Speed Up Recovery After Total Hip Replacement: (a PT’s Advice)

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After seeing hundreds, if not thousands of total hip replacement patients in the past 40 years, be they in the hospital immediately after surgery, in their homes a day or two after surgery, or in the outpatient clinic about three weeks after surgery, these are the things that I see that are the most important to recover as quickly as possible after hip replacement surgery.

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How can I speed up my hip replacement recovery?

  • Start rehabilitation within 48 hours after surgery.
  • Control the pain.
  • Stay in “the lane” of the rehab protocol.
  • Control the swelling.
  • Stay on the walker longer that you think necessary.
  • Follow your physical therapist’s instructions.

It makes no difference if the total hip replacement was done using the surgical approach of posterior, lateral, or anterior, applying these rules will get my patients to their earliest recovery to independence.

Start rehabilitation within 48 hours after total hip replacement surgery.

I am lucky enough to be seeing total hip replacement patients from about a half-dozen top-notch orthopedic surgeons working out of teaching facilities in Los Angeles. One common denominator is they all want their patients to start home rehabilitation within 48 hours of discharge from the hospital.

In the beginning, it was somewhat aggravating to accommodate this rule as it is not uncommon to have the surgeons discharge their total hip patients on a Friday and expect to have that patient seen before Monday to get their in-home rehabilitation started.

However, after seeing these same surgeon’s patients that, for whatever reason, were not able to initiate home physical therapy within 48 hours, it has become clear to me they are absolutely right in the vast majority of cases. Patients that I see for the first time more than 48 hours after surgery just don’t do as well initially. And the further away from the surgical date the first physical therapy session takes place, the worse they do in the initial phase of their recovery.

My observations and conclusions are consistent with a research paper published in the National Institute of Health in an article “Factors that may influence the functional outcomes after primary total hip arthroplasty”.

Of course I have seen exceptions to the rules, and some people will do fine without any physical therapy rehabilitation after a total hip replacement, but those are the exceptions, not the normal.

And they were all very active prior to surgery and were in much better physical condition than their peers.

However, I have also seen total hip replacement patients who had a prior total hip replacement but did not seek physical therapy for rehabilitation. Usually I see these patients because of a lingering post-surgical problem either in function or pain.

Occasionally I have seen a patient that had simply worn out the other hip from overuse due to the incorrect or absent physical therapy home program and outpatient follow-up rehabilitation protocols.

I have become convinced that in some cases the reason for the hip replacement surgery on the second hip is, at least in part, because of the lack of rehabilitation after the first hip replacement surgery.

The take-away of starting total hip rehabilitation within 48 hours:

Start the home physical therapy rehabilitation process within 48 hours of coming home, preferably having a home health physical therapist do an evaluation of you and your home, then build a rehabilitation program specific to the deficits found in the initial physical therapy evaluation.

Additional long-term thoughts of starting rehabilitation of a total hip within 48 hours:

There is a period of time after a total hip replacement that requires the rehabilitation process to be more gentle and “ease” the patient into a more functional state before initiating a more aggressive rehabilitation program such as one would expect in an outpatient physical therapy setting.

My sense is that patients I see that do not get their home program started until 3 or 4 days after surgery, take more visits to reach the goals I set for them.

The period of time home physical therapy is needed varies in my patients, but on average I would say I usually ask for 3 times a week for 3 weeks, but expect to have met all goals by about the 5th through 8th session. By the time the patient has met all the physical therapy goals I have set for them, they are ready to initiate outpatient physical therapy.

Here is another important part: $$$

Medicare considers any home visits after hip replacement an extension of the hospital stay and pays those bills from a designated source of funds guided by the hospitalization portion of the insurance contract that generally pays 100% of the home health care agency billings of nursing and physical therapy visit. That is known as “Part A” of Medicare.

Once a patient is discharged from home health, Medicare switches buckets of funds and starts paying the outpatient physical therapy under the outpatient portion “Part B” of the insurance plan.


