Hip Osteoarthritis: What Physiotherapy Can Do Before a Replacement

If you have hip osteoarthritis and are weighing a replacement, the question underneath the appointment is usually the same: do I need surgery now, or is there something worth trying first? For most people, the honest answer is that exercise comes first. Not as a delay tactic, but because the major osteoarthritis guidelines put it there.

Exercise is the recommended first-line treatment, not a last resort

Structured exercise and education are the core treatment for hip osteoarthritis in the two most cited clinical guidelines, which surprises a lot of people who assume a worn hip means surgery is the only real option. The Osteoarthritis Research Society International (OARSI) 2019 guidelines name arthritis education and structured land-based exercise as core treatments for hip osteoarthritis, recommended for essentially everyone with the condition. The UK's National Institute for Health and Care Excellence osteoarthritis guideline (NG226) is more direct still: therapeutic exercise is a core treatment offered to all people with osteoarthritis, and joint replacement is considered only when symptoms substantially affect quality of life and non-surgical management has been ineffective or unsuitable.

In plain terms, both guidelines put exercise before the operating room, not because surgery is bad, but because a meaningful number of people improve enough with exercise that surgery becomes a later question or no longer the obvious next step. That reframes the whole decision. You are not choosing between doing nothing and having surgery. There is a well-evidenced middle path, and it is the recommended starting point.

What the evidence says exercise actually does

It helps, and the honest framing is that the benefit is real but moderate. A Cochrane systematic review of land-based exercise for hip osteoarthritis found high-quality evidence that exercise reduced pain and improved physical function in people with symptomatic hip osteoarthritis. The effect sizes were described as slight rather than dramatic, roughly 8 points of pain reduction on a 100-point scale, with the benefit sustained for three to six months after the program ended. Because the evidence was rated high quality, the review's authors judged that further research is unlikely to change that estimate much.

We say this plainly because overselling exercise does no one any favours. It will not regrow cartilage or reverse the arthritis. What it can do is reduce pain, improve how far and how comfortably you move, and build the strength and control that a painful, guarded hip tends to lose. For some people that is enough to change the calculus on surgery. For others it improves the months of waiting and the recovery afterward. Both are worth having.

What a physiotherapy program for hip osteoarthritis targets

A good program is not a generic set of stretches. After a screening assessment, a physiotherapist builds it around the specific things a hip with osteoarthritis loses: strength, load tolerance, and gait.

Strength work usually centres on the muscles around the hip and thigh, particularly the glutes, because a weak, deconditioned hip offloads onto the joint in ways that provoke pain. Load tolerance means gradually asking the hip to do more, in controlled steps, so the tissue and the nervous system relearn that movement is safe rather than something to brace against. Gait, meaning how you walk, often changes when a hip hurts, and those compensations can spread pain to the back or the other side. Retraining a smoother, more even walking pattern is part of the work. Education runs through all of it: understanding what osteoarthritis is, why hurt does not always mean harm, and how to pace activity so a flare does not derail the whole plan.

The structured programs studied in the research tend to combine these ingredients. One large multi-country study of a standardised education-and-exercise program that pairs a small number of education sessions with about twelve supervised neuromuscular exercise sessions analysed 28,370 patients with hip or knee osteoarthritis: participants improved by roughly 26 to 33 percent in average pain intensity and showed measurable gains in walking speed and in the ability to rise from a chair. That is the kind of structured, progressive approach a physiotherapist is trained to deliver and adjust.

The honest role and timing of a hip replacement

None of this means surgery is a failure or something to avoid at all costs. Hip replacement is one of the more reliably successful procedures in modern medicine for the right person at the right time, and for a hip that has worn to the point where pain limits sleep, walking, and independence despite a real attempt at conservative care, it is often the correct decision.

The timing question is where physiotherapy and surgery stop being rivals. Exercise first is the guideline-recommended sequence, but exercise is not a reason to white-knuckle through a hip that is clearly past that stage. The signs that push the conversation toward surgery are things like night pain that breaks sleep, pain that no longer eases with rest or a sensible exercise plan, and function that keeps shrinking despite genuine effort. Those are decisions made with an orthopedic surgeon and your family physician, not on a website. What we can do is give the non-surgical path a fair, well-run trial so that whenever the surgical decision is made, it is made from information rather than from never having tried.

