After the artificial hip is in and the wound has healed, what many patients most want to know is when they can pick up old interests again. When can the golf clubs put away for so long be swung again? On a hot summer day, when can the patient get into the pool for a swim? Can the patient revisit the Dragon’s Back and the 家樂徑 trails walked so often in retirement? This page takes apart the sport side of rehabilitation. It does not stay with the general principle of low impact good, high impact bad. It looks at each sport in turn: how many people actually return, how long they wait on average, and the criteria for judging whether the body is ready. The return data for golf are quite encouraging. For swimming, the key is the state of the wound and not the months since surgery. For hill walking, it depends on being able to cope with the stone steps and downhill sections common on Hong Kong trails.
Readers can first grasp a basic idea. Swimming, cycling on the flat, walking, golf and hill walking are all low-impact activities that can generally be resumed once the wound has healed and the orthopaedic surgeon agrees (mostly within about 3 months of surgery). Running, jumping and contact ball sports are impact activities that speed up wear of the artificial joint, and most doctors advise waiting at least 6 months after surgery before considering them, with some not advising them at all (Vu-Han 2021; Telang 2024). It must be noted that this dividing line comes mainly from consensus surveys of surgeons and not from the evidence of randomised controlled trials. This page concentrates on sports and not on daily activities such as driving, returning to work and sexual activity.
Classifying sports by level of impact
The first consideration in judging whether a patient can return to a sport is the impact the activity puts on the artificial joint. In theory, the greater the impact, the faster the joint surfaces wear. Swimming, cycling on the flat, walking, golf and hill walking fall in the low-impact group. Running, jumping, basketball and football are high-impact. This classification agrees closely across two large surgeon surveys. The review by Vu-Han and colleagues (2021) found that low-impact activities are recommended by the great majority of doctors with almost no restriction. Klein and colleagues (2007) surveyed 549 surgeons of the Hip Society and AAHKS (a 72% response rate) and divided 37 sports into four levels: allowed, allowed with experience, not allowed and undecided. The result likewise showed that low-impact sports are generally allowed and impact activities are generally approached with caution.
One point needs to be made clear: this dividing line between low-impact and high-impact sports is set mainly on consensus surveys and clinical opinion of surgeons and has not been measured directly in randomised controlled trials. It is of course a practical safety guide, but it is not an absolute rule. As the next section shows, the instinctive idea that impact will certainly wear out the joint is not yet supported consistently by medical evidence.
The effect of impact on the life of an artificial joint
Why does the artificial joint need protecting? The intuitive reasoning is that repeated impact speeds up wear of the polyethylene or metal joint surfaces, and the wear particles released may provoke osteolysis and in the end loosening of the prosthesis, so that revision surgery is needed. This physiological mechanism makes sense and is why the medical profession is cautious about impact activities, but it does not mean that a high level of activity will necessarily shorten the life of the prosthesis.
A systematic review by Telang and colleagues (2024), which screened 7,420 papers and finally included 28 studies, found that the survival of the prosthesis in highly active patients after surgery was similar to or even better than that in less active patients. In the highly active groups, the all-cause revision rate was about 0.9% to 8.57% and the aseptic revision rate 0.4% to 5.7%, while in the less active groups they were 0.7% to 3.4% and 0.0% to 2.1% respectively, with the figures of the two groups overlapping. The level of activity was also not significantly linked to the dislocation rate, and on the contrary staying active after surgery was positively linked to mental health and patient satisfaction. In other words, the claim that the more active, the faster the joint wears out has no consistent evidence behind it.
Even so, the data should not be read too optimistically. The review by Krismer (2017) cited a cohort study by Ollivier and colleagues, which found that prosthesis survival at 15 years was about 80% in the high-impact sport group and about 93.5% in the low-activity group (n=70 against 140). But this is data from a single cohort study and not a final conclusion, and the sample was small and not randomly allocated. A more reasonable reading is that low-impact sports have good grounds for being recommended. For impact activities, the patient should do what he or she can manage, according to an understanding of the risk and how comfortable the body feels, and should not draw a conclusion from isolated data.
Points to note on swimming after a hip replacement
Swimming is one of the best sports after a hip replacement. The buoyancy of water takes off most of the body weight, so the hip is almost free of impact, and it also exercises the heart, lungs and the strength of the whole body, which is why it is recommended in a number of surgeons’ opinions (Krismer 2017). What decides when the patient can get into the water, however, is not the month since surgery but the state of the wound.