The $$$ Dilemma:

If a total hip replacement patient goes directly from surgery to outpatient physical therapy after a total hip replacement, that physical therapist will have to go through the same post-surgical protocol that would have been done in the home setting, THIS MEANS THE PATIENT’S OUTPATIENT BENEFITS WILL HAVE BEEN EXHAUSTED BY ABOUT 50% BEFORE THEY ARE TRULY READY FOR OUTPATIENT PHYSICAL THERAPY!

That means the outpatient therapist has two choices:

  • Speed up the progression of the rehabilitation protocol.
  • Discharge the patient when they are not yet fully rehabilitated and ready to continue on their own.

Plus the patient will be paying an outpatient co-pay with each outpatient physical therapy visit. Medicare does not have a co-pay for home physical therapy visits after total hip replacement surgery.

Neither option of speeding up the progression or early discharge from outpatient physical therapy is optimal.

If I’m faced with one of these suboptimal choices as an outpatient physical therapist, my experience tells me to choose the option of following the initial 2-3 week home therapy protocol as if they were a home health care patient rather than starting at the more seasoned aggressive outpatient protocol which is best started at about the 3 week mark after surgery.

That means at least the 1st two weeks of outpatient physical therapy will be devoted to the protocol that is usually a home therapy protocol.

That will leave me getting only halfway through the traditional outpatient protocol of a total hip replacement rehabilitation before benefit exhaustion.

I’m trusting I can teach the patient enough to get them to complete the other half of the outpatient protocol on their own, often times accompanying them to their local gym and setting up a program of progression that will return them to optimal function.

The option of speeding up the process in the 1st couple of weeks post-surgery has the very real risk of overdoing it and causing a rehabilitation setback of 7 to 10 days.
This happens with about 50% of my hip replacement patients that are “Type- A” personalities, they feel if the protocol asks for 10, 20 would be better. It’s not!

For the total hip replacement patients that are left to do their own home rehabilitation for the first three weeks after surgery, most show up at my clinic with much more pain than patients I have seen for home therapy, and their function is usually significantly reduced, especially walking endurance and independence.

Patients that I see within 48 hours after their total hip surgery are walking ¼ mile or more daily, walking without a walker or cane, and are off opioids with pain levels in the 3/10 range controlled with Tylenol and cold packs as needed.

Bottom line is: the fastest way to total recovery after a total hip replacement surgery is to get home health physical therapy started within 48 hours of coming home and continue the rehabilitation all the way through the outpatient rehabilitation program to the end with no breaks in therapy.

Control the pain

Generally, when I first see a total hip replacement patient 48 hours after the surgery, they all say the same thing:
“Boy, I was feeling really good in the hospital after surgery, but since coming home…..”
Just remember, they have really good drugs in the hospital.

On my first visit, I expect the patient to tell me their pain is about 5-6/10 at worst and 3-4/10 at its best, mostly dependent on time-duration between pain medications, cold application, rest, and leg elevation, but also affected by activity.

Regardless of the patient’s perceived level of pain tolerance, whether it be high or low pain tolerance, the pain level that they all have trouble controlling the pain when it reaches 7/10 pain level.

I always want my total hip patient’s pain to be less than 7/10.
A patient that is 7/10 pain can not effectively perform an adequate home therapy rehabilitation session, although doing the program as they tolerate it usually will bring the pain down about a point after therapy.

Patients with pain at 7/10 or above at rest are always quizzed about what they have done over the past 48 hours and if any activity can be identified as a major contributor to the pain levels.
It frequently surprises me at the patient’s inability to connect recent activity with experienced pain levels. And sometimes there is nothing that can be identified.

The good news for both me and my patient; it is usually over-activity or medication non-compliance that are responsible for the excessive pain the patient is experiencing.

Pain increases secondary to overactivity and can usually be avoided by using cold therapy correctly and using adequate cold therapy equipment.
Hospital-issued cold therapy equipment is usually totally inadequate.
Using a good commercial cold pack (Amazon link) such as the packs I use in the clinic, or better yet, a cold therapy machine (Amazon link) like the one I use at home, is much more effective at controlling the pain and swelling.

Ice Pack Machine Watermarked
Commercial Gel Pack & Cold Therapy Machine

Push to, not through pain

No pain no gain does not work in total hip replacement surgical rehabilitation.

