortages, and uncertainty about optimal delivery cited as the main barriers. For patients in Lincolnshire and across the wider non-London catchment, this means a structured programme cannot be assumed — it must be specifically asked for.

The practical first step is to contact the surgical team or GP directly and ask whether a hospital or community prehabilitation programme is available and how to access a referral. Where no formal programme exists, the exercises described throughout this guide — performed consistently within a pain-free range — are meaningfully better than no preparation at all. Individual physiotherapy assessment remains the most reliable route to a programme personalised to a patient's current pain level, strength, and fitness baseline.

Lincolnshire Hip is part of the MSK Doctors group and accepts patients without referral for hip assessment, including prehabilitation guidance as part of the full hip replacement pathway.

1. [1] The Effects of Structured Prehabilitation on Postoperative Outcomes Following Total Hip and Total Knee Arthroplasty: An Overview of Systematic Reviews and Meta-analyses of Randomized Controlled Trials.. (2025). https://doi.org/10.2519/jospt.2025.13075 https://doi.org/10.2519/jospt.2025.13075
2. [2] 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
3. [3] 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