A prehab program before joint replacement: what it can claim, who it suits and what to measure

What a prehab program before joint replacement may claim is narrower than most clinics advertise, and getting that right is the first decision you make about the service. You can say that you will measure and improve strength and function before the operation, and that the direction of effect across the reviews is positive on low certainty evidence and mostly gone by 6 months. You cannot say that it speeds up recovery, improves the long-term result, shortens the hospital stay or avoids the operation. Everything below is how to run a program that stays inside that.

This is a clinician page. The patient versions are knee replacement prehab exercises and hip replacement prehab, and those are the pages to hand over.

The order this page is written in is not the order you use it in, so take the screen before you read the rest. In an appointment it runs: screen and ask the surgical team (who is a candidate, and who is not), measure (what to measure), then prescribe (what the program contains), then the education and the handover, and the patient-facing warning signs before surgery go home with them. The warning signs sit near the end because that is where a sheet to hand over belongs, not because they come last in the appointment.

Do not load the limb until you have these: which operation and which side, any restriction on loading, range or activity and who set it, anything in the joint or the bone around it that changes what the limb will take, medical clearance where a heart or lung condition or blood pressure that is not under control needs it, a falls assessment where there has been a fall in the past year, and any break in the skin over the limb being operated on, however long it has been there.

These go to the surgical team the same day rather than at the next session, and a session does not run with somebody who is feverish or generally unwell: any infection anywhere, a cold, a cough or a temperature, a dental problem, a new or changed symptom in the limb, and anything else matching the warning signs. Take a medicine list at intake and keep it current, naming anticoagulants and antiplatelets, because that list changes what you do if the patient falls and it is the first thing a hospital asks for.

What a prehab program before joint replacement can and cannot claim

The strongest single piece of evidence here is also the one that constrains the marketing, so take it first.

Nguyen and colleagues (2022) ran a prospective, open-label randomized clinical trial of multidisciplinary prehabilitation before total knee replacement across three French tertiary care centers. They randomized 262 people aged 50 to 85 with knee osteoarthritis already scheduled for surgery, 131 to each group, mean age 68.6, and 178 of them, 68%, women. The program was four supervised group sessions, twice weekly, at least 2 months before surgery, each 90 minutes: 30 minutes of education and 60 minutes of exercise. Controls had usual care, an information booklet and standard surgeon advice.

Neither primary outcome favored prehabilitation. At about 4 days after surgery, functional independence was reached by 34 of 101 in the prehabilitation group, 34%, and 26 of 95 in the control group, 27%, a risk ratio of 1.4 with a 97.5% confidence interval of 0.9 to 2.1 and P equal to .15. At 6 months, the area under the curve for the WOMAC function subscale was 38.1 against 40.6 square millimeters, an absolute difference of minus 2.8 square millimeters with a 97.5% confidence interval of minus 7.8 to 2.3 and P equal to .31 after multiple imputation. There were no differences in the secondary outcomes. The authors concluded there was no evidence that prehabilitation improved short-term functional independence or reduced midterm activity limitations after surgery.

The reviews are more positive and still modest. Gränicher and colleagues (2022) found 16 trials in 968 people and pooled 14. Knee function was better before surgery and for up to 3 months afterward on low to very low certainty evidence, with no significant difference at 6 to 12 months.

Keogh and colleagues (2025) gathered 3 systematic reviews and 21 meta-analyses, which on the knee side came to 46 trials in 3,362 people. They found prehabilitation favorable for complication rates, strength, measured function, quality of life and patients' own ratings of function in both operations. The effects faded over time and were generally confined to the first 6 months, on evidence they rated from critically low to moderate quality.

One finding deserves to be better known. Konnyu and colleagues (2023) reviewed prehabilitation for elective, unilateral knee or hip replacement for primary osteoarthritis. On the knee side they had 13 randomized trials. On the hip side they had 6, and reported no evidence or insufficient evidence for every hip outcome they examined.

Keogh and colleagues (2025) land somewhere else on the hip, and the difference is not resolved here because it is not resolved in the literature. Their overview counted 19 hip trials in 1,110 people inside the reviews they gathered, and the favorable finding above covers the hip as well as the knee.

The two are not weighing the same thing in the same way: Konnyu is a systematic review of trials with a strength of evidence rating applied to each hip outcome, and Keogh is an overview of other people's reviews. Picking the kinder of the two would be the error. What both support is that the hip evidence is thinner and less certain than the knee evidence, so a clinic quoting a knee number to a hip patient is extrapolating. Say so, and do not hide it.