That old saying is true if you are starting a gym program to build muscle, but it is not true for rehabilitation after a total hip replacement surgery.

The sign that a patient is overdoing the exercise or activity is:
Pain lingering longer than 5 minutes after stopping the activity or exercise.

Pushing to but not through the pain is not a well-understood concept with most patients.
What I mean is that the patient can do an exercise or activity that causes some pain during that exercise or activity, even at or above the 7/10 level, but the pain must return to the pre-exercise level or less within 5 minutes of the patient stopping the exercise or activity and putting the leg at rest.

Stay in “the lane” of the rehab protocol

I see three types of patients after total hip surgery:

  • Those that “stay in the lane” of the total hip rehabilitation program.
  • Those that I have to “push a little” to get them in the lane of total hip rehabilitation.
  • Those that I have to “pull back” into the lane of total hip rehabilitation.

Those patients that “stay in the lane” and follow the steps in a progressive total hip replacement protocol do great. In 5 to 8 visits I expect them to be ambulating over 1,000 feet, walking without any device, do their home exercise program independently, and are safe to leave the home independently.

Those patients that I have to “push into the lane” are not usually lagging behind because of pain, but rather because of a lack of confidence in balance. These patients usually have to be talked into doing activities that initially feel uncomfortable to them, but as soon as they discover they can do these things without pain consequence or loss of balance, they step their game up to entering the lane and they also achieve rehabilitation goals.

Those patients that I have to “pull back into the lane” are the afore-mentioned “type A” personalities that think more is always better. These are the most difficult patients to get to the goals within the 5 to 8 visits I see as normal. My experience is that about 50% of these patients will over-do exercises and activities and at some point in those first two weeks do something that causes a flare-up setting their rehabilitation progress back by 7 to 10 days.

Control the swelling

Swelling after a total hip replacement surgery is best controlled with:

  • Cold packs.
  • Rest.
  • Leg elevation.
  • TED hose.

Most pain after a total hip replacement surgery comes because of the swelling, although there is some pain from the surgical incision. The posterior approach surgery cuts the most tissue while the anterior approach cuts very little tissue at all.

THR Scar Posterior cropped Watermarked
Surgical scar – Total Hip Posterior Approach
THR Scar Anterior cropped watermarked
Surgical scar – Total Hip Anterior Approach

Total hip replacement surgery using the posterior approach, having more swelling than the normal biological process can eliminate, frequently develops a serious fluid cyst (a pocket of fluid that is too much for the body to remove) that often requires needle aspiration, another potential for infection.

Cold therapy after a total hip replacement

I have yet to meet a total hip replacement patient that didn’t love their cold packs or cold therapy machine.

The Big Mistake:

I can’t tell you how many total hip replacement patients I have seen that have been told to:
“Put the cold therapy on for 10-20 minutes then take it off for 20 minutes and repeat the process”.

In my opinion, that is exactly the wrong thing to do to prevent or reduce swelling.

That is the way one would use ice if they were treating a sore muscle. They would be looking for a “blood flush” of that sore muscle to remove the lactic acid responsible for the muscle soreness.

We DO NOT want a “blood flush” after total hip surgery, we want a “swelling reduction”, not a “blood flush”.

If I put a cold pack on the back of my hand, the first thing my body says is “let’s shut down the blood flow to that hand to protect our core temperature”.

If I remove that cold pack in 10 to 20 minutes my body says: “we like that hand too, so let’s send a bunch of blood down to the hand to warm it back up again”.

The problem is “the bunch of blood”. We don’t want a bunch of fluids (blood) coming into the surgical site because that “bunch of blood” carries a high potential to increase the swelling.

If, however, I put a cold pack on the back of my hand, the same as before, the body decreases blood flow to the hand to protect core temperature.

If now, however, I don’t take that cold pack off my hand for 40 minutes or longer, when I do take it off my body says: “we like that hand but we don’t trust that hand, so let’s warm it up slowly”.
So there is no “blood flush” effect and the swelling is decreased.

