Why your hip muscles need work before surgery

By the time a hip replacement date is confirmed, most patients have already been losing muscle strength for months or years. Chronic hip osteoarthritis pain discourages movement, and reduced movement means progressive weakening of the gluteal and quadriceps muscles, stiffening of the lower back, altered walking patterns that redistribute load away from the painful joint, and a gradual decline in aerobic capacity. Patients arrive for total hip arthroplasty already significantly deconditioned compared with their age peers — and surgery temporarily adds to that deficit before recovery can begin.

Prehabilitation addresses this directly. Rather than entering the operating theatre at a functional low point, structured preoperative exercise raises the baseline — so that when hip arthroplasty does temporarily reduce strength and mobility, the starting level is meaningfully higher. A 2025 overview of systematic reviews found that structured prehabilitation improves muscle strength, objective function, and quality of life following THA, with benefits most pronounced in the first six months post-surgery, when functional gains matter most for daily life.

The NHS lists muscle strengthening before hip replacement surgery as a formal preparation measure alongside smoking cessation and weight management, recognising its role in reducing complications. Despite this, prehabilitation is inconsistently offered across the NHS — a 2025 national survey found it available at only 14 of 29 UK hospitals for patients awaiting total hip replacement. For patients on a waiting list, a 6–8 week window of structured exercise is both clinically achievable and evidence-supported — and that window already exists.

What the evidence actually shows

The evidence base is now substantial enough to draw reliable conclusions. A 2025 overview of systematic reviews, synthesising 19 randomised controlled trials involving 1,110 patients, confirmed that structured pre-operative exercise before total hip arthroplasty reduces complication rates and improves muscle strength, objective function, quality of life, and patient-reported outcomes following surgery.

The critical qualification — worth stating plainly rather than relegating to a footnote — is that these benefits are most reliable within the first six months after surgery. By around that point, outcomes in prehabilitation and usual-care groups tend to converge. That convergence matters clinically: it means prehabilitation accelerates early recovery rather than guaranteeing superior long-term results over standard care. An earlier return to independent walking, safer transfers, and fewer complications in the weeks immediately after hip arthroplasty are themselves meaningful gains for patients and their households.

Specific trial data strengthen this picture. The Norwegian AktivA programme — a randomised controlled trial in adults aged 70 and over, using a 6–12 week intervention — produced significant pre-operative gains in gait speed (+0.15 m/s) and hip-related quality of life before participants had even reached the operating theatre. A 2025 pilot RCT using six weeks of twice-weekly physiotherapist-supervised resistance and aerobic training achieved 80% adherence and a clinically relevant 2-second improvement in Timed Up and Go scores pre-operatively, including in deconditioned patients with higher BMI.

What remains less settled is the optimal combination of exercise type, dose, and timing. Current guidance reflects clinical consensus and available RCT data rather than a single finalised protocol — a gap the research community continues to address.

Floor and chair exercises for hip strength

Five exercises form the non-weight-bearing core of a hip arthroplasty prehabilitation programme — all performed lying on a firm surface such as a bed or exercise mat, making them accessible even to patients whose pain currently limits standing activity. Stop any exercise that produces sharp pain, and return to it only once that pain has settled.

Ankle pumps — Flex and extend the foot rhythmically, pulling toes toward you then pointing them away, 10–20 repetitions every hour or so. Beyond maintaining ankle mobility, the pumping action activates the calf muscle, which assists venous return from the lower leg — directly relevant to DVT risk in patients awaiting hip replacement surgery.

Quadriceps sets (thigh squeezes) — Lying flat, press the back of the knee down into the bed and hold for five seconds, then release. This isometric contraction activates the quadriceps without placing any load through the hip joint — important for patients whose pain makes more dynamic movements difficult.

Glute squeezes — Squeeze both buttocks firmly together, hold for five seconds, then release. The gluteal muscles are central to hip extension and stable, Trendelenburg-free gait after total hip arthroplasty; this simple exercise begins loading them from day one of prehabilitation.

Heel slides — Lying on your back, slowly slide one heel up toward the buttocks, bending the hip and knee gently, then return. This maintains hip flexion range and keeps the hip flexors active through their functional arc.

Hip abduction leg slides — From the same lying position, slide one straight leg outward across the bed surface and return. This targets the hip abductors — the muscles most directly responsible for lateral hip stability during single-leg stance after arthroplasty.

All five exercises can be performed on both sides, 10–20 repetitions per set, once or twice daily.

Standing and functional exercises

Once a patient can manage the floor exercises without sharp pain and feels stable enough to bear weight through the operative side, the programme progresses to standing work. This is a criteria-based step — readiness to stand, not a fixed day on a calendar.