Here is the honest claim set:

You may say	You may not say
We will measure your strength, function and range before surgery, and we expect to improve them in the weeks before the operation	Prehab will make your recovery faster
Across the published reviews the direction of effect is positive, on low to very low certainty evidence, and mostly gone by 6 months	Prehab gives you a better result a year from now
Starting with strength and knowing the exercises is one less thing to learn in a sore first week, which is practice experience rather than a trial finding	Prehab will get you home sooner
Across 13 knee trials prehabilitation may not lead to increased harms, on low strength of evidence, and on the hip side there was no evidence either way	Prehab is proven safe, or prehab can save you the operation

Read the left column as whole sentences, because the qualifier is the claim and not a hedge attached to it. Clipped, rows two and four become something else: "the direction of effect is positive" and "prehab does not cause harm" are both claims this literature does not support, and both are one deletion away.

If you want a line for a website, use this one, which fits inside everything above: "We assess you, we measure your strength and function, and we build both in the weeks before your operation, so you go in as strong as we can get you and already knowing the exercises." It promises what you control and nothing that you do not.

NICE sets the floor underneath all of that. Its joint replacement guideline asks for people having a hip or knee replacement to be given advice on rehabilitation before the operation, including exercises to do before and after surgery that will aid recovery, alongside lifestyle advice covering weight management, diet and stopping smoking, and advice on keeping independence and quality of life (NICE NG157). What is recommended is the advice. The guideline does not set out a program or a dose.

Who is a candidate, and who is not?

Everyone on a hip or knee replacement list is a candidate for the advice, because that is what NICE asks for. A supervised program is an addition on top of it, and that is where selection starts.

The trials do not define eligibility in a way you can copy, and Keogh and colleagues (2025) found that the amount of resistance training did not change postoperative outcomes in their two meta-regressions, with no analysis at all of what changing frequency or load does. So your entry criteria are a local decision. Write them down anyway, because an unwritten criterion is applied inconsistently by the third member of staff who uses it.

Exclude, or clear first, in these situations.

• A restriction from the surgical team that has not been checked with them.
• A heart or lung condition, or blood pressure that is not under control, without medical clearance.
• A fall in the past year that has not had a falls assessment.
• Any new or changed symptom in the limb, or anything matching the warning signs before surgery near the end of this page.
• Any open or non-healing break in the skin on the limb being operated on: a leg ulcer, a diabetic foot lesion, a weeping rash between the toes, new or there for years. A break in the skin raises the infection risk whatever its age, an infection means the operation is cancelled, and a long-standing one is the kind nobody mentions.
• The patient for whom every version of every exercise is painful, including isometric work with the joint barely moving. That patient needs the pre-admission team and a review of pain relief, not a place in a class.

Four things to ask the surgical team before anyone joins, and get in writing if you can.

1. Which operation is planned, and on which side.
2. Whether any restriction on loading, range or activity applies before surgery, and who set it.
3. Whether there is anything in that joint or in the bone around it that changes what the limb can take. Three in particular: a known bone lesion, a previous infection in that joint, and a revision rather than a first replacement.
4. Roughly when the operation is expected.

The first two change what you prescribe in the first session. The third is the question clinics do not think to ask and is the only one that can make loading the limb the wrong thing to do: a hip being replaced because of a tumor, a failed implant or an old infection is not the same hip as an osteoarthritic one, and how much that bone will take is a surgical judgement, not a physiotherapy one. If the answer to any of the four is that nobody knows, that is the answer to act on. Ask before you load, not after.

Do not turn these two away. The patient whose joint is too sore to load much, because the other limb, the arms, the trunk and general fitness are all still available and all of them matter after the operation. And the patient with a long wait, because the weeks are free and the NHS advises getting on with the exercises while waiting, since waiting lists can be long (NHS, Preparing for a knee replacement).

The conservative program for the joint itself is a different service from prehab and should be priced and recorded as one. Knee osteoarthritis and hip osteoarthritis carry those programs.

What the program contains, and how long before surgery

Nobody can give you a tested dose. The trials used different lengths, frequencies and loads, and the one overview that looked for a dose response did not find an analysis to settle it (Keogh and colleagues, 2025). So describe the Nguyen program as the dose that was tested, not the dose that is recommended: four supervised group sessions, twice weekly, at least 2 months before surgery, 90 minutes each, half an hour of education and an hour of exercise. That is the session structure from the one adequately sized trial on this page, and that trial found nothing, so it tells you what has been tried and not what to do.

Two things in that overview are dose relevant and they pull in different directions. Its favorable comparison was structured resistance training against exercising controls who were not doing resistance training, so resistance training is the component with support behind it, not activity in general. And resistance training volume did not change postoperative outcomes in its two meta-regressions, so adding sets is not the lever it looks like (Keogh and colleagues, 2025).

That is the end of what the prehab literature will give you, and a clinic still has to put numbers on a sheet. Take them from the general resistance training evidence for this population and label them as exactly that. Older adults new to strength work start lighter and progress by load rather than by volume: 2 to 3 sessions a week for each muscle group, beginning at 1 set and a load the patient can control for 10 to 15 repetitions, moving toward 8 to 12 at a harder load once technique holds, and stopping each set with a few repetitions still in reserve.