The reason for the swelling after the total hip replacement surgery is the body’s aggressive attempt to do tissue repair by bringing in more blood supply for the minions of the body to do their work at repairing this injury. They produce a lot of waste products in this healing process.

Our goal is to decrease this “inflammatory response” to a level the body can handle the waste products effectively, which reduces the swelling and pain.

A good example of this principle in action is a football player that has injured his knee in the first half of the game but comes back out and sits on the bench for the second half of the game.
He sits there with this HUGE ice pack on his knee for the entire second half of the game.
The trainers do not take the ice pack off every 10 to 20 minutes then re-apply it 20 minutes later.
They understand the difference between “blood flush” and “inflammation control”.

For more information on how to use cold therapy on the hip, see my article:
“Ice After Total Knee Replacement: A PT’sComplete Guide”…..

The icing principles apply to the hip as well.

Rest after total hip replacement

Rest after total hip replacement surgery is a double-edged sword.

  • On one hand, the patient will achieve the fastest recovery rate if they do not over-do activity, especially in the first three weeks post surgery.
  • On the other hand, movement is what the hip joint is made to do. Inactivity can lead to increased swelling, stasis, muscle atrophy, and joint stiffness.

The key is to “listen to your body”. When it is telling you to rest, do so. Don’t just “push through” the activity.

Most of my patients find the most comfortable rest position is in a recliner chair with their feet up. Some of my patients even sleep in the recliner for the first few days after coming home.

For total hip replacement patients that had a posterior approach surgical procedure and have the restriction of “no bending the hip past 90 degrees”, the recliner chair presents a big obstacle to maintaining that restriction, it simple is very difficult to stand up from a recliner chair without bending the hip more than 90 degrees as the patient leans forward both to come to the front edge of the chair as well as standing up from the recliner chair.
See my article “Can I Sit In A Recliner After Hip Replacement? A PT’s Advice”…..

Many of my posterior approach total hip patients have solved this issue by purchasing a recliner lift chair.

Leg elevation after total hip replacement

Elevation of the leg after total hip replacement is all about decreasing the swelling.
Swelling produces pain that, when bad enough, slows the patient’s ability to advance the rehabilitation protocol.

The swelling that is being addressed primarily is the swelling of the surgical site, however, I see many total hip replacements with swelling of the entire leg, all the way to the foot. That swelling needs to be addressed as well for optimum conditions to promote quick recovery.

Elevating the leg helps the body get rid of swelling by not making the body pump that swelling up hill, such as sitting in a hard chair with the feet on the ground (called sitting in the dependent position).

I recommend my total hip patients do not sit in this dependent for longer than 15 minutes before elevating the operated leg. This can be accomplished by simply placing the leg on another hard chair seat surface to get that leg to horizontal instead of remaining in the dependent position.
Sitting in the dependent position (foot on the ground) can cause stasis ulcers on the foot.

The most common way I see my patients breaking this rule is when they just can’t stay off the computer and sit at their desk in the dependent position for prolonged periods of time.

This certainly sets the patient up to develop stasis blisters, usually on the top of the foot. They are small to large blisters that contain fluid the body was unable to remove. Left unattended, and the dependent position issue is not resolved, they will progress to full-blown stasis ulcers.

The picture below is a patient that insisted on sitting in a comfortable chair with her feet on the floor. She also slept in the chair in the same position.

121213 Stasis blister dorsum of foot 3 cropped watermarked
Huge Stasis Blister From Sitting And Sleeping In Chair With Feet On The Floor

Many of my patients are being told by other health care providers they must elevate the leg above the heart. While this is certainly the most effective way to reduce/prevent swelling (water does run downhill passively), I find just having the leg near horizontal (such as in a recliner chair), is completely adequate unless the patient has a secondary diagnosis of congestive heart failure, in which case I would want the leg above heart level.

Keeping the leg above heart level is a completely dysfunctional position. It is difficult to eat, drink water, or even watch television. And given the amount of time it requires for the leg-above-heart position to be effective, I find most patients will not spend most of their time in this position. But they will spend that same amount of time in a recliner with their feet up.

