Crossing Legs After Total Hip Surgery: (A PT’s Complete Guide)

As an orthopedic physical therapist, I have treated hundreds, if not thousands, of patients with complete hip replacements over the course of the past 40 years. The one instruction that most patients do not comprehend is “Don’t cross your legs.

This article is written for your edification of why or why not your surgeon may restrict “crossing the legs” and what that restriction means. It has been a point of common misunderstanding among the total hip replacement patients I have seen with the restriction of “no leg crossing”.

There are three ways to cross the legs:

  • “Tight-Leg” cross
  • “Ankle-Lock” cross
  • “Figure-4” cross

These instructions can be very different from surgeon to surgeon, depending on which surgical approach the surgeon has used:

  • The posterior approach.
  • The lateral approach.
  • The anterior approach.

Can I cross my legs after total hip replacement?

Can I Cross My Legs After Total Hip Replacement?“Tight-Leg” crossing“Ankle Lock” Crossing“Figure-4” Crossing
Posterior ApproachNoNoModified
Lateral ApproachNoNoModified
Anterior ApproachYesYesYes

Always clarify the “don’t cross your legs” instruction with your surgeon.
The surgeon knows exactly where the joint capsule was cut to receive the hip implant, and they also know exactly what Range of Motion Restrictions they want their patients to follow.

What is the “Tight-leg” leg crossing position?

Croos legs Knee stack
“Tight-Leg” leg crossing

The “Tight-leg” crossed-leg sitting position is when one leg is brought over the top of the other legs and the knees “stack” on top of each other.

What is the “Ankle-lock” leg crossing position?

Cross legs at ankles
“Ankle-Lock” leg crossing

The “Ankle-lock” crossed-leg sitting position is when one leg is brought over the top of the other leg and the ankles are “stacked” on top of each other.
The “Ankle-lock” leg crossing is what people tend to do in a recliner chair position.

The ankle-lock position may apply in the upright-seated position as well and may be one of the restrictions for the total hip replacement patient who has had a posterior or lateral surgical approach to hip replacement.

What is the “Figure-4” leg crossing position?

Cross legs Figure 4
“Figure-4” leg crossing

The “Figure-4” crossed-leg sitting position is when one ankle is brought over the top of the other knee and the “stack” looks like the number 4.

The Figure-4 leg crossing is perfectly fine to do if the hip has been replaced using the anterior surgical approach.
In fact, I have one surgeon whose home exercise protocol includes this position as a position of recommended stretches.

While the figure-4 leg crossing is fine for an anterior hip replacement patient, it may not be allowed by the surgeon using a posterior or lateral approach to surgery.

Modified Figure-4 Leg-Crossing For Posterior & Lateral hip replacement approaches:

The Modified Figure-4 leg crossing technique is considered acceptable by some surgeons using the posterior or lateral total hip replacement approach.

Be sure to get approval from the surgeon before crossing the legs in this fashion if your hip replacement was done using the posterior or lateral surgical approach.

Only the surgeon knows EXACTLY where the surgical incision is for your specific surgery, and preventing the femoral head & neck from pushing into, and stretching out, the hip capsule surgical incision is the entire reason for the precautions.

A tight hip joint capsule rather than one stretched out is a primary restraint preventing hip dislocation in the posterior or anterior approach to hip replacement.

Modifications of the Figure-4 leg cross to Consider

A modification consideration to a Figure-4 leg crossing is to prevent hip flex past 90 degrees when crossing the legs in this fashion (if 90 degrees of hip flexion is a restriction).

Below is a patient seated crossing the legs with a “Figure-4” that has greater than 90 degrees of hip flexion:

Cross legs Figure 4 Too much hip flexion cropped watermarked
“Figure-4” but hip flexion is greater than 90 degrees

It is hard to cross the ankle at the knee without flexing the hip past 90 degrees in a soft-seated chair or sofa, or even a hard-back chair such as a dining room chair (if no hip flexion past 90 degrees is one of your restrictions).

A good modification would be reclining a little in a recliner chair and crossing the legs using the Figure 4 technique.

Cross legs after THR seated with less than 90 degrees hip flexion watermarked cropped
“Figure-4” leg crossing modification with less than 90 degrees of hip flexion

In a recliner chair, the patient can be in a seated position with the chair back slightly reclined and will be able to cross the legs Figure-4 style without flexing the hip more than 90 degrees of flexion (if 90 degree flexion is a restriction).

Notice the use of the recliner chair armrest to support the weight of the leg.

How could I accidentally cross my legs after total hip replacement without realizing they were crossed?

  • By side-lying on the unoperated side and allowing the operated leg to drop off to the mattress.
  • By pivoting on the operated leg toward the side of the operated leg while standing.

Side-lying on the unoperated side and allowing the operated leg to drop off to the mattress:

Most of my patients start off by sleeping on their backs.
Many elevate the head and torso a little, some even sleep in their recliner chair.

But sooner or later, they will want to lie on their side.
Since the operated side is still too tender to lie on comfortably, they sleep on the unoperated side and will allow the upper leg (the operated leg) to fall off toward the bed and rest on the mattress.
This breaks the “no leg crossing” restriction if there is that restriction from the surgeon.

Crossing legs side lying wartermarked 200711
Operated leg crosses mid-line without the use of pillows

The patient can safely sleep on the unoperated side without breaking the “no crossing the legs” restriction, but the operated leg must be supported from groin to ankle to prevent the operated leg from crossing the mid-line of the body.

TKR Sidesleeping JBB 3 edited
Side-lying with pillow props to prevent leg crossing mid-line

Pivoting on the operated leg toward the side of the operated leg while standing:

Another common way I see patients cross their legs (allow the leg to go past the mid-line of the body) is by turning toward the operated side.

They tend to pivot on the operated leg when turning toward the operated leg, stepping ACROSS the operated stationary leg with the unoperated leg.

Crossing legs Standing Pivot Watermarked cropped 200711
Turning toward the operated leg incorrectly and crossing mid-line

This can be prevented by starting a turn toward the operated leg by lifting the operated leg and setting the foot about 45 degrees toward the direction of the turn before pivoting on the operated leg.

Crossing Legs Pivot correctly watermarked cropped 200711
The correct way to turn to the operated side – start with the operated foot first!

Final Thoughts:

  • This article is not written as a prescription for your range of motion restrictions regarding crossing the legs after a total hip replacement surgery. That prescription must be a specific range of motion restriction protocols developed by the surgeon and the physical therapists based on their knowledge of you personally.
  • This article is written for the three primary surgical approaches to hip replacement: the posterior, lateral, and anterior approaches.
  • Please be aware that there are several other specific approaches identified by more modifiers of these three approaches, but they are based on these three primary concepts.
  • The “no crossing legs” rule may be applied differently with each variation, but in general, this restriction rule will apply as described above.

Read my other articles about Total Hip Replacement

Wishing you a safe and speedy recovery.

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Dr. Robert Donaldson

Dr. Donaldson is dually licensed; physical therapy in 1975 and doctor of chiropractic in 1995. He held credentials of Orthopedic Clinical Specialist in physical therapy for 20 years, QME in California, and taught at USC. He owns and operates an orthopedic physical therapy practice. See "About Me" page.

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