The FITT principle carries those figures with their sources, including the dose work in knee osteoarthritis specifically. None of that is a prehab finding, so do not present it as one. It is the ordinary dose for the population, used in the weeks before an operation, which is a defensible place to start and an honest thing to say you are doing.

Say out loud how that dose is delivered, because the arithmetic surprises people. Two to three sessions a week for several weeks is far more than any supervised prehab program contains, so most of it is the patient's own work at home and the supervised sessions are for teaching, checking and progressing it. Build the program around that from the first appointment, not in week three, and make the home record part of what you hand over.

The sheet needs one more thing than the sets and repetitions, and it is the one most often left off: the rule for pain. This is the group whose joint hurts through the range you are loading, so a patient at home with only the repetitions will read the repetitions as the instruction and the pain as their own failing. Give them the rule in the same words the patient pages use.

A little discomfort is common and is usually fine if it settles by the next morning and is not building up from week to week. Sharp pain during a repetition means stop that exercise. A joint that is clearly worse the next morning means the load was too much, so the next session drops back a step rather than stopping altogether. Add the part that stops the rule being used on the wrong thing: a joint that is hot to touch, or swollen along with a temperature or feeling unwell, is not an overdone session and needs medical advice the same day, because an infection in a joint feels much the same from the inside as too much exercise.

What goes in the hour is less contested. For a knee, thigh strength first, because that is the muscle group the operation is hardest on. Then the movements the first fortnight at home is actually made of: getting out of a chair, the first part of the bend, and walking. Sit to stand, the mini squat and step ups cover the pattern in the position the patient will need it, and each exercise page carries its own starting dose. Adjust those numbers to the joint in front of you; do not run them as written.

Prescribe the regression at the same time as the exercise, because the sore-day version is what keeps a program going in a joint that is waiting to be replaced. Most of these patients start at sit to stand using the armrests rather than the hands-free version, which a knee on a bad day often cannot manage.

The mini squat is a small bend at a worktop, about a quarter of the way down, and is not the exercise to chase depth in. A step up starts at a height the patient can control without the knee drifting in, which for many of them is lower than the step they came in on. Where even a small range is too painful on the day, quad sets and the same work for the hip keep the muscle switched on with the joint still, so the answer to a flare is a smaller version rather than a week off. Write the regression on the sheet next to the exercise, not only in your note, because the patient is the one who has to pick it.

Three things get skipped and all three cost the patient later. The hip abductors and extensors, which keep the pelvis level while walking with a stick or a frame. The other limb, which does most of the work getting out of bed and out of chairs in the first weeks. And the upper body, because OrthoInfo asks people having a hip or knee replacement to strengthen it so that crutches or a walker are manageable.

On a hip list the abductors matter for a second reason, and it is a surgical one. The approach decides which soft tissue the operation goes through, and the lateral and anterolateral transgluteal approaches divide the front part of the gluteus medius and minimus (Bertin and Röttinger, 2004). A 2026 meta-analysis of 26 studies and 245,620 patients compared the Hardinge, or direct lateral, approach with the posterolateral: the posterolateral group had better gait velocity and better abductor muscle strength, with no significant difference in the Harris Hip Score. The Hardinge group had a lower dislocation rate, and higher risks of heterotopic ossification and of infection, so it is a trade in both directions and not one advantage (Sun and colleagues, 2026).

Those are observational studies, and the authors say the differences may not be down to the approach alone, so read it as a reason to prepare the abductors and not as a league table of operations. You will not know which approach is planned unless you ask, you do not get a say in it, and you cannot train your way around it afterward as easily as before. That is an argument for building abductor strength while the patient is still waiting.

Then the item with the best return and the least glamour: rehearsing the post-operative exercises and the walking aid. OrthoInfo's advice is to learn the exercises in advance so the patient is ready to do them after surgery. The first days afterward are a poor time to learn a movement, and a patient who already knows how to switch the thigh on has one fewer thing to work out while sore and on new medicines. Teach the movements and the set-up, not a dose, because the dose they follow afterward comes from the ward physio and the operation they had.

Two things must not be rehearsed, and both are the surgeon's decision. The first is a set of hip precautions. What a new hip is allowed to do afterward is set by the operating surgeon and varies far more than clinicians expect: in a survey of American and Canadian arthroplasty surgeons, 44% universally prescribed post-operative precautions and 33% never prescribed them, and direct anterior approach surgeons were significantly less likely to prescribe either precautions or equipment (Carli and colleagues, 2018).

The familiar list, no bending past a right angle, no crossing the legs, no turning the leg inward, was written for a hip reached from the back, and even there the evidence is thin. Across 4 randomized trials and 5 non-randomized studies in 8,835 people having posterior-approach replacement for primary hip osteoarthritis, there may be no or negligible difference in dislocation within 3 months with precautions or with minimal or none, on low certainty for the trials and very low for the rest, and the authors concluded the current evidence does not support prescribing them routinely (Korfitsen and colleagues, 2023).

