Physiotherapy after hip replacement,
moving safely and walking again

Dislocation is in fact uncommon. The traditional advice is to avoid three main movements: bending the hip too far (beyond 90 degrees), crossing the affected leg past the midline (adduction), and turning the hip inwards (internal rotation), especially after the posterolateral approach. But several randomised controlled trials and pooled analyses in recent years show that relaxing these usual restrictions does not increase the dislocation rate (van der Weegen et al., 2016: about 1.5% with strict adherence versus about 1.0% with relaxed precautions; Tetreault et al., 2020 randomised controlled trial: 1.03% versus 0.68%, no significant difference). Sensible protection in the early period after surgery is still the safe course, but there is no need to be fearful, and the approach and the individual's risk should be decided individually with the treating team.

In the early period after surgery (roughly the first 6 to 12 weeks) the soft tissues are still healing and the precautions make sense. But the traditional approach of requiring them to be extremely strict has been challenged. Two pooled analyses, Korfitsen et al. (2023) and Guo et al. (2024), both found that relaxing the usual precautions after total hip replacement through the posterolateral approach did not affect early dislocation or early recovery. It is advisable to discuss with the physiotherapist how tight or loose the precautions should be according to the approach and the person's risk of falling, and not to copy the strictest version across the board.

A limp is often linked to weakness of the gluteus medius (the hip abductors). When standing on the affected leg, the pelvis drops towards the opposite side, producing the typical Trendelenburg gait. Targeted strengthening of the hip abductors and gluteal muscles improves gait stability. Coulter et al. (2013) confirmed that physiotherapy raised hip abductor strength by an average of 16 Nm (95% confidence interval 10 to 22), with improvement in walking speed and cadence as well. Progressive resistance training also helps to restore strength and function, although the evidence is preliminary (Skoffer et al., 2015), and it should be combined with balance and fall prevention training.

It depends on the weight-bearing guidance given by the surgeon and on individual progress. The discharge notice states which level of weight bearing applies, and at home that level should be followed and not worked out from the number of days since surgery. Research shows that systematic physiotherapy clearly improves walking speed and cadence (Coulter et al., 2013: walking speed up by about 6 metres per minute and cadence up by about 20 steps per minute), and with step-by-step training most people progress from a walking frame to independent walking. Actual progress should advance step by step according to the physiotherapist's assessment.

A systematic review (Coulter et al., 2013) showed that after total hip replacement, self-directed training at home and supervised outpatient training give similar results in hip abductor strength, walking speed and cadence. The key is whether there is professional supervision, and not where the training is done. For patients who still have limited mobility after surgery, rehabilitation at home allows daily movements (such as getting in and out of bed safely and transferring to the toilet) to be practised in the real home setting, which is both practical and convenient.