1. Definition and goals of THA
2. Hip anatomy and biomechanics relevant to replacement
3. Indications and contraindications
4. Prosthesis components and fixation: acetabular cup, liner, femoral stem, head; cemented vs uncemented
5. Surgical approaches: posterior, direct lateral/anterior, and their precautions
6. Preoperative PT assessment and education
7. Postoperative complications and red flags
8. Sequential physiotherapy protocol
   • Immediate postoperative phase: day 0-3
   • Early recovery: weeks 1-6
   • Intermediate recovery: weeks 6-12
   • Advanced return to activity: after 12 weeks
9. Transfers, gait training, stairs, and assistive-device progression
10. Home program, outcome measures, and discharge criteria

Phase-wise Total Hip Replacement Physiotherapy Protocol

Key precautions

Phase 0: Preoperative Phase

Goals

• Educate patient and caregiver.
• Record baseline pain, ROM, strength, gait, transfers, balance, and function.
• Teach precautions and use of walker/crutches.
• Improve confidence, respiratory status, and lower-limb strength.

Assessment

• Pain score and medications.
• Hip ROM and muscle strength, especially gluteus medius, gluteus maximus, quadriceps, and ankle muscles.
• Gait pattern and current walking aid.
• Functional tests when appropriate: Timed Up and Go, 5-times sit-to-stand, stair ability.
• Home setup: stairs, toilet height, bed height, availability of family support.

Preoperative exercises

• Ankle pumps.
• Static quadriceps contractions.
• Gluteal sets.
• Gentle heel slides within tolerance.
• Upper-limb strengthening for walker/crutch use.
• Breathing exercises.

Education

• Demonstrate bed mobility, sit-to-stand, walking aid use, stairs, toilet transfer, dressing technique, and hip precautions.
• Arrange raised toilet seat, shower chair, long-handled reacher, sock aid, and firm chair if required.

Phase 1: Immediate Postoperative Protection and Mobilization

Goals

• Protect the surgical hip and prevent dislocation.
• Control pain and swelling.
• Prevent chest complications, DVT, pressure injury, and loss of circulation.
• Achieve safe bed mobility, transfers, and short-distance walking.
• Begin muscle activation.

Monitoring before PT

• Vital signs and orthostatic symptoms.
• Pain control and sedation.
• Wound dressing, drain if present, and excessive swelling.
• Hemoglobin status if symptomatic.
• Weight-bearing and movement orders.
• Motor/sensory function, especially if regional anesthesia was used.

Interventions

1. Positioning

• Maintain prescribed hip precautions.
• Avoid pillows directly under the knee for long periods.
• For posterior approach, use an abduction pillow or pillow between knees if ordered, especially while lying or turning.
• Avoid low chairs and low toilet seats.
• Keep operated leg aligned, avoiding crossing the midline.

2. Respiratory and circulation exercises

• Deep breathing, supported coughing if needed.
• Incentive spirometry if prescribed.
• Ankle pumps: 10-20 repetitions hourly while awake.
• Ankle circles.
• Gentle calf contractions.
• Early walking as medically safe.

3. Early muscle activation

• Quadriceps sets: hold 5 seconds, 10 repetitions.
• Gluteal sets: hold 5 seconds, 10 repetitions.
• Hamstring sets if comfortable.
• Heel slides, avoiding prohibited range.
• Gentle hip abduction in supine, only within precaution limits.
• Short-arc knee extension.
• Active knee flexion and extension.

4. Bed mobility and transfers

• Move operated leg with assistance from a strap, towel, or helper initially.
• Roll using precautions.
• Sit at edge of bed without excessive hip flexion.
• Sit-to-stand from a raised, firm chair with walker.
• Extend operated leg slightly forward when sitting down or standing up if needed to reduce hip flexion.

5. Gait training

• Begin with walker or crutches according to weight-bearing order.
• Short, frequent walks are preferable to one long walk.
• Emphasize upright posture, equal step length as tolerated, heel strike, and avoiding pivoting on the operated limb.
• Turn with small steps, not by twisting.

Discharge criteria

• Safe transfers in and out of bed/chair/toilet.
• Independent or supervised walker/crutch use.
• Safe stair technique if needed at home.
• Understands precautions and home exercise program.
• Pain reasonably controlled and no concerning wound or medical signs.

Phase 2: Early Recovery Phase

Goals

• Continue wound and edema management.
• Restore safe functional ROM without breaking precautions.
• Improve hip and knee muscle control.
• Progress from walker toward cane or no aid when gait is safe.
• Improve independence in activities of daily living.
• Prevent a limp and reduce falls risk.

Precautions

Exercises

Mobility and ROM

• Ankle pumps and calf mobility.
• Heel slides within safe range.
• Seated knee extension.
• Gentle seated hip flexion only within the permitted range.
• Supine hip abduction and adduction only to neutral, if permitted.
• Gentle standing hip flexion, extension, and abduction while holding support, within approach precautions.

