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Rehabilitation after Hip Surgery

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About Rehabilitation after Hip Surgery

Hip fractures are a major health issue among older adults, and incidence is rising as the population ages. At the same time, the number of individuals undergoing total hip arthroplasty for end-stage osteoarthritis has also increased. 

These two populations—individuals with hip fractures and those undergoing elective hip arthroplasty—represent distinct but overlapping clinical groups. Both are at risk of functional decline, loss of independence, and reduced participation in daily life following surgery.

After hip surgery, periods of reduced mobility and physiological stress may contribute to muscle weakness, balance impairment, worsening of pre-existing comorbidities, and development of new complications. Recovery trajectories vary widely and are influenced by baseline health status, cognitive function, comorbid conditions, surgical factors, and social context.

Post-surgical rehabilitation plays a central role in supporting recovery of function and participation after hip surgery. Outcomes depend not only on surgical success but also on how well rehabilitation addresses the interaction between the individual, their health condition, and their environment.

The World Health Organization defines rehabilitation as “a set of interventions designed to optimize functioning and reduce disability in individuals with health conditions in interaction with their environment.” Consistent with this definition, rehabilitation after hip surgery extends beyond physical recovery alone and should consider activity limitations, participation restrictions, and contextual factors that influence recovery and longer-term outcomes.

About CCG Care Pathways

Purpose

CCG care pathways provide structured, evidence-based guidance for clinicians delivering conservative, non-operative care for common musculoskeletal conditions. They outline key steps of the clinical encounter, support safe and appropriate decision-making, and assist with referral or co-management when indicated. Pathways are designed as practical, user-friendly tools that complement, not replace, clinical judgment.

Development

Pathways are developed using the best available evidence from high-quality clinical practice guidelines when they exist, and from systematic reviews and expert consensus when guideline evidence is limited or evolving. Content is reviewed periodically to reflect emerging research and current best practices. Input from clinicians, educators, and researchers helps ensure pathways remain relevant, aligned with real-world practice, and responsive to user needs.

Principles of Conservative Care

Musculoskeletal conditions are multifactorial and often influenced by physical, psychological, social, and environmental factors. As such, there is no one-size-fits-all approach to care. Effective management should be ethical, evidence-informed, transparent, flexible, and tailored to individual needs. Shared decision-making ensures care aligns with patient goals and values. Ongoing monitoring and outcome assessment support a person-centred approach and enable timely adjustments to care plans. Care may be delivered in-person, virtually, or through hybrid models, guided by patient preference, access, and clinical judgment.

Disclaimer

CCG care pathways are intended to support, not substitute for, professional clinical decision-making or the advice of a qualified healthcare provider. Recommendations are evidence-informed and presented in simplified, accessible language to support clinical understanding and application. Terms used throughout are not intended as formal diagnostic or billing terminology, nor are pathways prescriptive, authoritative, or regulatory.

Providers are expected to apply their clinical expertise and consult authoritative sources such as regulatory standards and policies, diagnostic classification systems (e.g., ICD-10-CA), scope-of-practice documents, continuing professional education resources, and peer-reviewed literature. Pathways may not apply to every clinical scenario and should always be interpreted in the context of individual patient needs.

Post-Surgical Hip Care Pathway

1. Record Keeping

Accurate, timely, and comprehensive documentation is an essential component of high-quality, evidence-based care. Clinical records must clearly reflect patient interactions, clinical reasoning, and progress over time, and should meet all jurisdictional regulatory standards.

Providers are encouraged to use a structured note format, such as the SOAP framework, to support consistency, clarity, and continuity of care.

Subjective: Document the patient’s reported symptoms, concerns, functional changes, contextual factors (e.g., psychosocial or environmental influences), and responses to prior care.

Objective: Record measurable or observable findings, including physical examination results, relevant diagnostic tests, functional assessments, and any clinically significant changes.

Assessment: Provide the clinical interpretation of findings, including diagnostic impressions or updates, identification of key risk factors or modifiers, and evaluation of the patient’s status or progression.

Plan: Outline the management strategy, including treatments delivered, modifications made, patient education and self-management recommendations, referrals, co-management decisions, and planned follow-up.