TED hose after total hip replacement

TED hose are those white compression hose most patients were put into while in the hospital and instructed to wear for about three weeks. The purpose of the TED hose is to help prevent a blood clot from forming, usually in the calf muscle.

But TED hose also functions to help decrease the swelling of the operated extremity.

Crossing Legs Pivot correctly watermarked cropped 200711
Thigh-High TED Hose

TED hose come in different compression strengths and the surgeon will determine which strength is appropriate for each individual patient.

TED hose also comes in two general lengths:

  • Thigh high.
  • Knee high.

More and more I see total hip replacement patients being issued knee-high TED hose after hip replacement. In the past I saw almost all of my total hip replacement patients being issued thigh-high TED hose.

While I understand the primary reason for issuance of the compression hose is to prevent blood clot formation in the calf, I know the thigh high compression hose also helps decrease the amount of swelling in the thigh.

With this new trend of issuing knee-high TED hose to my total hip replacement patients, I have seen a corresponding increase of swelling in the thigh, and complaints of the thigh pain from the swelling being a factor in the decreased patient’s ability to progress the rehabilitation protocol for the quickest recovery.

My preference would be to see all my total hip patients be placed in a thigh-high TED hose instead of a knee-high TED hose.

Stay on the walker longer than you think necessary

Staying on a walker after a total hip replacement is not so much about reducing weight-bearing on the new hip prosthesis as it is about fall prevention and getting rid of old “limping” motor memory patterns.

The new hip prosthesis should be able to structurally full weight bear on the day of the surgery.

Fall prevention after a total hip replacement

The body is more interested in where every joint in the body is in space even than how much pain the patient is experiencing.

That’s why when you hit your finger with a hammer, it feels better to shake the hand rapidly. The body’s interest in where it is in space overrides the pain it is experiencing and as a result, shaking the hand decreases the pain in the finger.

The receptors in the body that tell the brain where everything is in space are called proprioceptors. They are everywhere. They are in the cartridge in the joint, the tendons, ligaments, and muscles.

The proprioceptors are the reason one can put their hand behind them (out of sight) and know their hand is in a claw position without ever looking at the hand.

The primary and fastest proprioceptors are in the cartilage on the end of a bone. These are the proprioceptors that tell the brain instantly when the body is off balance.

A total hip replacement patient no longer has these receptors in the replaced hip, which means the patient could be far enough off balance before the secondary proprioceptors in the muscles, ligaments, and tendons informs the brain of the balance issue in time to prevent the weakened patient from falling.

It will take a couple of weeks of re-training the secondary proprioceptors to be as fast as the now absent primary proprioceptors before this increased fall risk is eliminated. But rest assured, these secondary proprioceptors will become just as fast as the original primary proprioceptors.

A walker is the most effective way to combat this increased fall risk and almost invariably the patient will feel like they can abandon the walker 3 or 4 days before I feel comfortable to allow the patient to walk with no device. This most likely to happen with my patients in about 10 to 12 days after surgery.

Those last 3 or 4 days on the walker will allow me to transition the patient from walking with a walker to walking without any device.

“Motor memory limp” after total hip replacement surgery

Many of my total hip patients have been instructed to transition to a cane from the walker and most want to make that transition as soon as possible, but they change their mind once I have explained what transitioning to a cane does.

First I explain a cane is an ambulation assistive device designed to reduce weight-bearing on a joint. A total hip recipient does not need weight reduction on the new hip, the more weight they can bear the better.

The second thing a cane does is cause the patient to lean to one side to put weight on the cane. This will mimic the exact same limp the patient had before the total hip surgery and will kick that old “motor memory” back into play, and that will just cause another problem to overcome later down the road.

This abnormal gait pattern will cause other joints to move in an abnormal way causing more stress and wear on these other joints, joints that are often already compromised with wear and tear of previous limping and aging.

The main reason a total hip patient uses a cane is not to reduce weight bearing on the new hip, but rather to provide a third point of reference to the ground to help them with balance.