Making good use of a BC surgical waitlist

If you are already on a waitlist for a hip replacement in British Columbia, that waiting time is not dead time. Scheduled surgeries in BC are booked through the public system, and you can look up current wait times by procedure, hospital, and surgeon through the provincial Surgery Wait Times tool. Wait times vary, and they change, so the tool is the place to check your own situation rather than any number we could print here.

The point is what you do with that window. There is good reason to think that walking into surgery stronger and better conditioned gives you a better starting point for recovery, and the strength and gait work described above is exactly the kind of preparation a physiotherapist can supervise while you wait. In our clinic, we treat time on a waitlist as an opportunity to build capacity, keep the hip and the surrounding muscles as strong as pain allows, and prepare you for the rehabilitation that follows the operation, rather than deconditioning while the pain quietly talks you into moving less. If a replacement is on your horizon, the same logic that applies to knees is worth reading in our note on prehab and rehab around a joint replacement in BC.

When to start, and who to see first

The most useful time to start is before the decision feels forced. A physiotherapy assessment can confirm whether what you are feeling fits the pattern of hip osteoarthritis, screen for anything that needs a physician instead, and build a program around your specific hip rather than a generic one. Physiotherapists in BC are regulated by the College of Health and Care Professionals of BC (CHCPBC), and part of that first visit is knowing when to refer you onward.

If you are also dealing with a knee, or unsure which joint is driving your symptoms, the same first-line logic applies there too, and our companion piece on knee osteoarthritis and physiotherapy before surgery covers it. Coverage and booking details are on our rates and FAQ page, and any of our five studios across Metro Vancouver can start with an assessment. The strongest outcomes tend to happen when exercise starts early, is supervised and progressed properly, and is treated as the real first-line treatment it is, whether or not surgery ends up being part of the plan.

This article is general information, not personal medical advice. A regulated practitioner can confirm whether the patterns described apply to you.

Frequently asked questions

Can physiotherapy cure hip osteoarthritis or avoid a replacement?

It cannot reverse the arthritis, but it can reduce pain and improve function, and for some people that is enough to delay or reconsider surgery. A Cochrane review found high-quality evidence that exercise reduces pain and improves function in hip osteoarthritis, though the benefit is moderate rather than dramatic.

Is exercise really recommended before surgery, or just an insurance requirement?

It is the recommended first-line treatment. Both the OARSI 2019 guidelines and the UK NICE guideline (NG226) name structured exercise and education as core treatment for hip osteoarthritis, with joint replacement considered when symptoms are severe and non-surgical care has not helped.

What does a hip osteoarthritis physio program actually involve?

After an assessment, it usually targets hip and thigh strength, gradually building load tolerance, and retraining your walking pattern, alongside education about pacing and managing flares. Structured programs of this kind combine a few education sessions with about twelve supervised exercise sessions.

Should I keep exercising if my hip is on a surgical waitlist?

Yes, unless your surgeon or physician has told you otherwise. Time on a waitlist is a chance to build strength and condition the hip so you enter surgery in a better starting position, and a physiotherapist can supervise that safely.

How do I check my hip replacement wait time in BC?

The provincial Surgery Wait Times tool lets you look up current wait times by procedure, hospital, and surgeon. Wait times vary and update over time, so check the tool for your own situation rather than relying on a general figure.

Who should I see first for hip pain I think is arthritis?

A physiotherapy assessment is a reasonable first step to confirm the pattern, rule out anything needing a physician, and build a program. If pain is severe, unremitting at night, or rapidly worsening, that is a conversation with your family physician about imaging and a possible surgical referral.

Sources

• OARSI Guidelines for the Non-surgical Management of Knee, Hip, and Polyarticular Osteoarthritis, Osteoarthritis Research Society International (2019)
• Osteoarthritis in over 16s: diagnosis and management, Recommendations, NICE guideline NG226 (2022)
• Exercise for osteoarthritis of the hip, Cochrane systematic review (CD007912)
• Immediate outcomes following a standardised education and neuromuscular exercise program in Denmark, Canada and Australia: a longitudinal analysis including 28,370 patients, Osteoarthritis and Cartilage (2021)
• Surgical wait times, Province of British Columbia