So teaching a precaution list before the operation either installs a restriction the patient was never given or teaches the wrong one for the approach they are having. A patient who has learned the posterior list before an anterior or lateral replacement has learned nothing about the positions that approach actually asks about. Rehearse the movements and the transfers, and hand over hip precautions, what they are and how long after the operation, not before it.

The second is weight bearing. That is set in theatre and depends on the implant, the fixation and what the surgeon found, so do not teach a crutch or frame pattern that assumes a status. Teach the height of the aid, the grip, standing up with it and getting through a doorway, and leave the pattern and the amount of weight to the ward. Both points are left open here on purpose, because the honest answer is specific to one patient and one operation: the instructions the surgical team gives after the operation come before anything taught before it.

Say that last part to the patient too, and put it in writing on what they take home, because otherwise it stays in your notes and they never hear it. Every number they were given here stops at the operation. A patient who has spent six weeks doing a set number of sit to stands, mini squats and step ups walks out of hospital with that number still in their head and nothing has cancelled it, and some of those exercises are the wrong thing entirely until somebody has told them how much weight the leg may take. So name who gives them the new instructions, which is the ward physiotherapist before they are discharged and the surgical team at follow up, and tell them what to do if nobody has: ask before starting anything, rather than picking up the old sheet. Do not assume there will be a long stay in which someone goes through it unprompted.

On timing, start when the patient is listed instead of counting back from a date. Exercise progression covers how to keep moving the program along across what can be a long wait.

Dates move in both directions and the program has to survive that, so decide in advance what happens each way. If the date comes forward and only days are left, strength is no longer available to you: drop to the part that can still be done in one session, which is rehearsing the post-operative exercises, the walking aid and the first fortnight, plus the handover. That is the half of the program with the shortest lead time and the half most worth protecting.

If the date slips by months, re-measure and re-screen instead of carrying on. The clearance you were given, the surgical answers you collected and the warning-sign screen all described the patient as they were then, and a joint that has deteriorated in the meantime is a message to the surgical team, not a reason to work harder. A program that has quietly run for a year without a new date is ordinary osteoarthritis management, and should be recorded and charged as that.

Does prehab shorten the hospital stay?

The reviews do not agree, and the strongest claim available is weak, so this one does not belong in anything you publish.

Konnyu and colleagues (2023) reported, from 13 randomized trials on the knee side, that prehabilitation may result in increased strength and reduced length of stay, and rated that low strength of evidence. They noted that large heterogeneity across the programs prevented strong conclusions. Nguyen and colleagues (2022) found no differences in their secondary outcomes. Gränicher and colleagues (2022) and Keogh and colleagues (2025) both describe effects that fade, generally within the first 6 months.

There is also a practical reason to leave it alone. Length of stay in a modern joint replacement pathway is driven mostly by the pathway itself: the anesthetic, the day of surgery mobilization the hospital runs and the discharge criteria it uses, none of which your program controls. NICE NG157 asks for rehabilitation on the day of the operation where that is possible, and within 24 hours at the latest. Promising a shorter stay puts your service's reputation on a variable that belongs to the hospital.

Group or one to one?

Decide it on staffing, space and screening, not on the evidence, because the evidence does not compare them.

The Nguyen trial used a group format, four supervised sessions of education and exercise delivered to groups of 4 to 6 people at each center, and found nothing on either primary outcome. That is not a finding against groups, because no arm of that trial ran one to one, and reading it as one would be the error. It does mean a group program cannot be sold as the version that works.

Being unsuitable for a class is not the same as being unsuitable for the program, and the two get confused. Take these people one to one instead of turning them away:

• anyone who needs hands on help or close watching to load a single limb safely
• anyone whose medical clearance came with conditions attached
• anyone with a fall in the past year, or who cannot be left standing on one leg unsupervised
• anyone who cannot follow group instruction because of cognition, hearing or language
• anyone whose warning-sign screen is not yet resolved

A class is a staffing model, not a clinical judgment, and nobody should be in one because it is the only slot available.

What a group loses is the individual part, and you have to build it back in. Each participant still needs an individual assessment before they join, an individual record of what they were prescribed and what they managed, and a named route for reporting a change between sessions. That is the thing a class most often drops, and it is also the thing a surgical team and a complaint both ask for.

Practical limits to set in advance and write down:

• the number of participants one clinician can watch doing loaded single limb work
• the equipment available per person
• the screening done before anyone walks in
• what happens when somebody has a warning sign in the middle of a session

Education, expectations and the handover to the surgical team

The education half of the session is where a prehab program earns most of its value, and the single most useful thing in it is accuracy about what is coming.

Cover what the patient will be asked to do on day one and in the first fortnight, what the walking aid feels like, what help they need at home, and what the realistic shape of the first 3 months is. The NHS preparation page covers the rest of getting ready: stopping smoking, eating well, managing weight, arranging help at home, putting things within reach, transport, and talking to an employer.

