Why the first six weeks carry so much weight

Two risks peak at the same time in the days and weeks after hip arthroplasty, and both respond directly to how quickly — and how consistently — a patient begins moving. Understanding that pairing explains why physiotherapists organise early rehabilitation around urgency rather than arbitrary scheduling.

The first risk is venous thromboembolism. Reduced mobility after surgery slows venous return through the lower limbs, raising the likelihood of deep-vein clot formation. The second is disuse atrophy. The muscles around the hip — particularly the gluteal abductors — are often already weakened before surgery from months or years of painful, guarded movement. Without early activation, that atrophy deepens rapidly during the post-operative period, making compensatory Trendelenburg gait — where the pelvis dips on the unsupported side — progressively harder to reverse.

Studies comparing bed exercise combined with gait re-education against gait re-education alone found a Harris Hip Score of 78.1 versus 71.5 at five weeks, and a DVT rate of 2.7% versus 14.1% in favour of the combined approach. Over a six-week programme, weight-bearing exercise produced 56.4% improvement in hip function scores compared with 39.8% for non-weight-bearing protocols.

The practical implication is straightforward: effort invested in the first six weeks prevents considerably harder rehabilitation work later.

Circulation first — ankle pumps and DVT prevention

Before a patient attempts to stand, bend a knee, or squeeze a muscle, ankle pumps are already on the programme. They begin in the recovery room — often within the first hour after surgery — because the calf's venous pump action is one of the body's primary mechanisms for returning blood from the lower limbs to the heart. Hip arthroplasty temporarily disrupts normal lower-limb movement, slowing that return and raising the risk of deep-vein thrombosis in the early post-operative hours.

A 2025 meta-analysis of 16 randomised controlled trials covering 1,704 patients found that ankle pump exercises reduced DVT incidence by 73% (OR=0.27, p<0.001) following lower-limb orthopaedic surgery, with measurable improvements in maximum venous outflow and venous capacity — Level I evidence for a simple bedside exercise.

The technique is straightforward: pull the toes and foot upward toward the shin, hold briefly, then push them away. Ankle rotations — slow circular movements in both directions — accompany pumps to engage the full range of calf-muscle fibres and support more complete venous return. Physiotherapists typically advise 10–20 repetitions every hour while awake and resting, whether lying in bed or seated in a chair. As the patient becomes mobile, walking itself takes over much of this circulatory work — but in the early hours, ankle movement is the practical substitute.

Rebuilding gluteal control: the muscle activation sequence

The muscle activation sequence after hip arthroplasty follows a deliberate clinical logic: each exercise earns its position by building something the next exercise needs.

Gluteal squeezes — isometric buttock contractions performed lying flat — are the entry point. They ask nothing of joint range or load-bearing capacity, yet they reactivate the neuromuscular connection between the brain and the gluteal muscles before any movement is attempted. Without that foundational activation, more demanding exercises later in the sequence draw on compensatory muscles rather than the ones that actually need strengthening.

Heel slides and quadriceps sets come next: a heel slide draws the foot slowly along the bed in a controlled arc, rehearsing hip flexion within a safe range, while a quadriceps set tightens the thigh muscles against the surface without movement. Together they re-establish coordinated control across the lower limb and set the stage for load.

Bridging follows once pain and tissue tolerance allow. Lifting the hips from a lying position places genuine demand on the gluteus maximus and builds the hip-extension capacity that every step of walking requires. It is the first exercise in the sequence that asks the body to move against gravity in a way that resembles functional load.

Standing hip abduction — raising the leg sideways while bearing weight on the operated side — is typically the final step, and arguably the most consequential. It directly targets the gluteus medius, the abductor most responsible for keeping the pelvis level during the single-leg stance phase of walking. Pre-operative pain and guarded movement often leave this muscle significantly weakened before surgery; if the deficit is not addressed early, Trendelenburg gait deepens, placing uneven mechanical stress on the new prosthesis and distorting walking symmetry.

Progression through the sequence is governed by the patient's ability to complete each stage without pain or compensation — not by the calendar.

Walking from day one: gait re-training as a core exercise

Standing up and taking the first steps after hip arthroplasty is often prescribed within 24 hours of surgery — sometimes on the same day. That early timing is deliberate: walking is a therapeutic exercise in its own right, not simply a sign that the patient is well enough to move around.

Initial sessions are intentionally brief — typically 5–10 minutes, repeated three to four times a day — with a walking frame providing the base of support. Physiotherapists introduce a conscious heel-to-toe pattern from the outset, because the natural post-operative instinct is to shuffle, shorten the stride on the operated side, or hitch the hip upward to clear the foot. Any of these compensations, left uncorrected, can become habitual within days.

