Why glutes weaken after hip replacement

The most common sign that the gluteal muscles are not firing properly after hip arthroplasty is a characteristic limp: the pelvis drops towards the un-operated side with each step, a pattern known as Trendelenburg gait. It is uncomfortable to experience and inefficient to walk with — and it places uneven load across the prosthetic components of the new hip joint. Understanding why it happens helps explain why glute-focused rehabilitation is a clinical priority, not an optional extra.

Gluteus maximus and gluteus medius originate from the ilium and sacrum and insert on the femur. Maximus is the primary hip extensor — essential for rising from a chair, climbing stairs, and driving the walking cycle forward. Medius is the principal hip abductor and pelvic stabiliser; without adequate medius strength, the pelvis cannot stay level during single-leg stance, which is what produces the Trendelenburg drop.

By the time of surgery, most patients have already lost meaningful strength in both muscles. Months of pain-limited movement cause disuse atrophy — the muscles reduce in both size and neuromuscular efficiency before a surgeon makes the first incision. The operation itself compounds this: surgical tissue handling and temporary disruption to local blood supply further suppress the neuromuscular signals that allow the glutes to contract effectively in the days immediately after hip replacement.

Gluteus medius weakness is consistently the dominant functional deficit at six weeks post-operatively. Reactivating it — progressively and consistently — is how gait symmetry is restored and the new hip joint is protected during early loading.

How your surgical approach affects glute rehab

Two patients can leave the operating theatre on the same day, with the same prosthetic components, yet follow meaningfully different exercise timetables in the weeks that follow. The reason is almost always the surgical approach — specifically, what happened to the short external rotator tendons at the back of the hip during the operation.

Traditional posterior hip arthroplasty and the 90-day restriction

In a standard posterior approach, the piriformis and obturator internus tendons are cut to access the hip socket. These structures are not merely mechanical — they house Golgi tendon organs and muscle spindles, the proprioceptive receptors that relay continuous joint-position information to the nervous system. Once severed, that feedback loop is interrupted until the tissues heal. Because the cut tendons also provide posterior stability, traditional posterior THA protocols have mandated hip precautions — no flexion beyond 90°, restricted internal rotation and adduction — for up to 90 days, the biological timeline required for tendinous reattachment to the proximal femur. Within the first six weeks, those precautions rule out a meaningful range of glute exercises that involve hip flexion or rotation.

How SPAIRE changes the picture

The SPAIRE technique (Saves Piriformis And Obturator Internus with Repair of Obturator Externus), developed by Professor Paul Y. F. Lee, takes a modified posterior route that leaves both the piriformis and obturator internus intact. The preserved obturator internus wraps around the posterior femoral head and creates a 'strap effect' — a dynamic biological tether that resists dislocation without the need for strict movement precautions. Because the tendons are never severed, the Golgi tendon organs and muscle spindles within them continue to deliver uninterrupted proprioceptive feedback from the first day of rehabilitation. This may allow patients to begin progressive glute loading earlier and across a wider range of movement than is safely possible after a standard posterior approach.

Anterior and anterolateral approaches also avoid cutting the posterior tendons and may similarly reduce precaution periods, though the specific protocols vary by surgeon and patient profile.

The practical implication is that approach-specific guidance from the treating surgical team — not a generic timetable — should govern how quickly glute exercises are advanced.

Glute exercises in the first 48 hours

For many patients, the idea of exercising on the same day as surgery feels counterintuitive. Yet rehabilitation begins in the recovery room — not as a formality, but because early muscle activation reduces the risk of blood clots and begins reversing the neuromuscular inhibition that surgery triggers.

The exact sequence of exercises follows the operating surgeon's protocol and varies with surgical approach; what is consistent across most pathways is the starting point.

The first exercises are circulatory rather than glute-specific. Ankle pumps — slowly pushing the foot up toward the shin, then pointing it away — are recommended every five to ten minutes from the outset, promoting venous return and maintaining lower-limb muscle tone without loading the hip. Ankle circles follow the same principle.

Isometric gluteal squeezes are typically introduced within the first one to three days, while the patient remains largely bed-rested. The technique involves squeezing both buttock muscles firmly and holding for approximately five seconds before releasing. No leg movement is required. At this stage the goal is neuromuscular re-recruitment rather than strength — the nervous system is re-learning to find and fire a muscle group that surgical inhibition has temporarily muffled.

Bed-supported knee bends (supine heel slides — slowly drawing the heel toward the buttocks along the bed surface, then back) begin within the same window, preserving gentle hip flexor mobility without joint loading.

The American Academy of Orthopaedic Surgeons recommends 20 to 30 minutes of exercise per day, or two to three short sessions, throughout early recovery. Spreading activity across the day rather than compressing it into a single sitting is generally better tolerated in the immediate post-operative period — and it establishes the daily exercise rhythm that the following weeks depend on.

Weeks 1 to 3: from isometrics to active movement

Moving from bed-based exercises to gravity-resisted movement is the defining shift of weeks one to three — the phase when rehabilitation starts to feel purposeful.