Strengthening

• Quadriceps sets and short-arc quads.
• Long-arc knee extension.
• Gluteal sets.
• Standing hip abduction.
• Standing hip extension, if compatible with precautions.
• Mini-squats holding a stable support.
• Heel raises.
• Weight shifts in standing.
• Supported marching only if cleared and without unsafe hip flexion.

Functional training

• Sit-to-stand from progressively lower surfaces, but do not violate hip-flexion precautions.
• Bed, chair, toilet, and car transfer practice.
• Walking progression: walker to two crutches, then one crutch or cane, depending on gait quality.
• Cane is held in the opposite hand to the operated hip.
• Stair practice.

Stair sequence

1. Non-operated leg up first.
2. Operated leg next.
3. Walking aid last.

1. Walking aid down first.
2. Operated leg next.
3. Non-operated leg last.

Criteria to progress toward Phase 3

• Wound healed without infection concern.
• Pain and swelling reducing.
• Independent home exercise performance.
• Safe gait with appropriate aid.
• Ability to activate hip abductors without major pelvic drop.
• No increase in pain or swelling lasting more than 24 hours after exercise.

Phase 3: Intermediate Strengthening and Functional Recovery

Goals

• Restore near-normal gait.
• Improve hip abductor, extensor, quadriceps, calf, and trunk strength.
• Improve balance and endurance.
• Wean from assistive device only when gait is safe.
• Return to independent household and community activities.

Important principle

Exercises

Progressive strengthening

• Bridge progression, if cleared and comfortable.
• Mini-squats progressing toward controlled squats within safe range.
• Sit-to-stand repetitions.
• Step-ups: start with low step, progress height gradually.
• Controlled step-downs.
• Resistance-band hip abduction and extension.
• Standing hip flexion only within safe range.
• Terminal knee extension with band.
• Leg press in a protected range, if cleared.
• Calf raises progressing from bilateral to single-leg support as tolerated.

Balance and proprioception

• Weight shifting in multiple directions.
• Semi-tandem and tandem stance with support nearby.
• Single-leg stance progression, only when pelvic control is adequate.
• Foam or unstable-surface balance later in the phase.
• Direction-change practice using multiple small steps instead of pivoting.

Gait and endurance

• Increase outdoor/community walking distance gradually.
• Treadmill walking when gait pattern is controlled.
• Stationary bicycle, usually after adequate ROM and wound healing, with seat high enough to avoid excessive hip flexion.
• Pool walking or aquatic exercise only after complete wound healing and medical clearance.

Functional targets

• Independent dressing and bathing using adaptive devices only as needed.
• Household chores with pacing and safe body mechanics.
• Improved stair confidence.
• Car transfer with precautions maintained.

Criteria to progress toward Phase 4

• Minimal pain and swelling after activity.
• Healed incision and no infection signs.
• Functional hip and knee ROM consistent with goals and precautions.
• Independent community ambulation with no significant limp.
• Good pelvic control during single-leg loading.
• Able to manage stairs safely.

Phase 4: Advanced Function and Return to Activity

Goals

• Maximize strength, endurance, balance, and confidence.
• Return to work demands and safe recreation.
• Maintain long-term joint protection.
• Prevent falls and abnormal gait habits.

Exercises

• Progressive resistance training for hip abductors, extensors, quadriceps, hamstrings, calves, and trunk.
• Functional squats, step-ups, controlled lunges only if cleared and mechanically safe.
• Advanced balance drills.
• Longer outdoor walks, treadmill, cycling, swimming, and elliptical trainer.
• Task-specific training for work, household tasks, or recreational demands.
• Gradual golf practice or other rotational tasks after clearance, with attention to controlled foot position and no forced twisting through the hip.

Usually appropriate long-term activities

• Walking.
• Cycling.
• Swimming.
• Water exercise.
• Golf.
• Low-impact dancing.
• Doubles tennis or other modified low-impact activities if cleared.

Generally avoided or restricted

• Running and jogging.
• Jumping sports.
• Contact sports.
• High-impact aerobics.
• Repetitive heavy lifting.
• Deep squatting or extreme hip positions.
• Sudden pivoting or twisting under load.

Sample Home Exercise Frequency

Red Flags: Stop Exercise and Seek Urgent Medical Review

• Sudden severe groin, buttock, or hip pain.
• A popping sensation, deformity, inability to bear weight, or sudden shortened/rotated leg: possible dislocation or fracture.
• Fever, chills, increasing wound redness, warmth, pus, persistent drainage, or wound separation.
• Increasing calf pain, calf swelling, warmth, or redness: possible DVT.
• Chest pain, shortness of breath, coughing blood, fainting, or sudden confusion: emergency assessment for possible pulmonary embolism.
• Rapidly worsening swelling, pain, weakness, or numbness.
• Persistent uncontrolled pain or a major fall.

Suggested Outcome Measures

• Pain Numeric Rating Scale.
• Timed Up and Go.
• 30-second chair stand or 5-times sit-to-stand.
• Gait speed.
• Hip disability and Osteoarthritis Outcome Score, Joint Replacement version (HOOS-JR), if available.
• Ability to walk, manage stairs, transfer, and perform activities of daily living.