Why physiotherapy starts on the day of surgery

The physiotherapy team does not arrive days after surgery — they are there on the day itself. Within hours of leaving the operating theatre recovery area, most patients are assisted to sit up, stand, and take their first steps with support. This is standard practice across NHS hospitals and aligns with guidance from the American Academy of Orthopaedic Surgeons (AAOS); the physiotherapy team typically aims to see inpatients twice daily from that point onwards.

The goals in these first twenty-four hours are not about building strength. They are circulatory — ankle pumps repeated as often as every five to ten minutes, and ankle rotations performed three to four times daily, help maintain blood flow and reduce the risk of clots. They are also neurological: early movement begins to reawaken the movement patterns on which safe, confident walking depends. Stiffness sets in quickly after surgery; starting early is a straightforward way to limit it.

How long a patient remains in hospital depends on their procedure, baseline health, pain control, and home support. A traditional posterior hip replacement commonly involves a stay of three to five days. For selected suitable patients on a muscle-sparing pathway, earlier discharge may be clinically appropriate — though this is never universal.

The sections that follow outline what recovery typically looks like week by week, from the first days at home through to a return to everyday activity.

Exercises in the first two weeks

Most of the work in the first two weeks happens in bed, in a chair, or along a short corridor — and that is by design.

The earliest exercises target circulation rather than strength. Ankle pumps (pushing the foot up and down at the ankle) are begun immediately after surgery and repeated as often as every five to ten minutes while awake. Ankle rotations — five circles in each direction, three to four sessions a day — complement these. Both movements activate the calf muscle pump, promoting venous return and reducing the risk of deep vein thrombosis. Simple as they are, consistency matters more than effort here.

By day one or two, the focus broadens. Bed-supported knee bends — sliding the heel slowly towards the buttock while keeping it on the mattress — begin to reactivate the quadriceps and hip flexors without placing load through the joint. Static quadriceps contractions (tightening the thigh muscles with the leg flat) serve a similar purpose: rebuilding the neuromuscular connection between brain and leg muscle, which surgery temporarily disrupts.

Short walking sessions with a frame or crutches also start on day one. Distance increases gradually — a few steps on the ward, then slightly further each day — rather than jumping to longer circuits. The aim is consistent repetition, not distance records.

Stair training typically follows within the first day or two. The guiding rule is straightforward: step up with the unoperated leg first, step down with the operated leg first. This minimises load on the recovering hip until strength returns.

On frequency, NHS guidance recommends exercises at least five times a day; the AAOS advises 20–30 minutes once or twice daily. Both approaches emphasise regularity over intensity. The specific programme a physiotherapist sets will reflect individual progress, so it is worth treating their plan — not any general guide — as the reference point throughout this phase.

Recovery milestones: weeks three to twelve months

Around week three, the character of recovery shifts. Most patients find they can move around the house with less reliance on a walking frame, and some progress to a single crutch or stick. The goal in weeks three to six is not speed — it is pattern. Gait quality matters more than distance: a smooth, symmetrical stride with the pelvis level is the target, not pushing through a limp to reach an arbitrary step count. Light household tasks within comfortable range become manageable, and most people are sleeping better as post-operative pain settles.

By around week six, the first formal review typically takes place. For many patients this is also when driving may be discussed — though clearance requires confirmation from the surgical team and a check with the motor insurer, as policies vary. Neither alone is sufficient. At this stage, balance and proprioception exercises are often introduced: single-leg weight shifts, side steps, and gradual progression away from support. Stair climbing, which began one step at a time in week one, usually transitions to a near-normal alternating pattern for most patients somewhere between weeks six and eight.

The window from three to twelve months is less dramatic to live through than the early weeks, but it is no less important. Soft tissues continue to mature, strength continues to build, and the hip gradually becomes less of a focus. Recreational activities — walking further, swimming, cycling — are typically appropriate from around six to twelve weeks; higher-impact activities are discussed case by case with the surgical team rather than cleared on a blanket timetable.

Milestones in this phase are often felt rather than measured: less fatigue, a more instinctive gait, less conscious effort to protect the hip. Consolidation, rather than dramatic visible change, is what this period delivers — and it is worth knowing that in advance.

How preserved tendons support earlier confidence

Those milestones reflect a broadly typical recovery — but how confidently a patient moves through them depends, in part, on what happened to the soft tissues at the back of the hip during surgery. The surgical approach shapes the physiotherapy experience in ways that are worth understanding before the operation, not just after it.