When a physiotherapist visits a patient who wants to return to the pool, the first thing checked is not how many weeks have passed since surgery but whether the surgical wound has healed completely and whether there is any discharge. Getting into the water before the wound is stable raises the risk of infection, and this is the real precondition for swimming. The points below should be checked before getting into the water:
- The surgical wound has healed completely, the stitches are out, and there is no discharge, redness or swelling.
- The orthopaedic team has agreed to the patient getting into the water.
- Avoid breaststroke in the early period, because it needs the thigh to be opened wide outwards and turned inwards, and avoiding such movements lowers the risk of dislocation of the joint (clinical practice advice).
- Getting into the water while the wound still has a scab, is discharging, or has not yet had the stitches removed.
In short, the two keys to returning to swimming are wound healing and avoiding movements that carry a high risk of dislocation, and not simply counting weeks after surgery. Provided the wound is secure and the stroke is suitable, swimming is a good and safe starting point for rebuilding fitness.
Return data and performance for golf after a hip replacement
Of all the sports after a hip replacement, golf has the most encouraging research data. The systematic review and meta-analysis by Robinson and colleagues (2023) shows that the rate of return to golf after hip replacement is as high as 90% (95% confidence interval 82% to 98%), the highest of the three types of joint replacement (hip, knee and shoulder). The average return time is about 4.4 months, and the change in handicap is close to zero (average −0.1), which means the standard of play has not worsened.
Another study, by Pioger and colleagues (2021), gives more specific data. It followed 599 regular golfers for at least 2 years and found that returning to a full 18-hole course took about 4.7 months on average. 88% of respondents said that their drive distance had increased or stayed the same. Hip pain on playing fell sharply, from a VAS of 6.8 to 2.5, and handicap improved by 1.8, which shows play after surgery was better than before. Playing golf after a hip replacement is therefore not only possible, but comfort when hitting the ball and performance on the course often improve.
In clinical practice, the thing golf lovers worry about most is whether the swing will damage the artificial hip. The physiotherapist first assesses the range of rotation of the operated hip and the stability of the core muscles, then restores the swing range step by step. Since research confirms that nine in ten golfers can return to the course and that drive distance is not reduced and may even increase, patients can feel free to make returning to the course a rehabilitation goal. The rotation movement of the swing, though, must be restored in stages, and only released further once the range of movement is confirmed to be adequate. The actual time to go back on the course likewise depends on wound healing and is decided case by case with the agreement of the orthopaedic team.
Hill walking after a hip replacement and coping with downhill steps
Hill walking (walking in the countryside) is in itself a recommended low-impact activity (Krismer 2017), and walking on the flat puts little load on the artificial hip. What really needs care is the particular terrain of Hong Kong’s trails. Routes such as Dragon’s Back and the 家樂徑 trails often have many stone steps and steep sections, and when going downhill and down steps, the load on the operated hip is much higher than on the flat. This load is the hurdle that must be mastered before returning to the trails, and the assessment criterion is actual functional performance and not the number of weeks since surgery.
Going downhill tests muscle control more than going uphill. Going uphill relies mainly on the muscles pushing upwards, but going downhill and down steps relies on the operated hip slowly generating force to brake the body, which puts the greatest load on the hip. Clinically we advise going step by step, starting with gentle, short routes and using walking poles to share the body weight. Before setting out, it must also be confirmed that the muscle strength and balance around the hip are enough. If walking up and down slopes or stairs still feels unsteady, a physiotherapist should assess first, and the patient should not rush onto the hill.
Before the patient returns to the trails, the home-visiting physiotherapist carries out functional tests through actual movements such as going up and down stone steps and walking on slopes. The therapist observes whether the eccentric weight-bearing ability and balance of the operated hip reach the standard, and guides the correct use of walking poles to share the load. This assessment logic follows that of other daily activities: the key is whether the operated hip can bear the actual load of the particular environment, and it is not decided by the number of weeks after surgery alone.