Documentation should be completed contemporaneously and maintained in accordance with regulatory requirements for privacy, security, and record retention. High-quality records support patient safety, facilitate interprofessional communication, enable shared decision-making, and promote continuity and accountability in care.

2. Informed Consent
  • Definition: A process where the patient voluntarily agrees to proposed healthcare interventions after receiving adequate information on the nature, benefits, risks, and alternatives.
  • Key Aspects:
    • Prior to interaction: Obtain consent before any diagnostic testing or treatment. Ensure the patient understands the planned examinations, treatments, expected outcomes, and is given the opportunity to ask questions.
    • Voluntarily and specific: Consent must be given willingly, without coercion, and pertain to the specific condition and proposed treatment. The patient should also understand that they can withdraw consent at any time. 
    • Transparent process: Consent must be obtained honestly, with a clear explanation of the condition and proposed interventions. Consent is not a one-time event, and involves ongoing discussions with the patient.
    • Patient understanding and agreement:
      • Diagnosis/prognosis: Explain findings clearly, using understandable language and visuals if needed.
      • Treatment plan: Outline recommended treatments and how they align with patient goals. Discuss benefits, risks, and alternatives.
      • Questions: Encourage questions and confirm understanding (e.g., “teach-back”).
    • Documentation: Record the consent process, including information provided, patient questions, and explicit consent given.
3. Health History
  • Apply cultural awareness and trauma-informed care principles.
  • Sociodemographic: Age, gender, sex, race/ethnicity.
  • Main concern: Post-surgical status following hip surgery. Document current symptoms and concerns, including pain, mobility limitations, balance issues, fatigue, or functional difficulties, as well as factors that aggravate or relieve symptoms.
  • Surgical history: Indication for surgery (e.g., traumatic hip fracture, fragility fracture, end-stage osteoarthritis), type of surgical procedure (e.g., total hip arthroplasty, hemiarthroplasty, internal fixation), date of surgery, peri-operative complications, weight-bearing status, and post-operative precautions. Document in-patient course and any rehabilitation received prior to current presentation.
  • Medical history and body systems review: Review relevant systems with attention to conditions that may influence recovery, including:
    • Cardiovascular and respiratory conditions
    • Neurologic and cognitive status (including history of dementia, delirium, or stroke)
    • Musculoskeletal conditions (including osteoporosis or prior fractures)
    • Genitourinary and gastrointestinal issues
    • Skin integrity
    • Mental health conditions (e.g., depression, anxiety)
  • Medications and polypharmacy:
    Current medications, including analgesics (opioids and non-opioids), anticoagulants, corticosteroids, psychotropic medications, and supplements. Identify potential medication-related risks affecting rehabilitation (e.g., falls risk, sedation).
  • Health behaviours and functional baseline: Pre-fracture or pre-surgical mobility, use of gait aids, physical activity level, sleep, nutrition, tobacco or alcohol use, and baseline independence in activities of daily living.
  • Cognitive and psychosocial considerations: Assess orientation, memory, attention, and capacity to follow instructions as appropriate. Explore mood, fear of falling, confidence with movement, and expectations for recovery.
  • Social history and supports: Living situation, availability of caregivers, family or social support, caregiving responsibilities, and anticipated discharge destination (e.g., home, assisted living, long-term care).
  • Social determinants of health: Factors such as education, income, housing stability, access to transportation, insurance coverage, and access to rehabilitation services that may influence recovery, length of stay, and outcomes.
  • Previous care and responses: Prior conservative or surgical treatments for hip or lower-extremity conditions and responses to care.
  • Beliefs, goals, and expectations: Patient understanding of their condition and recovery, priorities for function and participation, and individual goals.
  • Flag considerations: Screen for red, yellow, and orange flags for potential referrals or co-management.

​​Outcomes Assessments:

Prioritize outcome measures that align with the individual’s goals, clinical presentation, and post-surgical phase. Selection should be appropriate to the care setting and population (e.g., hip fracture versus elective arthroplasty).

