Ice After Total Hip Replacement: A PT’s Complete Guide

This article will explain the correct way to use cold therapy options to reduce pain and swelling after a total hip replacement surgery.

As a physical therapist, this is what I advise my patients after having seen hundreds of post-op total hip replacement recipients over the first three weeks after surgery.

An almost universal problem my total hip replacement patients have, when I see them in their homes a day or two after surgery, are the incorrect instructions they have received on the use of ice packs and the incorrect size of the ice pack they have been provided after surgery for their use at home.

The ice packs the patients are receiving at discharge from the hospital are totally inadequate. They do not have the size and bulk that an ice pack needs to be effective at reducing pain and swelling after a total hip replacement surgery.

Along the way, the patient has invariably been instructed to ice the hip for 15 to 20 minutes, remove the ice pack for 20-30 minutes, then re-apply the ice pack to the hip again for another 15-20 minutes.


So let’s talk about the RIGHT way to use cold therapy after a total hip replacement surgery.

What is the best way to apply cold therapy after total hip surgery?

The best way to apply cold therapy after total hip surgery is by using a Cold Therapy Machine.
The second-best way to apply cold therapy is by using commercial cold packs.
A third alternative is to make your own cold packs from frozen vegetables.

    Cold Therapy Machine

    Electing to use a cold therapy machine eliminates the possibility of causing frostbite and decreases the attention required to change cold packs every hour or to replenish the ice every 4-6 hours in the cold therapy machine.

    A cold therapy machine is basically a six-pack insulated cooler with a submersible pump that pumps cold water through attached exterior outflow and inflow lines to continually circulate cold water.

    One of several differently designed pads is attached to these lines.
    Cold water circulates through a network of small water lines embedded in the pad to control the hip swelling and pain.

    The pad is placed on the new total hip replacement surgical site with a thin layer of insulation between the pad and the hip. That insulation could be as thin as a pillowcase or as thick as a thin hand towel.

    20230430 113746 scaled

    The instructions with the cold therapy machine state to fill the unit with ice and then add water up to the line that is marked “water line” inside the cold therapy machine.

    There is not any refrigerator whose ice maker can keep up with the demand to keep the cold therapy machine operational, so patients need to make a daily run to the store to buy big bags of ice.

    Replenishing the ice is a sloppy, floor-wetting task that is aggravating to the caregiver and a slipping danger for the patient.

    The solution is to use bottled water (a size that will fit into the cold therapy machine) that has been frozen in the freezer. No more fuss or muss; simply wipe the water bottles dry when removing them and replace them with new frozen bottles of water (and put the removed bottles back into the freezer for reuse).

    There will be a need for two sets of bottles to rotate into the cold therapy machine. A set of frozen bottles in the cold therapy machine will last for about 6 hours. That is plenty of time for the previously used bottles to re-freeze.

    All cold therapy machines are not created equal.

    Before buying my own cold therapy machine I spoke to a durable medical equipment vendor that rents cold therapy machines to patients after surgery. They chose a machine for their rentals that has the best life expectancy and the fewest problems.

    That is the machine I purchased for my family’s own personal use.
    The trademark is Cold Rush by Ossur (Amazon affiliate link).

    The Cold Rush by Ossur system can be purchased without a pad but is unusable without a pad.
    I prefer the “Universal Pad” for my total hip patients, and that is the pad I also purchased.

    20230430 111135
    Cold Rush Machine with Universal Pad

    Commercial Cold Packs

    Commercial cold packs are another, less expensive way of controlling the pain and swelling after a total hip replacement surgery, but these cold therapy packs carry the possibility of frostbiting the patient.

    Size makes a difference!

    My patients are never sent home from the hospital with any type of cold pack that has the size or flexibility needed to adequately control pain and swelling.

    One would think that after a very expensive surgery, the insurance carriers would not cheap-out on a $12 cold pack, but they do!

    The correct size to adequately service a total hip surgery is a gel pack 10” x 13”.

    This size will cover the side of the hip and the front of the hip (if an anterior approach surgery) or the back of the hip (if a posterior or lateral approach surgery), from above the surgical site to below the surgical site.
    It must be a moldable gel pack, so the top and both sides of the hip are in contact with the cold pack.

    The cold packs I personally use and suggest to my patients are cold packs made by Core Products (amazon affiliate link). They are very durable, I have cold packs that have lasted years.

    20230501 122445 scaled

    Cold gel packs can’t be placed on bare skin; they will frostbite the flesh!

    Here is a picture of a friend of mine who placed the cold pack directly on the skin of his low back and when he took the cold pack off, the skin came off with the cold pack.

    This picture is 10 weeks after the frostbite. Notice the brown coloration around the primary spot which indicates tissue damage as well.

    2019 Steves Frostbite 10 weeks post 3 cropped and enhansed

    Please remember, when these cold gel packs come out of the freezer they are about 0 degrees Fahrenheit!