Four things belong in the education every time. First, do not shave or tidy the skin around the joint, because NICE's guidance on preventing surgical site infection is that hair should not be removed routinely, and where it has to be removed the hospital does it on the day with electric clippers rather than a razor (NICE NG125). Second, never stop or change a prescribed medicine on your own advice: medicines before surgery belong to the pre-admission clinic, and OrthoInfo asks patients to take a full list of what they take to that appointment, with doses and how often, including supplements and anything bought over the counter.

Anticoagulants and antiplatelets are the ones to name out loud, because a patient on one usually arrives having been told something by somebody. Whether it is stopped, continued or bridged before a joint replacement is an individual decision for the pre-admission team, and NICE's perioperative guideline found no evidence comparing low molecular weight heparin with unfractionated heparin as bridging therapy for people taking a vitamin K antagonist, which is a fair measure of how little a general rule is worth here (NICE NG180). Record what the patient takes, say that the timing is the hospital's decision, and give no view on it yourself. What does change in your clinic is the threshold: a patient on an anticoagulant or an antiplatelet who falls or takes a knock during a session is assessed more cautiously than one who is not, because the bleeding that matters is not the bleeding you can see.

Third, dental work, which comes up in class more often than you would expect and has its own timing. OrthoInfo asks people to schedule dental work such as an extraction or periodontal treatment well in advance of the operation, and not to schedule any dental work, routine cleanings included, for several weeks afterward, because of the infection risk. The timing belongs to the surgical and dental teams together, so the answer in a class is to raise it with them now rather than book it and mention it later.

Two escalations go with it, because a dental infection does not wait for an operating list and the same day line in the warning list routes toothache to the surgical team, which is the right place for the operation and the wrong place for an airway. Take the emergency tier first. Trouble breathing, speaking, swallowing or opening the mouth, a lot of swelling in the mouth, swelling of the neck or around the eye, or a swollen or painful eye or sudden trouble with eyesight means emergency services or an emergency department straight away, and not driving themselves, because that is a spreading infection and the airway is the risk (NHS, Dental abscess). The patient's own copy of that is the second emergency line in warning signs before surgery, and it is handed over as written rather than summarized.

Then, and only with none of those signs present, the urgent tier: toothache or gum pain with a swollen face or jaw, a bad taste, swollen glands in the neck, redness inside the mouth or a high temperature needs an urgent dentist appointment the same day, or an urgent or out-of-hours dental service if none is available, because a doctor's surgery cannot give dental treatment. Swollen glands each side of the neck and a swollen neck are not the same finding, and a patient who cannot tell them apart goes up a tier rather than down. The surgical team is told as well, not instead: the dentist treats the infection and the surgical team decides what happens to the date.

Fourth, and this is the one the handout usually narrows too far: tell people to check all of their skin, not just the leg. OrthoInfo asks for a skin check in the mirror covering the groin, under the breasts, behind the knees and under the arms, with anything abnormal reported, and says plainly that if you have an infection your surgery will be cancelled. The warning line further down names the leg being operated on, because that is where the risk is highest, but an infection anywhere counts: a chest infection, a water infection, an infected toenail, a leg ulcer or a break in the skin on the other side. If your clinic spots one of those in a class, it goes to the surgical team the same day, for the same reason the line gives, whether or not the patient thinks it is worth mentioning. Say the team by name in your own procedure, because "report it" with no recipient is how a finding sits in a class register until the pre-admission call.

Then set the expectation about prehab itself, out loud. A patient who has been told the program will speed up their recovery and then has an ordinary recovery has been let down by the promise, not by the program.

The handover should be one page and should go before the operation, not after it. Put on it:

• what you measured and when, from the set in what to measure, on both limbs
• the range you recorded
• the program the patient was following, and what they actually managed
• any restriction you were given, and by whom
• anything you flagged to the pre-admission team

When to consider surgery for knee arthritis covers how the decision to operate is made, which is useful background for a conversation you will have often and should not be leading.

What to measure

Use measures that exist, have published properties and can be repeated in a corridor. The OARSI recommended set was built for people diagnosed with hip or knee osteoarthritis and for people following joint replacement, which is why it is the right set here: the same tests carry across the operation, so your before and after numbers are comparable. Its minimal core set is three tests, the 30-second chair stand, the 40-meter fast-paced walk and the stair-climb test, with the timed up and go and the 6-minute walk also recommended. The set came from the consensus of 138 clinicians and researchers in 16 countries, and the authors ask for more work on the measurement properties of the tests they chose, so treat them as repeatable rather than as precise (Dobson and colleagues, 2013).

On who runs them: all five are delegable to an assistant working from a written protocol, but only after a clinician has done the intake assessment and the screen, and the stair-climb and the 6-minute walk need somebody present who will recognize chest pain, undue breathlessness or light-headedness and stop. These are the two tests on the list that push an older patient with waiting-list comorbidity toward their limit. Whoever runs a test at intake runs it at every repeat, because changing the tester changes the instrument.