  • Physical performance and mobility:
    Hip range of motion (as relevant), Timed Up and Go (TUG), 10-metre walk test, 6-minute walk test, and balance or step tests, selected based on safety and functional level.
  • Pain:
    Pain intensity using validated scales (e.g. NRS) and body diagrams to document pain location and distribution.
  • Function and participation:
    Patient-reported measures assessing impact on daily activities and participation, such as HOOS, WOMAC,  PSFS, WHODAS,  LEFS, selected based on surgical population and relevance.
  • Recovery: Self-rated recovery scales.
  • Quality of life: Generic health-related quality of life measures (e.g. SF-12).
  • Sleep: Sleep quality where relevant (e.g. PSQI).
  • Falls risk and confidence (as appropriate): History of falls, fear of falling, or confidence with mobility, particularly in hip fracture populations.
  • Work, role, or activity status: Return to usual activities, roles, or work where applicable.
  • Individual goals:
    Establish SMART goals (Specific, Measurable, Achievable, Relevant, Timely) in collaboration with the patient and caregivers as appropriate.
  • Patient experience: Gather and integrate patient-reported experience, preferences, and satisfaction to guide care planning and ongoing monitoring.
4. Red Flags and Differential Diagnosis Requiring Medical Attention

ACTION: Refer immediately to emergency care:

  • Suspected infection or sepsis
    • Fever or chills, increasing pain unresponsive to usual care
    • Redness, warmth, swelling, discharge, foul odor, or red streaking near the surgical site
    • Systemic symptoms in the context of recent surgery or immunosuppression
  • Deep vein thrombosis or pulmonary embolism
    • New or worsening calf, groin, or thigh pain; unilateral swelling, warmth, or redness
    • Sudden shortness of breath, chest pain, dizziness, syncope, or coughing up blood
  • Neurovascular compromise
    • Acute onset of progressive weakness, numbness, loss of distal pulses, or severe pain out of proportion to findings
  • Acute fracture or dislocation
    • Sudden deformity, inability to weight-bear, severe pain following a fall or trauma

ACTION: Refer to appropriate medical provider:

  • Hardware failure or implant-related complications
    • Progressive or worsening pain, mechanical symptoms, limb length discrepancy, or instability
    • Known risk factors such as osteoporosis, prolonged corticosteroid use, advanced age, or history of malignancy
  • Bone or joint pathology
    • Suspected periprosthetic fracture, implant loosening, or migration
    • Suspected spinal fracture in individuals with osteoporosis or trauma history
  • Pressure injuries
    • Non-blanching erythema, discoloration, warmth, swelling, blisters, or open wounds in areas of prolonged pressure
  • Medical or surgical complications
    • Persistent wound drainage, delayed healing, or signs of hematoma
    • New or worsening pain with unclear etiology
5. Orange Flags: Symptoms of Psychiatric Disorders Requiring Referral

Clinicians should promptly address symptoms of potential mental health disorders to prevent harm through appropriate and timely referrals.

ACTION: Refer for immediate care (emergency department, medical/mental health provider):

  • Suicidal ideation: Thoughts, plans, or statements about suicide or feelings of hopelessness.   
  • Severe, acute symptoms: Acute psychological distress, such as psychosis, severe panic.
  • Ideation of harm: Intent or plans to self-harm, commit violence, or harm others.

ACTION: Refer to appropriate medical/mental health provider:

  • Persistent, non-urgent symptoms: Symptoms affecting daily functioning (e.g., low mood, anxiety, sleep disturbances, social withdrawal, substance use).

ACTION: Co-management by non-medical/mental health providers:

  • Triage: Ensure primary management by medical/psychiatric providers.
  • Musculoskeletal (MSK) treatment: Manage MSK conditions related to or comorbid with psychological disorders.
  • Screening tools: Selectively use tools to monitor symptoms and severity, guide care, and support escalation without implying a diagnosis. Tools include:
    • PHQ-9 (depressive symptoms)
    • GAD-7 (anxiety symptoms)
    • FABQ (fear related to physical activity/work) 
    • PCS (catastrophic thoughts) 
    • ORT (opioid risk)
6. Yellow Flags: Psychosocial Factors that May Delay Recovery

Non-health barriers can delay recovery; early identification and intervention can enhance outcomes.