Gait re-education, rather than supervised walking alone, is the clinical priority. A physiotherapist watching a patient walk is watching for specific faults: hip hitching, lateral trunk lean toward the operated side (a Trendelenburg sign in motion), over-reliance on the frame, and uneven step length. Early correction matters because the nervous system consolidates movement patterns quickly, and a compensatory gait established in week one is harder to unlearn in week six.

During the hospital phase, walking frequency typically escalates. By discharge, most patients are walking several times per day and beginning to manage short distances on a ward or corridor. The progression from walking frame to crutches to a single stick follows the patient's abductor strength, pain control, and balance — not a fixed point on the calendar.

How the surgical approach changes what exercises are safe

The precautions a physiotherapist gives after hip arthroplasty are not arbitrary caution — they reflect the soft-tissue consequences of the specific surgical approach used.

In the traditional posterior approach, reaching the hip joint requires dividing the short external rotator tendons, including the piriformis and obturator internus. These structures take approximately 90 days to re-heal and reattach. Until they do, certain positions risk pulling the new joint out of socket: hip flexion beyond 90°, crossing the legs, and internal rotation are all restricted. These three constraints directly shape which exercises are safe in the first six weeks, and why certain movements — sitting deeply into a low chair, or crossing one leg over the other — are explicitly avoided. The consequences of dislocation in this setting are serious: 57% of patients who dislocate will do so again, and 45.6% ultimately require revision surgery.

Most hip replacements currently performed in the UK use a posterior or modified posterior approach, so the majority of patients will encounter these precautions in some form. A different picture applies for patients who undergo a SPAIRE procedure — a muscle-sparing posterior technique developed by Professor Paul Y. F. Lee that preserves the piriformis and obturator internus intact rather than dividing them. Because those tendons are never cut, their Golgi tendon organs and muscle spindles continue providing proprioceptive feedback from the outset, and the clinical case for imposing the same 90-day movement restrictions is considerably weaker.

Patients sometimes compare notes with others who have had hip replacements and find real differences in what they have been told to avoid. Those differences are usually clinically appropriate — a reflection of the specific approach and its soft-tissue consequences, not inconsistency in care.

Frequency, dosage, and knowing when to progress

Structured across the day rather than delivered in one long block, the standard prescription for the first six weeks runs to 20–30 minutes of active exercise daily — split into two to three sessions post-discharge, rising to four or five sessions during the hospital stay when a physiotherapist is close at hand.

The markers physiotherapists watch for when deciding whether to advance the programme are specific and functional: consistent heel-to-toe gait with a walking aid, pain-free weight-bearing through the operated leg, visible gluteus medius activation without a Trendelenburg lean, the ability to hold single-leg stance for a meaningful interval on the operated side, and confident stair use leading with the unoperated leg. When enough of these converge, the programme moves forward — not because a week has passed, but because the body has demonstrated it is ready.

Pain is an informative signal rather than an automatic reason to stop. Some muscle soreness in the hours following exercise is expected — the body is rebuilding tissue that was deconditioned before surgery. Sharp pain, discomfort that intensifies over successive sessions, or new joint symptoms warrants reporting to the treating physiotherapist, not suppression.

Age, pre-operative fitness, surgical approach, and adherence all shape how quickly milestones arrive. Two patients operated on the same day may be weeks apart in their readiness to progress, and both trajectories can be entirely within normal range. Recovery from hip arthroplasty is, ultimately, a conversation between what the tissues are doing and what the patient can consistently do — and that conversation continues well beyond the first six weeks.

1. [1] Effect of postoperative ankle pump exercises on DVT and venous haemodynamics – PMC meta-analysis. (2025). https://pmc.ncbi.nlm.nih.gov/articles/PMC12482818/ https://pmc.ncbi.nlm.nih.gov/articles/PMC12482818/
2. [2] Virtual reality for total hip arthroplasty rehabilitation – RCT (Nintendo Wii vs Kinect vs conventional). (2025). https://doi.org/10.1177/02692155251363417 https://doi.org/10.1177/02692155251363417
3. [3] Incorporating Functional Strength Integration Techniques during Total Hip Arthroplasty Rehabilitation – RCT. (2023). https://doi.org/10.1093/ptj/pzad168 https://doi.org/10.1093/ptj/pzad168
4. [4] An Evidence-Based Exercise Program for Total Hip Arthroplasty Rehabilitation – Delphi Study. (2025). https://doi.org/10.2147/CIA.S562419 https://doi.org/10.2147/CIA.S562419
5. [5] Rehabilitation Phases, Precautions, and Mobility Goals Following Total Hip Arthroplasty – PMC. (2023). https://pmc.ncbi.nlm.nih.gov/articles/PMC10626929/ https://pmc.ncbi.nlm.nih.gov/articles/PMC10626929/