Add strength on both limbs with whatever dynamometry you own, and record the absolute values rather than only a ratio. Add range, and for a knee record flexion specifically, because it is the number the surgical team will want and the one the patient will ask about afterward.

For patient-reported function, pick one tool and keep it. Outcome measures in physical therapy covers choosing between the joint-specific scores and the general ones and reading the change in them, and the lower extremity functional scale is one reasonable choice where you want a single measure across both joints.

Measure at three points: intake, handover before surgery, and again after the operation once the patient is back with you. The third one is the only way your clinic ever learns what its own program does, and it is the measurement nobody schedules.

It is also the first time your clinic sees the operated joint, so decide in advance what stops the appointment. Do not run a test, and contact the surgical team the same day, if the joint is hot, red or swollen, if the patient has a temperature or feels hot, cold or shivery, if the wound is leaking, opening or newly red, or if someone who was walking can no longer put weight on the leg.

Deep infection around an implant is not just an early problem. OrthoInfo is plain about it: an infection can sit in the wound or deep around the prosthesis, it can begin within days or weeks of the operation, and it can turn up years later, and any infection in the body can spread to a joint replacement. So a hot, swollen replaced joint is a same-day call whenever it turns up, and an infection elsewhere, a chest infection, a urine infection, an infected toenail, is treated promptly by whoever treats it and that person is told the patient has a replacement.

Sudden severe hip or groin pain with a leg that will not move or take weight, or a leg that suddenly looks shorter or turned in or out, is treated as a dislocated hip replacement until a hospital says otherwise: keep the patient still, call emergency services, do not walk them to the car and do not try to move the leg back. A fall onto the operated limb followed by severe pain or an inability to weight bear goes the same way, because the bone around an implant breaks differently from the bone beside it and a periprosthetic fracture is an operation, not a rest. Hand over warning signs after a hip replacement or warning signs to call your surgeon for the patient's own copy.

Ask at that appointment what clot prevention they were given and how long it runs, because it continues well past discharge and patients stop early. NICE's options after an elective hip replacement are 10 days of low molecular weight heparin followed by 28 days of aspirin at 75 mg or 150 mg, or 28 days of low molecular weight heparin with anti-embolism stockings until discharge, or rivaroxaban; after an elective knee replacement, 14 days of aspirin at 75 mg or 150 mg, or 14 days of low molecular weight heparin with stockings until discharge, or rivaroxaban (NICE NG89). You do not prescribe any of it and you should not comment on the choice, but a patient who ran out, stopped early or never started is a message to the surgical team, and the calf and chest warning lines below apply to them with more force, not less.

On fees, this page gives no figure: what a prehab program can be charged or claimed for differs by market and by payer, and the number has to come from the payer's or regulator's own current schedule rather than from a guide.

Warning signs before surgery

These are the site's own patient-facing wording and are reproduced exactly. Hand them over rather than paraphrasing them, in this order. The two emergency lines go first, because the most urgent label on a sheet should be the first one a reader meets. The dental one is second rather than beside the same day dental advice above, because a spreading dental infection is an airway, and a reader who meets the same day route first will use it. The one about an upcoming operation date leads the same day lines, because it is the one that changes whether the operation happens at all, and it is the one a patient is most likely to decide is not worth a phone call.

"Emergency: if chest pain, pressure or tightness does not ease quickly when you rest, spreads to your arm, neck, jaw, stomach or back, or comes with sweating, feeling sick, feeling light-headed or being short of breath, call emergency services straight away, as this can be a heart attack. If it eases quickly and none of these happen, get medical advice the same day, and do not exercise again until you have been checked."

"Emergency: you think you have a tooth infection, or your face or jaw is swollen, and you find it hard to breathe, speak, swallow or open your mouth, have a lot of swelling in your mouth, have swelling of your neck or around your eye, or have a swollen or painful eye or sudden problems with your eyesight. Call emergency services or go to an emergency department straight away, and do not drive yourself. This can be a spreading infection, for example from a tooth abscess."

"Same day: with an operation date coming up, you develop a cold, a cough, a high temperature or any other illness, or a cut, scratch, graze, rash or insect bite anywhere on the leg being operated on, or a dental problem such as toothache or a sore gum. Tell your surgical team the same day. Any break in the skin raises the risk of infection, and an infection means the operation is cancelled, so they need to hear about it while there is still time to act rather than on the morning of surgery. Keep taking your prescribed medicines as instructed; never stop or change one on your own."

"Same day: a calf or thigh that is newly swollen or getting more swollen, warm, tender, red or darker than usual, has swollen veins that are sore to touch, or has a throbbing or cramping pain that does not fit your injury or condition, or that feels different from normal muscle soreness after exercise. This can be a sign of a blood clot (deep vein thrombosis), especially after surgery, an injury, time in a cast or boot, a long trip or a spell of being much less mobile than usual. Get medical advice the same day. If you are also short of breath or have chest pain, call emergency services."