Factors:

  • Individual: Worry, fear of movement, low recovery expectations, limited self-efficacy, reliance on passive treatments, activity avoidance.
  • Social: Lack of family/social support, limited connections.
  • Socioeconomic: Employment status, financial stress, litigation/compensation.
  • Environmental/cultural: Social inequality, unsafe/unsupportive environments.
  • Life events: Major transitions (e.g., divorce, job loss), chronic stressors (e.g., caregiving).
  • Work/school: High stress, poor work-life balance, limited accommodations for injury/illness.

ACTION: Co-management by non-medical/mental health providers: 

  • Education & self-care: Provide resources for (e.g., stress management, coping strategies, graded activity).  
  • Monitor & coordinate: Regularly assess psychosocial challenges; refer to medical/mental health provider if persistent.
  • Screening tools: Selectively use tools to monitor symptoms and severity, guide care, and support escalation (aligned with Orange Flag guidance), without implying a diagnosis. Tools include:
    • PHQ-9 (depressive symptoms)
    • GAD-7 (anxiety symptoms)
    • FABQ (fear related to physical activity/work) 
    • PCS (catastrophic thoughts) 
    • ORT (opioid risk)

7. Physical Examination

The physical examination should be targeted, safety-oriented, and informed by surgical history, current precautions, and identified red flags.

  • Observation
    • General appearance, alertness, and ability to engage with assessment.
    • Inspection of the surgical site and surrounding skin for signs of infection, delayed healing, swelling, bruising, or discharge.
    • Posture, sit-to-stand strategy, balance, and gait pattern (with or without assistive devices).
    • Weight-bearing tolerance and adherence to post-operative precautions where applicable.
  • Range of Motion (ROM)
    • Assess active and passive hip ROM (flexion, extension, abduction, adduction, rotation) within post-surgical precautions and patient tolerance.
    • Note pain response, stiffness, asymmetry, or protective movement patterns.
    • Assess adjacent joints (lumbar spine, knee, ankle) as clinically indicated.
  • Strength and Motor Control
    • Screen key lower-limb muscle groups relevant to mobility and transfers, noting asymmetry, inhibition, or difficulty initiating movement.
    • Emphasize functional strength during tasks such as bed mobility, transfers, and ambulation rather than isolated maximal testing early post-surgery.
  • Palpation:
    • Assess peri-articular soft tissues for tenderness, swelling, temperature changes, or hematoma.
    • Avoid deep palpation over the surgical site.
  • Neurological Examination:
    • Motor strength testing: Assess for asymmetry or weakness in key muscle groups:
      • L2: Hip flexors (hip flexion)
      • L3: Quadriceps (knee extension)
      • L4: Tibialis anterior (foot dorsiflexion)
      • L5: Extensor hallucis longus (big toe extension)
      • S1: Gastrocnemius (plantar flexion)
      • S2: Hamstrings (knee flexion)
  • Sensory testing: Assess for sensory deficits in dermatomal distributions:
    • L3: Medial thigh at the knee
    • L4: Medial calf
    • L5: Top of foot and toes
    • S1: Lateral foot and little toe
  • Reflex testing: Assess for asymmetry, diminished/absent reflexes:
    • L4: Patellar reflex
    • L5: Medial hamstring reflex
    • S1: Achilles reflex
  • Functional Assessment
    • Observe bed mobility, transfers, sit-to-stand, turning, and gait as tolerated and safe.
    • Note need for assistance, compensatory strategies, or instability.
  • Special/Orthopedic Tests:
    • Selectively performed only when clinically indicated and safe in the post-surgical context.
    • Avoid provocative testing that may compromise surgical repair or precautions.
  • Imaging Considerations: Imaging is not routinely recommended in the absence of red flags or specific individual factors (e.g. contraindications to treatment).

8. Selection Criteria for Post-Hip-Surgery Rehabilitation

Individuals are eligible for this rehabilitation pathway when the following criteria are met. Clinical judgment should be applied to account for individual needs, care setting, and local resources.