Most of my patients transition from a walker to using no assistive device without any trouble if they stay on the walker for a couple of extra days beyond when they feel they can abandon the walker.
The main reason my patients tell me they want to get rid of the walker is because it makes them feel old and they are embarrassed to have family and friends see them on a walker.

For those that still require that third point of reference for balance, I use a walking stick.
One does not “lean” on a walking stick while walking, so the “leaning” to the side on a cane is eliminated and consequently, so is most or all of the old motor memory limp.

Walking Stick Rear view cropped and watermarked 1

Usually, by the second day of walking with a walking stick, the patient is carrying it instead of using it.

Follow your physical therapist’s instructions

When I first see a total hip replacement patient I usually set their home rehabilitation goals at:

  • Independent with safety in transfers, ambulation, and activities of daily living within 2 weeks.
  • Improve fall risk from their usually high fall risk status at initial evaluation to a low risk of falling at discharge using the standardized tests of Tinetti and TUG scores within 3 weeks.
  • Improving ambulation tolerance from the usual 200 to 500 feet with a walker to 1,000 feet or more without any device within 3 weeks.
  • Improve operated extremity strength back to 4/5 muscle strength.
  • Independence in performing their home exercise program.

When my patient has achieved these goals I feel they are ready to initiate an outpatient physical therapy program. This usually requires 5 to 8 home physical therapy sessions to meet these goals.

My first 3 sessions is usually all about reconnecting the patient’s brain to the weakened muscles. A patient does not lose muscle from the day before surgery to the second day after surgery, they lose the ability for the brain to recruit the muscles they do have.

In my opinion, most average adults can only recruit 50% to 65% of their muscle’s ability to contract. To contract more of their muscle’s potential to contract requires working the muscle harder than what they are doing in everyday life (activities of daily living – ADL).

To recruit more of the muscle requires exercise over and above ADL requirements.
See my article on Best Exercises To PREPARE For Total Knee Surgery…..
These exercises apply to the hip as well.

Once the patient has a total hip replacement, their brain is unable/unwilling to recruit more than about 35% of the muscle bulk.

So the first order of importance is to get the brain to recruit more muscle bulk. This is achieved through isometric and short arc range of motion exercises that are done 1 time twice daily and moved to 2 times once daily as the patient tolerates.

This move to 2 sets back-to-back usually happens on the third follow-up visit after the initial evaluation session where the exercises are initiated.

Once the patient tolerates this exercise progression, I switch to a new exercise protocol I call Phase 2, requiring the muscles to move the joints through full range of motion against the resistance of their own body weight.

Ambulation is progressed from initial tolerance with a walker to 1,000 feet with a walker within 3 or four sessions. The walker is then removed and the patient is progressed from initial tolerance without a walker to 1,000 feet or more without any device.

At that point, usually between 5 and 8 treatment sessions, the patient is ready for outpatient physical therapy. They are near full function, are usually off opioids and can now drive (2 weeks post-op for left hip, 3 weeks for right hip), and frequently can now drive themselves to outpatient physical therapy.

Once the patient is in the outpatient clinic I would follow the same principles at a more aggressive level to finish the strengthening and balance work the patient will need to be fully rehabilitated.

The takeaway point of following a physical therapist’s instructions

A seasoned physical therapist (be it home or outpatient physical therapist) has the skill-set and experience to get the best performance out of the patient regardless of where the patient is in the rehabilitation process.

They have the expertise to push the patient to their optimal edge and advance that patient at each session through re-evaluation and rehabilitation progression to achieve the fastest recovery possible.

If you have a therapist that is not paying attention to your progress and just repeating the same thing over and over without you seeing signs of functional improvement, consider changing physical therapists or get an explanation of why you are not functionally improving.

How can I tell if I’m doing too much after a recent total hip replacement surgery?

  • After an exercise or activity is stopped, the hip pain increase will continue for longer than 5 minutes.
  • Staining on the bandage, even if small pencil eraser-sized bandage stains appear, it may be an indicator of doing too much.

Read my other articles about Total Hip Replacement

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Wishing You A Speedy Recovery From Your Total Hip Replacement

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One option would be to do as I am doing.
Read my article How To Generate Retirement Income: Cash In On Your Knowledge.


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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