"Same day: a joint is hot, red and swollen, or you have joint pain with a high temperature or feel hot, cold or shivery. Get medical advice the same day, and go to an emergency department if you feel very unwell. This can be a sign of infection in the joint, which needs treatment quickly."

Two more things to pass to the surgical team instead of managing them yourself. A joint that is deteriorating while the patient waits, because pain relief, the walking aid and the urgency of the date are all theirs to review, and a worsening joint is not a reason to push harder through the exercises. And a recent or offered injection into that joint, because how an injection sits against an operation date is a surgical decision and not a general rule.

A fall during or between sessions is dealt with on the day, not written up for the next class. Severe hip pain after a fall, being unable to walk or put weight on the leg, or new tingling or loss of feeling in the leg after an injury all mean an emergency department, by ambulance rather than in someone's car (NHS, Hip pain). Do not see whether they can walk it off and do not finish the session first. Leave them where they are rather than helping them up to try again, and give no food or drink while you wait, in case an anesthetic is needed urgently. These are mostly older people with a stiff, painful hip or knee, and a fall onto that hip is one of the ways a broken hip presents: the elective operation they were waiting for becomes an urgent one, with a different implant and a different recovery, so the hours matter.

A head injury in the same fall has its own route and it is the one clinics get wrong, because the patient usually gets up and says they are fine. NICE's head injury guideline asks community health services to refer anyone who has hit their head to a hospital emergency department, using the ambulance service if necessary, if they are on anticoagulant or antiplatelet treatment other than aspirin on its own, and that risk factor stands on its own, with no loss of consciousness, no vomiting and no headache needed (NICE NG232). On a joint replacement waiting list that is not a rare patient: atrial fibrillation, a previous clot and coronary stents are all common at this age. So the question after a fall with a bang on the head is which medicines they take, and the answer decides whether they go home or go in.

Be straight about the scope, because it is ours and not NICE's. NG232 addresses that recommendation to community health services, and it defines them inside the recommendation itself as GPs, ambulance crews, NHS walk-in or minor injury centres and dental practitioners, a list that does not name physiotherapy. We apply it in a physiotherapy clinic anyway, and on purpose, because the risk factor belongs to the patient and the medicines they take rather than to the room they are standing in, and a clinic can no more rule out a bleed inside the head than a walk-in centre can. Do not narrow it later on the grounds that NICE was addressing somebody else.

Two things go with it. Where none of those risk factors applies, the same guideline asks the clinician to consider an emergency department referral anyway if nobody is able to watch the injured person at home, which on a joint replacement list is a large share of the people in the room (NICE NG232). And whoever goes in takes their medicines with them, as the NHS asks, because that list is what the hospital decides on.

Then pass the rule on, because almost none of these falls will happen in front of you. They happen at home, on the days between sessions, and a route that lives only in your procedure fires only when you are watching. So the patient, and whoever is at home with them, are told in their own words: a bang on the head while you are taking a medicine that thins your blood, anything other than aspirin on its own, means a trip to hospital even if you feel completely well, and it is a reason to call an ambulance rather than wait and see. Put it on the sheet next to the medicine list rather than in the record alone, and ask them to bring the list if they go. This is the item on the whole page most likely to be filed instead of handed over, and it is the one where filing it costs the most.

Can prehab mean the operation is avoided?

Nothing on this page tested that, so the page makes no claim about it, and neither should your service.

All four of the prehabilitation studies above drew on people already scheduled for or listed for a replacement, and all of them measured outcomes after the operation. Konnyu and colleagues say so in their own inclusion criteria, which were patients scheduled to undergo elective, unilateral knee or hip replacement. None of them was designed to find out whether a program changes who ends up having surgery. A clinic that advertises avoided surgery is making a claim with no evidence behind it in this literature and is also claiming a decision that is not ours: whether to operate belongs to the surgical team with the patient.

What is true, and is a different statement, is that structured exercise is core treatment for hip and knee osteoarthritis in its own right, before and whether or not an operation is on the table. That is the service to offer a patient who is still deciding, and it is covered on knee osteoarthritis and hip osteoarthritis. Calling it prehab when the patient is not listed for surgery muddles both the record and the claim.

The short version

Lead with the evidence, not the brochure. One adequately sized multicenter trial of a multidisciplinary group program found no benefit on either of its primary outcomes, the reviews find gains on low to very low certainty evidence that are mostly gone by 6 months, and on the hip the two syntheses on this page do not even agree on whether there is a signal. So offer measurement, strength, rehearsal of the post-operative exercises and accurate education, measure three times so you learn something, write your entry criteria down, hand over one page before the operation, and promise none of the four things a prehab program is usually sold on.

