The case for moving on the day of surgery

Physiotherapy beginning on the day of surgery is now the clinical standard in well-designed hip replacement pathways — not an optional extra or a mark of exceptional progress. A 2026 scoping review found that ambulation within 12 hours of surgery (Day 0) reduces hospital length of stay without increasing adverse events compared with later mobilisation protocols. A separate quasi-experimental study reinforced this: patients who completed four mobilisations by the end of Day 2 saw adjusted length of stay fall by 8.1%, with no rise in complications at 12 weeks.

The reason is physiological rather than motivational. Once the muscles of the leg begin to contract — even gentle walking with support — they act as a pump, pushing blood back towards the heart and reducing the risk of deep-vein thrombosis. Breathing deepens, helping to prevent the chest infections that bed rest invites. Joints receive fresh blood and the nutrients that healing tissue depends upon. And sustained physical activity helps the brain stay oriented, reducing the risk of post-operative delirium that can accompany prolonged immobility in older patients.

The goal, in other words, is not asking patients to tolerate discomfort for its own sake. It is unlocking a chain of benefits that begins within hours of leaving the operating theatre — and which depends on adequate pain control, baseline strength, and the design of the surgical pathway itself. Both of those last factors — the exercises that make up the early programme, and how the surgical technique shapes what is confidently possible from Day 0 — are worth examining in turn.

Exercises to do before getting out of bed

Four exercises make up the standard early programme, and most patients encounter them before leaving the bed for the first time. Each targets a specific function rather than a broad recovery goal — which is why they work as a set.

Ankle pumps — drawing the foot up towards the shin, then pointing it away, rhythmically and repeatedly — contract the calf muscles. Each squeeze pushes venous blood back up the leg and reduces the risk of clot formation during the hours when movement is most limited.

Quadriceps sets ask for something subtler: pressing the back of the knee gently into the mattress and holding the contraction for a few seconds. This engages the thigh muscles without placing any load through the new joint, beginning to re-establish the muscle tone needed for standing.

Gluteal squeezes are an isometric contraction of the buttock muscles, held briefly and then released. The gluteals are central to hip stability, and activating them from the first hours begins rebuilding the muscular foundation the joint depends on.

Heel slides complete the set. Bending the knee to draw the heel slowly towards the body and then straightening again maintains range of motion and prevents the stiffness that accumulates quickly with disuse.

NHS guidance recommends working through this sequence at least five times daily. At this stage, frequency matters more than session length — short, regular repetitions sustain circulation and muscle activation throughout the day, rather than leaving all the work to a single longer session.

Standing exercises and building strength at home

The move from lying to standing marks a shift in what the body is being asked to do — and in which muscles are most at risk of remaining weak. Of these, the hip abductors deserve particular attention. When abductor strength is inadequate, the pelvis dips on the unsupported side during each step, producing the distinctive post-operative limp known as a Trendelenburg gait. Standing hip abduction — raising the straight leg out to the side, away from the body — directly targets this muscle group and is arguably the single most important exercise for restoring a level, confident walking pattern.

The remaining standing exercises address complementary functions. Hip flexion (lifting the knee to hip height, no further than 90°) rebuilds the controlled forward movement needed on stairs and when sitting down. Hip extension — taking the leg gently behind the body while holding a support — counters the tendency to guard the hip in a slightly flexed position after surgery, which, left uncorrected, affects posture and stride length. Calf raises, rising onto the balls of both feet and lowering slowly, reinforce the lower-leg strength that underpins balance. A common target across these exercises is 10 repetitions in three sets per day, though individual progression should follow a physiotherapist's guidance.

Walking itself is therapeutic rather than simply functional. Two to three short sessions daily, each a little longer than the last, accumulate genuine cardiovascular and musculoskeletal benefit. Adding a 30-minute period of lying flat twice daily stretches out the hip into extension, countering protective guarding that can otherwise become habitual.

The principle binding all of this together is progressive loading: gradually increasing repetitions, distance, and eventually resistance over weeks is what converts early mobility into lasting functional strength.

How the surgical approach changes the physiotherapy picture

Behind every set of post-operative restrictions is an anatomical reason — and understanding it explains why the traditional rules exist, and why they may not apply in the same way to every patient.

In a standard posterior hip replacement, the surgeon must divide the piriformis and obturator internus tendons to gain access to the joint. Severed tissue needs time to fibrose and reattach, and during that window — conventionally set at 90 days — the hip is mechanically vulnerable. The restrictions that follow (no flexion beyond 90°, no crossing the legs) are not arbitrary caution; they are a direct response to the biology of cut tendons. With 57% of patients who dislocate going on to dislocate again, and 45.6% of those requiring revision surgery within two years, the protective logic is sound.

