Pre-habilitation — Getting Stronger Before Surgery

Part of The Joint Replacement Guide — Phase 2: Considering Surgery · Article 11 of 44 · Hip & Knee

Key Points

  • Prehabilitation, often shortened to “prehab”, means preparing physically and practically for surgery rather than waiting until afterwards to begin rehabilitation.
  • Exercise before hip or knee replacement may improve strength, confidence and readiness for recovery. However, the size of the benefit varies and prehab cannot guarantee a faster or better final result.[1–3]
  • Preparation may include exercise, nutrition, general health measures, psychological support and planning for recovery at home.
  • A programme should be adapted to your symptoms, general health and current level of mobility.
  • You do not have to become “fit” or pain-free before surgery. The aim is to help you approach it as well prepared as reasonably possible.

What Is Prehabilitation?

Rehabilitation helps you regain movement, strength and independence after surgery. Prehabilitation applies similar principles before an operation.

For hip or knee replacement, this often includes strengthening the muscles that support the affected joint. Examples include the quadriceps muscles at the front of the thigh and the muscles around the hip. It may also include safe aerobic activity, balance exercises, practising the exercises that will be used after surgery and learning how to use walking aids.

NICE recommends giving people having hip or knee replacement advice about exercises before and after surgery, relevant lifestyle measures, and ways to maximise independence and quality of life.[1]

Prehabilitation is not a test that you must pass. Pain, disability and other health conditions may limit what you can do, and a useful programme should take those limitations into account.

What Does the Evidence Show?

Research into prehabilitation is continuing. Some studies report improvements in strength, pain, function or mobility, particularly before surgery and during early recovery. Intensive programmes have also been associated with shorter hospital stays in some studies, although much of that evidence comes from healthcare systems where hospital stays are longer than they usually are in the NHS.[2]

The overall evidence is mixed. Programmes differ considerably in their exercises, intensity, supervision and duration, and many studies have been small or at risk of bias. Evidence is stronger for knee replacement than for hip replacement, but even for knee replacement the size and persistence of the benefit are uncertain.[3,4]

It is therefore reasonable to say that prehab can help some people prepare for surgery and early recovery. It should not be presented as a guarantee of fewer complications, a shorter hospital stay or a better long-term result.

What Might a Prehab Programme Include?

Exercise

Exercise should be selected according to the joint being replaced and your individual abilities. It may include:

  • strengthening the muscles around the hip, knee and trunk;
  • practising standing up, walking and using stairs;
  • balance exercises;
  • low-impact aerobic activity, such as walking, cycling or exercising in water, where suitable; and
  • practising exercises that will be used after surgery.

A physiotherapist can help if you have difficulty choosing exercises, marked weakness, poor balance or another condition that affects your ability to exercise. Where supervised treatment is unavailable, a clear home programme may still be useful.

Nutrition

Eating enough protein and having a balanced diet support muscle maintenance and healing. This is different from crash dieting or trying to achieve rapid weight loss immediately before surgery.

Tell the team if you have lost weight without intending to, have a poor appetite, difficulty swallowing or concerns about obtaining or preparing food. These can be signs that a nutritional assessment would be helpful. Do not start high-dose nutritional supplements unless advised to do so.

Preparing Your General Health

Prehab may take place alongside other preparation, including:

  • support to stop smoking;
  • improving diabetes management;
  • identifying and treating anaemia;
  • reviewing alcohol intake and medicines; and
  • managing other health conditions.

These areas are covered in more detail in the article on preoperative assessment and optimisation.

Psychological and Practical Preparation

Feeling worried before an operation is common. Clear information, realistic expectations and knowing whom to contact can make the process feel more manageable.

Preparation may include:

  • discussing what to expect in hospital and during recovery;
  • setting realistic, personally meaningful goals;
  • learning relaxation or coping techniques;
  • planning help with meals, shopping and transport;
  • removing trip hazards at home; and
  • arranging suitable chairs, walking aids or other equipment if recommended.

Ask for additional support if anxiety, low mood or another mental-health difficulty is affecting your sleep, daily life or ability to prepare.

When Should You Start?

Start when it is practical for you—often once surgery is being considered or planned. There is no single proven minimum duration. Some programmes last several weeks, but even a shorter period can be used to learn exercises, plan for discharge and establish a routine.

Regular, manageable activity is usually more sustainable than occasional strenuous sessions. A long wait for surgery should not be necessary simply to complete a standard prehab programme unless your team identifies a particular safety concern that needs attention.

Exercising Safely

Some muscle effort or a temporary, modest increase in joint discomfort can occur with exercise. The programme may need adjusting if pain becomes severe, remains substantially worse afterwards or repeatedly prevents your usual activities.

Stop exercising and seek appropriate medical advice if you develop:

  • chest pain, fainting or unusual severe breathlessness;
  • sudden marked swelling, redness or heat in the leg;
  • a new injury or inability to bear weight; or
  • another symptom that feels severe or concerning.

Ask your physiotherapist, GP or surgical team for individual advice if you have significant heart or lung disease, frequent falls, uncontrolled symptoms or uncertainty about which exercises are safe.

Setting Realistic Expectations

Prehab is one part of the surgical pathway. It cannot reverse severe arthritis, remove every surgical risk or replace rehabilitation after the operation.

A helpful aim is to maintain or improve what you can: strength, movement, confidence, general health and practical readiness. Progress may be gradual, and a programme should support you rather than make you feel responsible for factors outside your control.

This article provides general information and does not replace advice from your physiotherapist, surgeon or other healthcare professional. Exercise and preparation should be adapted to your health, symptoms and local surgical pathway.

References

  1. National Institute for Health and Care Excellence. Joint replacement (primary): hip, knee and shoulder. NICE guideline NG157. London: NICE; 2020. Recommendation 1.2.1. Last reviewed 19 December 2024. Available from: https://www.nice.org.uk/guidance/ng157/chapter/Recommendations
  2. National Institute for Health and Care Excellence. Joint replacement (primary): hip, knee and shoulder—rationale and impact: preoperative rehabilitation. London: NICE; 2020. Available from: https://www.nice.org.uk/guidance/ng157/chapter/Rationale-and-impact
  3. Adebero T, Omana H, Somerville L, Lanting B, Hunter SW. Effectiveness of prehabilitation on outcomes following total knee and hip arthroplasty for osteoarthritis: a systematic review and meta-analysis of randomized controlled trials. Disabil Rehabil. 2024;46(24):5771–5790. doi:10.1080/09638288.2024.2313128. Available from: https://pubmed.ncbi.nlm.nih.gov/38349251/
  4. Konnyu KJ, Thoma LM, Cao W, et al. Prehabilitation for total knee or total hip arthroplasty: a systematic review. Am J Phys Med Rehabil. 2023;102(1):1–10. doi:10.1097/PHM.0000000000002006. Available from: https://pmc.ncbi.nlm.nih.gov/articles/PMC9464791/
  5. Centre for Perioperative Care. Assessment, optimisation and shared decision making. London: CPOC. Available from: https://www.cpoc.org.uk/guidelines-and-resources/perioperative-optimisation-Top-seven-interventions/assessment-optimisation-sdm

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