Limits on impact activities and the time to recovery
As for running, jumping and ball sports that involve impact and body contact, mainstream medical opinion clearly leans towards setting limits. In the survey by Vu-Han and colleagues (2021), 34.3% of doctors did not advise taking part at all, and most of the rest felt that thorough training was necessary and advised starting at least 6 months after surgery. The survey of European Hip Society (EHS) members by Thaler and colleagues (2021) more explicitly listed handball, football, basketball, full-contact sports and martial arts as not permitted.
- Swimming, cycling on the flat, walking, golf, hill walking
- Mostly within about 3 months once the wound has healed and orthopaedics agrees
- Less wear on the artificial joint, which favours long-term use
- For golf there is also evidence that nine in ten return to the course with no loss in swing (Robinson 2023)
- Running, jumping, basketball, football, full-contact sports, martial arts
- 34.3% of doctors did not advise them at all, and most of the rest wanted thorough training first
- Most advise starting at least 6 months after surgery (Vu-Han 2021)
- Handball, football, basketball, full-contact sports and martial arts are among those not permitted (Thaler 2021)
However, as described above, the cautious attitude to impact activities rests mainly on reasoning about the mechanism of protecting joint surfaces from wear and not on any absolute conclusion that they will certainly wear out (Telang 2024). Whether a patient tries such activities must be discussed frankly with the orthopaedic team, and weighed carefully according to the patient’s own acceptance of the risk.
A staged timetable for returning to sport
Linking the timing of recovery across the various activities, the more practical way to understand it is as a timeline that opens up step by step and not as a rigid benchmark. The EHS survey by Thaler and colleagues (2021) reflects this staged pattern. In the first 6 weeks after surgery there are only 5 activities on which consensus allows participation, from 6 to 12 weeks 10, from 3 to 6 months 26, and after 6 months 37 of 47 activities are permitted. In other words, most activities are allowed after 6 months, though handball, football, basketball, full-contact sports and martial arts remain among those not permitted.
| Within 6 weeks of surgery | This stage is mainly for the wound to heal and for basic walking posture to return, and the fewest activities are approved by expert consensus (Thaler 2021). Swimming can start only after the wound has healed completely and the stitches are out. |
| 6 to 12 weeks after surgery | Low-impact activities can begin slowly at this stage. As long as the wound has healed and the doctor agrees, swimming, cycling on the flat and walking can generally start in this period. |
| 3 to 6 months after surgery | The number of activities approved by expert consensus rises greatly at this stage. The average time to return to golf, about 4.4 months, falls within this stage (Robinson 2023). |
| After 6 months of surgery | At this stage most activities can be done. Anyone who wants to try impact or contact activities is mostly advised to start only after this point, with thorough training beforehand. Some sports with full body contact are still not advised, however (Vu-Han 2021; Thaler 2021). |
It must be stressed that the weeks above are only reference ranges from expert consensus and not rigid benchmarks for everyone. In fact, there is evidence that rehabilitation exercise guided by a physiotherapist effectively improves hip abductor strength after surgery (an average of +16 Nm), walking speed (+6 m/min) and cadence (+20 steps/min), and that patients who exercise by themselves at home do about as well as those supervised in clinic (Coulter 2013). Laying a foundation of strength and gait at home first is therefore the real precondition for returning safely to any sport.
For assessment by a professional of the specific criteria for when to swim, play golf or go hill walking, according to the site of surgery, the target sport and the home environment, the physiotherapy at home provided by Nova Health’s registered physiotherapists assesses the weight-bearing ability, range of rotation and balance of the operated hip in full, and works closely with the orthopaedic team to break the return to sport into concrete, achievable stage goals. If the patient had a knee replacement and not a hip replacement, the criteria for returning to sport differ because of the different joint, and the details are in physiotherapy after knee replacement.
For local information, the orthoinfo patient education page of the Hong Kong College of Orthopaedic Surgeons sets out the points to note after total hip replacement, including that ordinary daily activities can be resumed in about 3 to 6 weeks, that running and contact sports should be avoided, and the key points for preventing dislocation (such as not crossing the legs and not bending the hip beyond 90 degrees) (https://www.orthoinfo-hkcos.org/?route=injuries-detail&c=5&i=21&t=69). For details of surgery and information on rehabilitation after joint replacement from the Hospital Authority, visit the Hospital Authority website (https://www.ha.org.hk/visitor/ha_visitor_index.asp?Content_ID=221223&Lang=CHIB5).