In a traditional posterior hip replacement, the surgeon detaches the piriformis and obturator internus tendons to gain access to the joint. Divided tendons need up to 90 days to biologically reattach — and during that window the hip is genuinely mechanically vulnerable. This is why strict precautions are imposed: no flexion beyond 90°, no crossing the legs, no low chairs. These are not arbitrary rules. They reflect a real absence of passive posterior restraint while healing is still under way.

The SPAIRE technique takes a different path. By preserving the piriformis and obturator internus intact — and repairing the obturator externus — the structural reason for those precautions is removed in suitable patients. The tendons were never divided, so there is nothing awaiting reattachment at the back of the hip.

There is a second consequence that matters specifically for physiotherapy, and it operates at a neurological level. Intact tendons retain their embedded mechanoreceptors — Golgi tendon organs and muscle spindles — which function as a continuous positional reporting system. From the first post-operative day, the brain receives real-time signals about joint position, loading, and rotation. This proprioceptive feedback supports instinctive joint protection and early gait confidence: the hip is not neurologically 'blind' to its own position.

When tendons are severed, that feedback disappears until tissues regenerate and neural pathways re-establish themselves. Patients must compensate cognitively — consciously monitoring movements that would ordinarily be governed automatically.

The physiological mechanism is well-supported, but comparative RCT data measuring physio outcomes specifically for SPAIRE against standard posterior approaches have not yet been published. Benefits for suitable patients are described as mechanistically coherent and likely — not as a guarantee of faster recovery. Professor Paul Lee, who trained in the SPAIRE technique at the Exeter Hip Unit under Professor Timperley and has made it his routine practice, incorporates this neurological rationale into his patient consultations as part of explaining what the recovery pathway is designed to support.

What shapes how quickly each patient recovers

Several factors set the pace of recovery, and most of them are knowable in advance.

Baseline fitness before the operation is one of the strongest predictors of how quickly independence returns. Physiotherapy evidence supports starting a prehabilitation programme three to four weeks before surgery — walking a little further each day, swimming, or doing gentle range-of-motion work. Patients who arrive at surgery with better muscle tone and cardiovascular reserve tend to engage more effectively with the post-operative programme from the first day. This is something readers can act on now, well ahead of any admission date.

Pain control in the early days matters more than many patients expect. Poorly managed pain suppresses the willingness to move, and movement is what drives recovery. Effective multimodal analgesia — agreed with the clinical team before discharge — allows the exercise programme to proceed at its intended pace rather than stalling.

Home environment plays a practical role that is easy to overlook. Low sofas, a bathroom that requires climbing stairs to reach, and being alone in the first two weeks can all slow the return of independence. Borrowing or hiring a raised toilet seat, rearranging ground-floor sleeping if possible, and arranging a helper for the first fortnight are straightforward preparations with a direct effect on early recovery.

The surgical approach also sets a different starting point, as the previous section details.

Age and co-morbidities influence how quickly tissues heal, though they need not alter the exercise plan itself. Older patients or those managing conditions such as diabetes or cardiovascular disease may simply require a longer consolidation window — this is biology, not failure to try.

Recovery by design: what a structured pathway looks like

Everything covered in this article — the day-one mobilisation, the tendon mechanics, the milestone structure, the individual variables — comes together differently depending on whether surgery was planned as a pathway or just as a procedure.

Professor Paul Lee's approach at the Lincolnshire Hip Clinic treats technique, implant choice, early mobilisation, and post-discharge support as a single integrated design rather than a sequence of separate decisions. Built around the SPAIRE technique, the pathway is constructed so that the structural advantages of preserved tendons — the stability, the continuous proprioceptive feedback — are supported from the operating theatre through to the first physiotherapy session and beyond. For selected suitable private patients, this integration can support earlier discharge than a traditional posterior approach would typically allow; individual anatomy, home circumstances, and clinical readiness determine whether that applies to a given person.

Post-discharge, the model includes unlimited physiotherapy at clinics in Grantham and Sleaford — no fixed session cap — with Professor Lee reviewing progress alongside the physiotherapy team and adjusting the plan as recovery unfolds rather than running to a predetermined timetable.

For any reader now considering hip replacement, the questions that flow from this article are specific ones: whether the planned approach preserves or divides the posterior tendons, how long any precautions will apply and why, what the neurological recovery of the hip is expected to look like, and what post-discharge physiotherapy support is included in the package. Those are questions only a surgeon who has thought carefully about the whole pathway can answer in full.