The SPAIRE technique, developed at the Exeter Hip Unit, changes the anatomical starting point. SPAIRE — which stands for Saves Piriformis And (Obturator) Internus with Repair of (Obturator) Externus — leaves those posterior tendons intact rather than dividing them. Without the biological vulnerability that creates the 90-day window, the conventional precaution framework can be reduced or removed for suitable patients. Critically, preserved tendons retain their proprioceptors — Golgi tendon organs and muscle spindles — providing uninterrupted positional feedback from the moment the patient first stands. A joint that has lost those mechanoreceptors through tendon division is, in effect, neurologically blind until healing allows them to regenerate.

Professor Paul Lee, who trained at the Exeter Hip Unit under Professor Timperley and has made SPAIRE his routine practice, frames the operation not as a standalone event but as one component of a complete pathway: technique, implant selection, and mobilisation planned together from the outset.

Suitability for a reduced-precaution pathway still varies. Individual anatomy, baseline health, and home support all influence what a given patient's recovery looks like — which is why the right conversation happens before the operation, not after.

Pain control is not separate from physiotherapy

Adequate pain relief and early physiotherapy are not competing priorities — they are designed to work together. Moving a replaced hip within hours of surgery is only achievable when pain is managed well enough to allow it; under-medicated patients move less, muscle weakness accumulates faster, and the risk of secondary complications such as thromboembolism and chest infection rises accordingly.

The evidence for this is concrete. A 2026 meta-analysis drawing on 26 randomised controlled trials (2,208 patients) found that the PENG nerve block — a targeted pericapsular injection used within multimodal analgesia protocols — reduced time to first mobilisation by 2.68 hours and improved quadriceps strength on the first post-operative day. That difference in hours matters: in a pathway where Day 0 mobilisation is the goal, anything that delays the first attempt reshapes the whole early recovery arc.

Multimodal analgesia combines nerve blocks with anti-inflammatories and other agents rather than relying on opioids, which carry their own risks and can cloud the alertness needed for safe early movement. The aim is functional: enough pain reduction to perform the exercises described in the preceding sections, not the elimination of all sensation.

Patients should expect a proactive pain management plan as part of their pathway from the outset. If pain is limiting movement at any point in the early days, that is worth raising directly with the clinical team — it is a clinical signal, not a complaint.

Realistic milestones from hospital to home

Recovery from hip replacement unfolds in recognisable stages, but the pace at which any individual moves through them depends on baseline fitness, pain control, the surgical approach used, and what support is available at home.

Day 0–2: from bed to first steps

Most patients move from the early bed exercises to standing and taking short walks within the first one to two days. A 2024 audit documented a meaningful difference in hospital stay — 15.1 days versus 18.1 days — in favour of patients mobilised promptly after arthroplasty, reinforcing what NICE and NHFD guidelines already advise: movement by Day 1 at the latest. Within a pathway that combines a muscle-sparing surgical technique with well-managed analgesia, selected patients — those with good baseline strength and reliable home support — may be discharged on the same day or the day after surgery. This is not a universal outcome; it reflects a specific combination of surgical planning, patient selection, and recovery design rather than a threshold every patient should expect to reach.

Weeks 1–6: building on the foundations

Once home, the focus shifts to gradually extending walking distance (two to three sessions daily, going a little further each time), continuing the standing exercises in three sets of ten, and managing swelling through rest and elevation. A walking aid — frame or cane — is typically needed for the first three to six weeks. Physiotherapy follow-up during this period helps ensure gait is improving and strength is returning evenly across the hip abductors.

Weeks 6–12: resuming daily life

Many patients are walking independently and managing light daily activities by the six-week mark, though the timeline for driving, climbing stairs confidently, and returning to work varies considerably by role and individual progress. Sedentary or home-based work may be feasible earlier; physically demanding roles take longer.

A note on prehabilitation

Practising the post-operative exercises in the weeks before surgery — prehabilitation — is a straightforward way to arrive at the operation already familiar with the movements. Evidence for its impact on outcomes is limited, but the rationale is sound: patients who know what ankle pumps and quad sets feel like are better placed to begin them confidently on Day 0. For anyone considering hip replacement, understanding the recovery pathway is part of making an informed decision — and worth raising during a surgical consultation.

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2. [2] Same-Day Discharge After Early Mobilisation and Increased Frequency of Physiotherapy Following Hip and Knee Arthroplasty. (2022). https://doi.org/10.4102/sajp.v78i1.1755 https://doi.org/10.4102/sajp.v78i1.1755
3. [3] Audit on the Prompt Mobilisation of Patients Following Hip Arthroplasty. (2024). https://doi.org/10.1093/ageing/afad246.004 https://doi.org/10.1093/ageing/afad246.004
4. [4] Role of the Pericapsular Nerve Group Block in Early Mobilisation After Total Hip Arthroplasty: Systematic Review and Meta-Analysis. (2026). https://doi.org/10.4103/ija.ija_1498_25 https://doi.org/10.4103/ija.ija_1498_25