Step 1: The Plan Begins with the Root Cause

● Osteoarthritis (OA): Chronic wear and tear leads to groin pain, difficulty walking, and "arthrogenic inhibition" – where joint sensory receptors shut down stabilizing muscles (gluteus medius, maximus, adductors). Post-surgery, these muscles need reactivation. In these cases, clients need to avoid complex movements initially; instead, start with low-load isometrics to re-engage these key muscles.

● Rheumatoid Arthritis (RA): RA affects connective tissues throughout the body, requiring a holistic, team-based approach focused on inflammation management and connective tissue protection. If a joint feels stiff, involving the rheumatologist for possible medication adjustments is a priority. Additionally, fitness professionals must exercise caution with aggressive stretching or quick load progressions since tissues will not heal well if overstressed.

● Acute Fracture: Hip replacements for sudden injuries often affect young adult clients with a great fitness baseline. They typically rebound quicker due to a lack of long-standing pain and arthrogenic inhibition in arthritis.

Step 2: Consider the Surgical Approach

● Anterior Approach:

○ Description: Surgeons access the hip from the front, typically retracting (not cutting) muscles like the sartorius, tensor fascia latae and rectus femoris. The anterior hip capsule is cut and reassembled.

○ Initial Precautions (First 6 weeks): Avoid stressing the healing anterior capsule. This means avoiding hip extension and hip external rotation on the involved side. Exercises like hip flexor stretches, butterfly stretches, full-height hip bridges, hip thrusts and cable hip extensions should be avoided.

○ Allowed Early On: Many clients can safely perform sit-to-stands and leg presses within a few weeks post-op.

○ Post-6 Weeks: Clients are often cleared for "no restrictions" except for impact activity. Limited impact (e.g., doubles tennis, pickleball, minimal running) may be allowed with specific surgeon permission.

● Posterior Approach:

○ Description: Surgeons access the hip from the back, typically cutting through the gluteus maximus, hip external rotators (e.g., piriformis), and posterior hip capsule.

○ Initial Precautions (First 6 weeks): Avoid stressing healing structures. Clients must protect healing by avoiding hip flexion > 90 degrees, hip adduction, and internal rotation on the involved side. These movement precautions present many practical considerations. Clients require elevated sitting surfaces. Clients must also avoid bending forward, such as reaching for shoes, hamstring stretches, and classic RDL/deadlift positions. Since the gluteus maximus and deep hip rotators are healing, early avoidance of tandem stance, single-leg stance, squats, lunges, leg presses, and hip adduction exercises is essential to prevent dislocation.

○ Post-6 Weeks: While some surgeons clear patients of their movement restrictions, long-term precautions may persist. Repetitive heavy loading in positions requiring > 90 degrees of hip flexion can pose a risk even years later. Even for clients with surgeon clearance, fitness professionals can help manage risk by including informed consent about risks vs. benefits for return to high-demand activities like power lifting, Olympic lifting, or martial arts. For clients with posterior replacements, high-impact aerobics, jogging, running, or snowboarding are generally not cleared at any point.

Step 3: Assess

● Pain: A body signal. If pain is > 2-3/10 dull ache, consult the rehab team/surgeon before lower body training.

● Posture: THA doesn't correct imbalances; it may increase them. The most common postural deficits include lower crossed syndrome and upper crossed syndrome. Fitness professionals can include stretches for the low back, hip flexors, calves, chest, and strengthening for the mid-back, posterior shoulder, gluteus maximus/medius, and anterior core to help.

● Gait: Common deviations include short stride, decreased stance time on the involved leg, and Trendelenburg (lateral hip drop). These deviations can be addressed with hip flexor/calf stretches, glute max/med (hip bridges, hip abduction) strength, and gait retraining with re-education on hip-over-foot alignment.

● Balance: While BOSU and foam pads seem tempting, skip the props. Instead, start with fundamental challenges on level surfaces. Can the client stand in multiple stances while moving their heads, arms, and legs? If not, master the foundations before progressing.

● Muscle Length Tests: Assuming rehab team clearance and assessing hamstrings, hip flexors, calves, adductors, and hip external rotators can help inform stretching choices. If a hard end feel or pain is observed, stop and consult with the rehab team.

● Muscle Performance Tests: If trained, manual muscle tests (MMT) for gluteus medius/maximus, hip rotators, anterior core, and adductors can help guide ideal initial strength choices. If not trained, try to obtain the physical therapist’s last report to see the scores. MMT scores < 5 indicate a need for basic isometrics and unweighted exercises. Rushing into compound exercises with isolated deficits increases compensations versus facilitating long-term performance.

Step 4: Program Design

● Phase 1: Early Rehabilitation & Foundation (6-12 weeks post-surgery)

○ Goal: Client education for safety, muscle activation, and movement pattern re-training.

○ Exercises: Supine heel slides, side-lying hip abduction, hip bridges, abdominal bracing, multi-directional gait training.

○ Key: Fine-tuned assessment and cueing for core symmetry and glute activation are crucial for future success.

● Phase 2: Intermediate Strengthening & Function (12-24 weeks post-surgery)

○ Goal: Functional movement pattern loading and strength.

○ Exercises: Squats (shallow, sit-to-stands), lunges (limited depth), balance training, low-speed/small-range agility, return to conventional gym machines.

○ Progression: Start with linear periodization (e.g., 3x20 low load initially), progressing to 4x8-12, then 5- 6x5- 6 for strength development.

● Phase 3: Advanced Training & Performance (24+ weeks post-surgery)

○ Goal: Progress towards high-level goals.

○ Exercises: Step-ups (higher boxes), lightly-banded monster walks, RDLs (controlled single-leg), multi-directional compound exercises, load/speed progressions of Phase 2 exercises.

○ Key: Goal-specific functional exercises. In all cases, avoid excessive twisting or impact.

Final Thoughts