After a hip replacement, there are aids and techniques for most daily situations such as sitting, sleeping and using the toilet. The hardest one is often putting on socks and shoes. Many patients cannot bend down to reach their feet, and forcing themselves to bend raises the worry of hurting the new hip. The situation is harder still for patients who live alone or have no family at home during the day.
The difficulty is not a lack of strength but the angle limit when bending. The solution is clear: there is no need to force yourself to bend over to put on trousers, socks or shoes. The patient sits securely and uses a long-handled shoehorn, a dressing stick, a sock aid and elastic laces so that the hands never reach past the knees. When dressing, the operated side goes in first, and when undressing it comes out last, so that the hip stays bent no more than 90 degrees and the legs do not cross. This approach is not just a formality. The forward bend used to put on socks and shoes can easily break all three movement limits at once. The sections below explain why, show how each aid is used, and give an easy order to remember.
Movements to avoid when putting on socks and shoes
First, it helps to understand why socks and shoes are riskier than an ordinary walk. The standard protection principle for a posterior-approach hip replacement is to avoid combined movements in three directions: hip flexion beyond 90 degrees, adduction across the midline of the body, and internal rotation. If the head of the femur is pushed towards the weakened back of the joint capsule in all of these at once, there is a risk of dislocation (Deak & Varacallo 2023). When putting on socks and shoes, these three movements often happen together: the upper body leans forward (flexion), the foot is drawn towards the inside while sitting (adduction), and the foot is twisted to adjust the sock top (internal rotation).
How far does the hip have to bend to reach the feet? A study that measured lower limb angles in daily movements (Hyodo 2017) gives specific figures. Whether sitting or standing, putting on trousers needs about 86 degrees of hip flexion, putting on shoes about 82 to 85 degrees and tying shoelaces about 89 to 90 degrees. Squatting while turning the trunk takes flexion to about 101 degrees. In other words, bending over to put on socks and shoes unaided will almost always push the hip close to or beyond the 90-degree limit.
One point must be made clear: the angles above were measured in healthy young people (average age about 20), not directly in hip replacement patients. They are quoted to explain, in mechanical terms, why bending down to reach the feet comes close to or passes 90 degrees. They are not measured values for patients after surgery. The safe range of movement for each patient still has to be set by the treating team according to the position of the surgical incision.
How to use the four dressing aids
Since bending over will always cross the limit, the answer is not to bend, and to use long-handled tools that cover the distance that would otherwise need leaning forward. Occupational therapists usually provide a set of dressing aids (including a sock aid, a dressing stick, a long-handled shoehorn and a reacher) and teach the principles of protecting the hip (Deak & Varacallo 2023). Each is described below. The rule common to all of them is to sit securely, keep the feet on the floor and keep the hands from reaching past the knees.
Keep in mind what the aids are really for: they help the patient dress independently without bending the hip too far, and they are not a cure-all against dislocation. For the full recovery overview, including the other daily situations of sitting, sleeping, using the toilet and bathing, see physiotherapy after hip replacement.
Order for dressing and undressing: operated side in first, out last
Once the aids are ready, the right dressing order makes the task easier and safer. The principle is easy to remember: the operated leg goes in first and comes out last. When putting on clothing (trousers, socks, shoes), always put on the operated side first and the healthy side second. When taking clothing off, always take off the healthy side first and the operated side last. This keeps the operated leg to the smallest amount of bending and rotation, without having to twist once more to accommodate the other leg.
- 1Dressing: operated side firstWhether it is trousers, socks or shoes, start with the operated side. Its movement is the most limited, so putting it in while the clothing is still loose avoids forced bending of the limb.
- 2Healthy side secondOnce the operated side is in, the healthy leg moves freely, so putting it into the trouser leg, sock or shoe is easy and does not make the operated hip bend one more time.
- 3Undressing: healthy side firstThe order for taking clothing off is the opposite. Take off the healthy side first and the operated side last. The operated leg then only has to come out of the clothing at the very end, with the smallest movement.