    A simple layer of a clean, dry, thin hand towel can offer protection from frostbite, especially if the hip is bandaged and has extra layers of protection from the bandage.

    If the total hip replacement surgery has been closed with metal staples, I would recommend using extra layers of insulation between the cold pack and the hip.

    Homemade Frozen Vegetable Cold Packs

    Some of my patients have been successful in making their own cold packs using frozen vegetables.

    Most often, I see my patients use this technique because they were discharged home with inadequate cold therapy packs, and they resort to using frozen vegetables while they wait for their cold therapy machine or cold packs to arrive.

    Things could have been so much easier for them had they only known they would need a cold therapy machine or cold gel packs BEFORE they had the surgery.
    Pain and swelling just doesn’t wait for them to get ready after the fact.

    So as they wait for a more permanent solution, they resort to frozen vegetables to get them through the interim.

    Believe it or not, there is a “correct” frozen vegetable to choose to get the job done.

    Two-pound bags of frozen baby lima beans are the perfect vegetable cold pack.
    Two of these two-pound bags in a pillow case are just the right size to completely cover the hip.

    20230426 143358 scaled
    This is a 1-pound bag.

    2-pound bags of baby lima beans are hard to find.

    If 1-pound bags are the only option, it will require 8 1-pound bags to have an adequate supply.

    Regular lima beans are too large, and the gaps between the beans leave the hip with “hot spots”.

    Smaller vegetables thaw too quickly and become ineffective, requiring multiple packs to make it through the amount of time the hip needs to be cooled in one session.

    My instructions to my patients using vegetable cold packs:

    • Buy eight 2-pound bags of baby lima beans.
    • Place two of the 2-pound bags in a pillowcase and drape them over a hip that is insulated with a thin hand towel.
    • Start by placing one of the packs on the front of the hip (if anterior approach), back of hip (if posterior or lateral approach), and wrap the beans over the hip to include the side of the hip as well.
    • Secure the entire pack by tucking the tail of the pillowcase under the hip.
    • Change the pack out after 30 minutes with a new lima bean cold pack to get an hour’s worth of cold therapy.
    • The remaining 4 bags of baby lima beans are held in the freezer to be used at the next icing session, allowing the previously used beans to freeze solid again.

    How much can a total hip surgery patient use cold therapy?

    A patient cannot use cold therapy too much after total hip surgery if the hip is adequately protected from frostbite.
    Patients can, however, use cold therapy for too short a period of time in one session.
    Removing the cold pack too soon can cause additional swelling.

    After a total hip replacement surgery, cold therapy is the patient’s best friend.

    Unfortunately, most total hip patients have been instructed to put cold packs on the hip for 15-20 minutes, remove the cold pack for 20-30 minutes, and reapply in this manner repeatedly.

    This on-off type technique is great if one is trying to do a blood-flush to a sore and achy muscle, but following this technique with a new total hip replacement can cause additional swelling, resulting in increased pain.

    Let me explain:

    If I place a cold pack on the back of my hand, the first thing my body will do is stop sending as much blood down to that hand as normal. The body shuts down the blood flow to the hand to protect the body’s core temperature.

    If I take that cold pack off my hand in, say about 20 minutes, the brain says “We like that hand, so let’s send a bunch of blood down to that hand to warm it back up”.

    I don’t want a “bunch of blood” being sent to my patient’s hip.
    That “bunch of blood” carries a lot of fluid with it and increases the swelling in the hip

    If I leave that cold pack on the back of my hand for 40 minutes or longer, when I remove the cold pack, the brain says “We like that hand, but we don’t trust that hand, so let’s warm it up SLOWLY”.

    That is what I want for my patients.
    The ability to control pain and swelling with cold therapy without adding any swelling.

    I advise my patients to use the cold therapy as much and as often as they want, but once the cold therapy is applied, do not remove it for at least 40 minutes.

    Still a doubter?
    Consider this:

    Have you ever been watching a football game and, in the first half, a player injures his knee?

    Then that same player comes out of the locker room for the second half and sits on the bench with his leg propped up with this HUGE ice pack on his knee.

    He sits there for the entire second half of the game without ever even once removing that ice pack.

    That’s because those highly qualified trainers (many of whom are physical therapists) understand this “blood-rush” concept, and they most certainly do not want that very valuable player’s knee to swell.

    Unfortunately, many healthcare providers treating the regular public understand the “blood-flush” technique but don’t understand cold therapy’s potential to cause swelling in a newly surgerized hip if the cold therapy is removed too quickly; hence, misinformation is given to the patient by doctors, nurses, and even hospital-based physical therapists.

    Read my other articles about Total Hip Replacement

    Wishing You A Pain-Controlled Total Hip Recovery

    Paying It Forward

    Perhaps you are approaching or already retired and wondering how you could earn extra money in retirement.
    One option would be to do as I am doing.
    Read my article How To Generate Retirement Income: Cash In On Your Knowledge.

    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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