References

1. Nguyen C, Boutron I, Roren A, et al. Effect of Prehabilitation Before Total Knee Replacement for Knee Osteoarthritis on Functional Outcomes: A Randomized Clinical Trial. JAMA Network Open. 2022;5(3):e221462. https://doi.org/10.1001/jamanetworkopen.2022.1462
2. Konnyu KJ, Thoma LM, Cao W, Aaron RK, Panagiotou OA, Bhuma MR, Adam GP, Pinto D, Balk EM. Prehabilitation for Total Knee or Total Hip Arthroplasty: A Systematic Review. American Journal of Physical Medicine and Rehabilitation. 2023;102(1):1-10. https://doi.org/10.1097/PHM.0000000000002006
3. Gränicher P, Mulder L, Lenssen T, Scherr J, Swanenburg J, de Bie R. Prehabilitation improves knee functioning before and within the first year after total knee arthroplasty: a systematic review with meta-analysis. Journal of Orthopaedic and Sports Physical Therapy. 2022;52(11):709-725. https://doi.org/10.2519/jospt.2022.11160
4. Keogh JAJ, Keng I, Dhillon DS, Bourgeault-Gagnon Y, Simunovic N, Ayeni OR. The effects of structured prehabilitation on postoperative outcomes following total hip and total knee arthroplasty: an overview of systematic reviews and meta-analyses of randomized controlled trials. Journal of Orthopaedic and Sports Physical Therapy. 2025;55(5):344-365. https://doi.org/10.2519/jospt.2025.13075
5. Bertin KC, Röttinger H. Anterolateral mini-incision hip replacement surgery: a modified Watson-Jones approach. Clinical Orthopaedics and Related Research. 2004;(429):248-255. https://pubmed.ncbi.nlm.nih.gov/15577495/
6. Sun M, Wang Y, Wei X, Yan L, Cheng H, Han X. Gait and function after total hip arthroplasty: a systematic review and meta-analysis of the Hardinge versus posterolateral approaches. BMC Musculoskeletal Disorders. 2026;27(1):236. https://doi.org/10.1186/s12891-026-09522-5
7. National Institute for Health and Care Excellence. Joint replacement (primary): hip, knee and shoulder. NICE guideline NG157. Published 4 June 2020. https://www.nice.org.uk/guidance/ng157
8. Dobson F, Hinman RS, Roos EM, Abbott JH, Stratford P, Davis AM, et al. OARSI recommended performance-based tests to assess physical function in people diagnosed with hip or knee osteoarthritis. Osteoarthritis and Cartilage. 2013;21(8):1042-1052. https://doi.org/10.1016/j.joca.2013.05.002
9. American Academy of Orthopaedic Surgeons. Preparing for joint replacement surgery. OrthoInfo. https://www.orthoinfo.org/en/treatment/preparing-for-joint-replacement-surgery/
10. NHS. Preparing for a knee replacement. Page last reviewed 9 September 2026. https://www.nhs.uk/tests-and-treatments/knee-replacement/preparation/
11. NHS. Hip pain. Page last reviewed 20 November 2025. https://www.nhs.uk/symptoms/hip-pain/
12. National Institute for Health and Care Excellence. Surgical site infections: prevention and treatment. NICE guideline NG125. https://www.nice.org.uk/guidance/ng125/chapter/Recommendations
13. Carli AV, Poitras S, Clohisy JC, Beaule PE. Variation in use of postoperative precautions and equipment following total hip arthroplasty: a survey of the AAHKS and CAS membership. Journal of Arthroplasty. 2018;33(10):3201-3205. https://pubmed.ncbi.nlm.nih.gov/29958753/
14. Korfitsen CB, Mikkelsen LR, Mikkelsen ML, et al. Hip precautions after posterior-approach total hip arthroplasty among patients with primary hip osteoarthritis do not influence early recovery: a systematic review and meta-analysis of randomized and non-randomized studies with 8,835 patients. Acta Orthopaedica. 2023;94:141-151. https://doi.org/10.2340/17453674.2023.11958
15. National Institute for Health and Care Excellence. Venous thromboembolism in over 16s: reducing the risk of hospital-acquired deep vein thrombosis or pulmonary embolism. NICE guideline NG89. https://www.nice.org.uk/guidance/ng89/chapter/Recommendations
16. National Institute for Health and Care Excellence. Perioperative care in adults. NICE guideline NG180. https://www.nice.org.uk/guidance/ng180/chapter/Recommendations
17. National Institute for Health and Care Excellence. Head injury: assessment and early management. NICE guideline NG232. https://www.nice.org.uk/guidance/ng232/chapter/recommendations
18. NHS. Dental abscess. Page last reviewed 18 March 2026. https://www.nhs.uk/conditions/dental-abscess/
19. American Academy of Orthopaedic Surgeons. Total knee replacement. OrthoInfo. https://www.orthoinfo.org/en/treatment/total-knee-replacement/

Written and checked by the PocketPhysio editorial team. Last updated 2026-10-24.