“Operated side in first, out last” is common clinical practice and not a figure measured in clinical trials. The order comes from standard discharge advice and aims to reduce the amount of flexion and rotation on the operated side. No randomised controlled trial has shown that this order alone lowers the dislocation rate. The patient only needs to follow the general idea and does not need to treat it as a rigid rule.
What the evidence says about dressing aids
Having described the method, it is right to be clear about how strong the evidence behind it is. In summary, the current evidence is not strong. The Cochrane systematic review (Smith 2016) found only 3 randomised controlled trials with 492 people, the certainty of evidence was very low, and it concluded that it could not tell whether aids or activity restrictions reduce dislocation or improve function. The real reason for using aids is therefore to reduce physical strain and avoid over-bending the hip so the patient can manage independently, and not that large data sets prove it prevents dislocation.
In recent years many studies have also asked whether the protective restrictions need to be so strict. A systematic review found that after a posterior-approach hip replacement, the early dislocation rate showed no statistical difference with or without precautions (2.2% in the restricted group against 2.0% in the unrestricted group, covering about 6,900 people; Crompton 2020). A more recent meta-analysis (4 RCTs and 5 non-randomised studies, 8,835 people) likewise found that precautions had no effect, or only a negligible one, on early dislocation and on early recovery (Korfitsen 2023). However, these are conclusions at the group level. They do not mean that an individual patient can bend over to put on socks straight after surgery. In the early period, before the soft tissue has healed, using aids to avoid extreme hip flexion is still the safe approach (Kostewicz 2022). Practical data add a useful point. Lee 2017 interviewed 97 patients 6 weeks after surgery. Only 22 said they followed the precautions fully, and 48 put on underwear without using an aid, but most respondents still depended on aids. The real value of the aids is that they let patients manage by themselves, and willingly do so safely.
Dressing in small Hong Kong homes and bathrooms
At home assessments, the most common situation is a patient dressing while sitting on a very low plastic chair or the edge of a bed. The hip is already bent past 90 degrees as soon as the patient sits down, never mind reaching for the feet. In practice, we suggest that the patient sits on the edge of the bed or on a dining chair with armrests, with a seat high enough that the hip does not bend beyond 90 degrees when sitting. Low sofas and plastic chairs should be avoided because sitting down puts the hip into deep flexion straight away. The sock aid, long-handled shoehorn and dressing stick should be kept within easy reach. Another common difficulty is a bathroom threshold combined with a narrow, separate wet area. When moving in and out of the shower, follow the “operated side in first, out last” idea (the healthy leg steps in first and the operated leg steps out first), and keep a long-handled shoehorn outside the bathroom door so non-slip slippers can be put on without bending.
Where to find local support. The patient information “Care after hip replacement” from the Department of Orthopaedics and Traumatology, Li Ka Shing Faculty of Medicine, The University of Hong Kong, states that after surgery the patient should avoid combined movements of flexion, adduction and internal rotation, that the hip should not bend more than 90 degrees, and that the recovery period is generally about 6 weeks to 3 months (ortho.hku.hk). For loans of dressing aids (including dressing sticks, sock aids and long-handled shoehorns) and guidance on self-care after surgery, patients can ask the occupational therapy department of a public hospital, or raise it at the follow-up visit with the orthopaedic or occupational therapy team (Hospital Authority hotline 2300 6555).
When to ask a therapist for help
After going home, if the sock will not go on however the sock aid is pulled, if the shoehorn still cannot get the heel into the shoe after a long struggle, or if the patient is not sure which chair at home is high enough, the patient should not force himself or herself to bend. These are signs that a professional home assessment is needed. The home physiotherapy provided by Nova Health’s registered physiotherapists can measure the height of chairs in the patient’s home, plan the route in and out of the bathroom, and demonstrate the correct angles and cord techniques for the four aids on the spot, so that putting on the operated side first becomes a daily habit and the patient can manage safely at home. When these deep-flexion restrictions can be relaxed depends on the surgical approach, and the surgical team’s instructions must be followed strictly. If there is continuing severe pain, a sudden clearly shortened or outward-rotated leg, fever, or redness and discharge at the wound, the patient should contact the orthopaedic team in charge as soon as possible.