Supine heel slides and inner-range quadriceps sets (gently tightening the thigh with the knee slightly bent) continue through week one, maintaining hip mobility and keeping the quadriceps engaged while the joint settles. These exercises consolidate the neuromuscular recruitment established in the first 48 hours without adding load to the new prosthesis.

Side-lying hip abduction

Side-lying abduction is typically the first exercise to target gluteus medius directly. Lying on the un-operated side, the patient lifts the operated leg sideways against gravity and lowers it in a controlled arc. Tolerance varies — some patients need a few additional days before a side-lying position is comfortable — but this exercise marks a meaningful step from isometric work to dynamic loading of the muscle whose weakness drives the Trendelenburg pattern described in the opening section.

Standing abduction with support

Once comfortable with weight-bearing, standing hip abduction — raising the operated leg sideways while holding a frame or worktop — brings gluteus medius training into an upright, functional context. This is a significant milestone: the muscle is now being trained in the same position it must work during every step of normal gait.

SPAIRE patients may reach supported standing abduction earlier in this window, because the intact piriformis and obturator internus tendons remove or substantially reduce the movement precautions that govern standard posterior THA recovery. Anyone who has had a traditional posterior approach should confirm their permitted range with their physiotherapist before progressing to this exercise, since protocols typically restrict hip flexion beyond 90° for up to 90 days while severed tissues reattach.

Short walks between rooms — to the kitchen, to the letterbox — accumulate over the day; as distance and confidence grow together, daily activity becomes a consistent low-intensity complement to the dedicated exercise sessions.

Weeks 3 to 6: progressing glute load

Bridging marks the transition into closed-chain glute work. Lying supine with both knees bent and feet flat, the patient presses through the heels and lifts the pelvis until hips and knees form a straight line — then lowers slowly. The controlled descent matters as much as the lift: gluteus maximus is working eccentrically on the way down, building the capacity needed for descending stairs and rising from low chairs. This exercise is typically introduced once pain is adequately managed and the patient can comfortably achieve the required hip extension range without discomfort at the operative site.

Step-ups

A low step — kitchen step-stool height — introduces genuine weight-bearing load through the operated limb. The operated leg steps up first; the lead hip must hold the pelvis stable as the trailing leg follows. What matters is control, not speed or height. If the hip dips on the operated side during the single-leg loading phase, the step height should be reduced until gluteus medius can hold the pelvis level through the full movement. Height and pace progress only when the patient can complete the exercise without compensatory trunk lean or pelvic drop.

Sustained walking

Gradual increases in outdoor walking distance across weeks three to six accumulate hundreds of gluteus medius contractions per outing, reinforcing the abductor pattern in real gait far more effectively than any isolated exercise. Progression follows a distance-first principle, guided by absence of post-walk pain and swelling rather than a fixed target number of steps.

The six-week checkpoint

The benchmark at six weeks is not which exercise a patient has reached — it is gait quality. Trendelenburg sign describes the pelvic drop visible when weight transfers onto the operated leg: the pelvis sags toward the un-operated side because gluteus medius cannot hold it level. When that drop has resolved and the pelvis stays stable through each step, meaningful gluteal recovery has occurred. That is the checkpoint that matters.

Signs of progress and when to contact your team

Progress after glute rehabilitation has a texture to it — each session feels fractionally less effortful than the last, the Trendelenburg dip that was visible in week one becomes smaller and then absent, single-leg stance grows more stable, and walking distance extends without triggering a pain flare that persists into the next day.

What is normal between sessions. Mild muscle fatigue and an ache in the worked muscles the following morning are expected responses to therapeutic loading. Slower progress on high-fatigue days is also normal; the trajectory matters more than any single session.

Contact your physiotherapist or surgical team if you notice:

• Any new, sharp pain in or around the hip during an exercise — distinct from the familiar muscle burn
• Wound-site swelling or warmth that is increasing rather than settling
• Calf swelling, calf pain, or calf tenderness — a potential DVT warning that always warrants prompt review
• Fever or flu-like symptoms in the weeks after surgery
• A sudden change in how the hip feels or moves — catching, giving way, or altered position sense

Recovery rate differs between patients. Age, pre-operative fitness, surgical approach, and how consistently rehabilitation is carried out all influence how quickly glute function returns; comparing your timeline with another patient's is rarely useful.

Hip Replacement Lincolnshire accepts patients without a referral. Where objective tracking of recovery is helpful, the team can use biomechanical gait assessment — including MAI Motion® — alongside clinical findings to monitor progress. Book an assessment at hipreplacementlincolnshire.co.uk.

1. [1] Gluteal muscles. https://en.wikipedia.org/?curid=3298206 https://en.wikipedia.org/?curid=3298206
2. [2] Gluteus medius. https://en.wikipedia.org/?curid=658129 https://en.wikipedia.org/?curid=658129
3. [3] Gluteus maximus. https://en.wikipedia.org/?curid=621267 https://en.wikipedia.org/?curid=621267