Pre-surgical condition

  • Surgery performed for:
    • Traumatic hip fracture or fragility fracture
    • End-stage hip osteoarthritis
    • Other hip pathology requiring surgical intervention

Surgical intervention

  • Applicable procedures include:
    • Total hip arthroplasty
    • Hemiarthroplasty
    • Hip replacement or prosthesis
    • Hip internal fixation (e.g., screws, plates, intramedullary devices)

Post-surgical status

  • Medically stable following surgery.
  • Cleared for rehabilitation participation according to surgical and medical guidance.
  • Rehabilitation may begin as early as 24 hours post-surgery, depending on clinical status, surgical procedure, and care setting.

Signs and symptoms

  • No unresolved red flags requiring urgent medical management (e.g., acute infection, thromboembolism, hardware failure).
  • Pain, mobility limitations, balance deficits, or functional impairments appropriate for conservative rehabilitation.

Cognitive and psychosocial considerations

  • Able to participate in rehabilitation with or without caregiver support.
  • Cognitive impairment, delirium risk, or psychosocial complexity do not preclude rehabilitation, but may require modified delivery or co-management.

Care context

Applicable across care settings, including acute care, inpatient rehabilitation, outpatient rehabilitation, and home- or community-based care, as appropriate.

9. Treatment Considerations for Post-Hip-Surgery Rehabilitation

Post-surgical hip rehabilitation should be individualized, goal-oriented, and responsive to change over time. A shared decision-making approach that integrates patient goals, clinical judgment, and best available evidence is essential. Rehabilitation should be adapted to surgical type, care setting, medical stability, and functional capacity.

General principles

  • Rehabilitation aims to reduce complications, restore mobility and function, and support return to home and community participation.
  • Care should remain flexible, with progression guided by patient response rather than fixed timelines.
  • Ongoing communication among surgical, medical, and rehabilitation providers is critical, particularly regarding precautions and weight-bearing status.

Education and Self-Management (Colibazzi 2020; Hawke 2019; NICE 2023)

  • Provide tailored, evidence-based information regarding recovery expectations, activity participation, precautions, and self-management. 
  • Education may be delivered using written, verbal, or digital formats and should be adapted to cognitive status and caregiver involvement.
  • No single educational approach has demonstrated superiority; combining education with active rehabilitation is supported.
  • Behavior graded activity, incorporating goal-setting and positive reinforcement, may help increase adherence to activity recommendations and reduce pain.  
  • Assistive devices (e.g., raised toilet seat, mobility aids, dressing aids, long-handle grabbers) may be recommended with appropriate instruction.
  • Address modifiable prognostic factors for recovery (e.g., physical inactivity, fear of movement, unrealistic expectations).

Mobilization (Colibazzi 2020; Min 2021; NICE 2023) 

  • Early mobilization following surgery is recommended once the individual is medically stable.
  • Mobilization frequency and progression should be guided by surgical procedure, precautions, tolerance, and care setting.
  • Regional or soft-tissue–based techniques may be incorporated as appropriate, without compromising surgical integrity.

Supervised Exercise Therapy (AAOS 2023; Colibazzi 2020; Min 2021) 

  • Exercise programs should be individualized and may include:
    • Gait and mobility training
    • Functional task training (e.g., transfers, stair negotiation)
    • Progressive strengthening of hip and lower-limb musculature
    • Balance and postural control activities
  • Programs should align with patient goals, baseline capacity, and psychosocial context.
  • Monitor psychological responses to rehabilitation (e.g., distress, fear, avoidance) and refer for co-management when indicated.
  • Weight-bearing progression should follow surgical guidance, with close interdisciplinary communication.

Unsupervised or Home-Based Exercise (AAOS 2023; Colibazzi 2020) 

  • Home-based or unsupervised programs may be appropriate for some individuals, depending on functional status, safety, and support.
  • Exercise, mobility, and physical activity are important components of recovery regardless of delivery format.
  • Some individuals may benefit from structured longer-term strengthening or task-oriented programs to reduce disability and support participation.
  • Selection of unsupervised programs should consider cognition, adherence, and access to follow-up.
10. Risk Factors and Prognosis Post Hip Surgery

Recovery following hip surgery varies widely and is influenced by individual, surgical, and contextual factors. Identification of risk factors supports realistic goal-setting, appropriate monitoring, and timely co-management.