Mini squats — Stand with feet shoulder-width apart, holding a worktop or chair back for light support. Bend the hips and knees to roughly 45 degrees, then straighten. The controlled descent and return is the same movement pattern as rising from a chair or the edge of a bed — performed hundreds of times in the first post-operative weeks.

Standing hip abduction — Holding a stable surface, lift one leg directly out to the side to hip height, then lower it slowly. The slow return is deliberate: it loads the hip abductors eccentrically. Needing to hold the surface for balance is correct form, not a shortcut; the single-leg challenge on the standing side is precisely the point.

Standing hip extension — Still holding support, extend one leg behind you with the knee straight and the trunk upright. This isolates the gluteus maximus in a standing position, which is the context in which it actually drives gait propulsion.

Glute bridges — Lie on your back with knees bent, feet flat. Lift the hips off the floor and hold briefly before lowering. This combines gluteal activation with lumbar stabilisation — both relevant to walking symmetry after arthroplasty.

Armchair push-ups — Sit in a firm chair with hands on the armrests and push to a near-standing position, then lower with control. This builds the combined upper-limb and quadriceps effort used when rising with a walking frame or crutches.

Aim for 10–20 repetitions of each, once or twice daily.

Cardiovascular fitness and lifestyle preparation

Strength and aerobic fitness address different recovery bottlenecks. The exercises in the preceding sections build the muscle capacity to perform individual movements; cardiovascular conditioning determines how well the body sustains repeated effort — walking corridors, attending physiotherapy sessions, climbing stairs — across the early post-operative days.

Walking is the most accessible starting point. Beginning with whatever distance is currently pain-free, the aim is to add roughly five minutes of continuous walking every few days over the 6–8 week prehabilitation window, working toward 20–30 minutes without stopping before surgery. Use any walking aid needed; shortening the stride to protect pain does not build fitness.

Swimming and pool walking remove the ground reaction force that makes land-based activity painful for some patients, while still building cardiovascular and muscular endurance — particularly useful for those whose hip pain reliably limits walking beyond short distances.

Stationary cycling provides a similar low-load option at home, adjustable for resistance and session length as tolerance improves.

Smoking cessation and weight management

Stopping smoking before hip arthroplasty reduces the risk of wound breakdown, surgical site infection, and respiratory complications under anaesthetic. The mechanism is largely vascular: nicotine impairs tissue perfusion and immune response at the wound site, slowing healing of both incision and the soft-tissue layers around the new joint.

Excess body weight increases mechanical load on the hip and raises anaesthetic complexity. Prehabilitation exercise supports modest weight reduction when combined with dietary adjustment; even a small reduction before surgery may lower surgical risk and reduce early strain on the implant.

How to structure the 6–8 weeks before surgery

Six to eight weeks before surgery is the practical planning horizon — enough time to build meaningful strength if the programme starts when the waiting period begins rather than in the final days before admission.

The structure layers progressively. Floor and chair exercises form the foundation, performed once or twice daily from the outset. Standing functional work is introduced when stability and pain allow, not on a fixed date. Cardiovascular sessions — walking, swimming, or cycling — run alongside at roughly three to five times per week, building endurance across the full window. There is no hard boundary between phases; the progression is criteria-led rather than calendar-driven.

For patients undergoing a tendon-sparing posterior approach such as SPAIRE (which preserves the short external rotators and their proprioceptive nerve structures rather than dividing them), pre-operative neuromuscular conditioning is particularly relevant. The tissues that prehabilitation strengthens are the same ones the technique leaves intact, meaning the hip enters surgery from a stronger functional baseline.

Despite the evidence, only 14 of 29 UK NHS hospitals currently offer structured prehabilitation to patients awaiting hip replacement. Those not offered it through their NHS pathway can access supervised programmes via private physiotherapy services or digital platforms; the HIPPER eHealth programme demonstrated feasibility and acceptability in older adults on arthroplasty waiting lists. Hip Replacement Lincolnshire, part of the MSK Doctors group, accepts patients without referral and can support pre-operative assessment — details at hipreplacementlincolnshire.co.uk.

Starting at the point of listing gives the body its full adaptation window — the factor the evidence consistently identifies as separating a patient who enters surgery prepared from one who does not.

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 RCTs. (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] Feasibility of a Preoperative Exercise and Nutritional Intervention in Sarcopenic Obese Individuals Undergoing Hip or Knee Arthroplasty: A Pilot RCT. (2025). https://doi.org/10.1016/j.arrct.2025.100524 https://doi.org/10.1016/j.arrct.2025.100524
4. [4] 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
5. [5] The hip instructional prehabilitation program for enhanced recovery (HIPPER) as an eHealth approach to presurgical hip replacement education: Feasibility RCT. (2025). https://doi.org/10.1016/j.ijotn.2025.101210 https://doi.org/10.1016/j.ijotn.2025.101210