Risk factors for adverse events or less favourable outcomes (AAOS 2023; NICE 2023)

  • Medical and physiological factors
    • Advanced age
    • Multiple comorbidities
    • Poorly controlled diabetes
    • Osteoporosis
    • Elevated body mass index
    • Frailty and reduced physiological reserve
  • Medication-related factors
    • Polypharmacy
    • Opioid use
    • Anticoagulant or corticosteroid use
  • Functional and cognitive factors
    • Pre-existing mobility limitations
    • Cognitive impairment or delirium
    • History of falls
    • Fear of falling or movement-related anxiety
  • Psychosocial factors
    • Depression, anxiety, fear-avoidance beliefs, catastrophizing
    • Low expectations of recovery
    • Limited caregiver or social support
  • Social determinants of health
    • Low income
    • Limited access to rehabilitation services
    • Housing instability
    • Transportation barriers
    • Insurance coverage constraints
  • Surgical and care-related factors
    • Surgical complications
    • Delayed mobilization
    • Fragmented transitions between care settings

Prognosis

  • Many individuals experience meaningful improvement in mobility, function, and participation following hip surgery when rehabilitation is timely and appropriately matched to needs.
  • Recovery trajectories differ between hip fracture and elective arthroplasty populations, with hip fracture patients generally facing greater risk of prolonged disability and institutionalization.
  • Persistent functional limitations may occur, particularly in the presence of medical complexity, cognitive impairment, or adverse social circumstances.
  • Long-term outcomes are shaped not only by surgical success but by the extent to which rehabilitation addresses modifiable physical, psychological, and contextual factors.
  • Ongoing monitoring and adjustment of care plans are important to optimize recovery and reduce preventable decline.
11. Ongoing Follow-up
  • Monitor progress: Reassess symptoms, functional status, and patient-reported outcomes at appropriate intervals. Confirm that care remains aligned with the patient’s goals, values, and expectations.
  • Adjust treatment plan: Continuously realign the management plan based on evolving goals, treatment response, clinical findings, and professional judgment. Modify interventions, dosage, frequency, or focus as needed to support meaningful improvement.
  • Support self-management: Reinforce the patient’s understanding of home strategies, activity recommendations, and behavioural approaches. Encourage adherence and address barriers that may affect progress.
  • Recognize plateaus or change in status: Identify when the patient is improving, stable, or worsening. Reassess for contributing factors such as comorbidities, psychosocial influences, or new functional limitations.
  • Referral and co-management: Consider referral or co-management with an appropriate provider when there is limited or no significant improvement within an expected timeframe (for example 6 to 8 weeks), when new or concerning findings emerge, or when additional expertise is required to support optimal care.
  • Documentation: Record follow-up assessments, changes to the plan, patient feedback, reassessment of goals, and any referral or co-management decisions.
12. Criteria for Discharge
  • Discharge criteria: Establish clear criteria for concluding active care. These may include achieving the patient’s initial goals, demonstrating meaningful improvement in symptoms or function, reaching a plateau in progress, or transitioning to self-management as the primary approach. Consider patient preferences, functional demands, and clinical judgment when determining readiness for discharge.
  • Clinical reassessment: Prior to discharge, complete a focused reassessment to confirm stability of symptoms, functional status, and the patient’s confidence in managing their condition. Address any remaining concerns and ensure no new issues require further evaluation.
  • Post-discharge planning: Discuss ongoing self-management strategies, including activity recommendations, home exercises, behavioural or lifestyle modifications, and symptom monitoring. Provide guidance on when to return for follow-up, when to seek additional care, and what indicators should prompt medical evaluation.
  • Future care needs: Clarify options for episodic care, preventive visits, or re-engagement with the provider if symptoms recur or functional demands change. Encourage ongoing communication if new concerns arise.
  • Documentation: Record the rationale for discharge, the patient’s status at the time of discharge, self-management recommendations provided, and the agreed-upon follow-up plan

References