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RETURN TO RUNNING AFTER HIP REPLACEMENT SURGERY?

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Lately, I got a patient asking me whether he could return to running after he had total hip replacement surgery. As he was significantly younger than most people receiving total hip arthroplasty (THA), this was the first time I personally came across this question. My first thought was, “Yeah sure!”. But then I scratched my head a little bit as I didn’t know the evidence about it.

The growing proportion of younger patients undergoing total hip and total knee arthroplasty places greater expectations on postoperative quality of life. It’s still unclear what the best practices are for sports when it comes to athletic exercise. So let me take you on this run to dive into the research evidence on return to running after hip replacement surgery. 

Why am I asking myself this question?

Commonly when treating patients after a hip replacement surgery, you’ll get precautions from their orthopedic surgeon. Often, avoiding hip flexion beyond 90° or avoiding excessive internal and external rotation will be the main focus. Furthermore, we all have heard about the possibility of revision of the prosthesis. In this light, running is increasing the demands around the hip and therefore it is seen as a possible cause for early revision surgery. I wanted to know what the current evidence tells us about running after hip replacement.

But equally important, physical activity guidelines recommend being active several days per week. As we all know, a vast majority of people don’t engage in sufficient amounts of physical activity. Among those who received hip replacement surgery, a large proportion indicates that fear is holding them back from sports participation. Even if running is not the priority for your patient, I think this blog may help you guide patients to re-engage in physical activities and meet the recommendations.

THE MAIN REASON FOR NOT PARTICIPATING IN RUNNING POSTOPERATIVELY WAS DUE TO FEAR (61%), FOLLOWED BY MUSCLE WEAKNESS (24%), AND PAIN IN THE LOW BACK OR KNEE (15%). ABE ET AL., (2014).

What does the evidence say about other hip procedures?

The most evidence concerning return to sport (RTS) after a total hip replacement came from opinions and surveys among surgeons. For example, Klein et al., in 2007, and Swanson et al., in 2009 used questionnaires to gather information from surgeons about their recommendations after THA. The latter study reported that surgeons generally don’t restrict low-impact activities such as level surface walking, stair climbing, level surface bicycling, swimming, and golf. Higher-impact activities were more commonly discouraged, although there was considerable variability in the responses. Swanson indicated that surgeons who performed many hip replacement surgeries generally were more likely to encourage participation in higher-load impact activities. 

Kraeutler et al., in 2017 conducted a literature review and proposed a physical therapy protocol for patients who underwent labral repair, acetabular rim resection, or femoral head osteochondroplasty for FAI. So to be clear, not in THA patients. They did so because they experienced many patients failing to return to activity as they were guided by tissue healing guidelines rather than by functional gains in strength, gait, and pain. Although this study discusses another pathology, it is interesting to see the rehab progressions made after a surgery that typically requires limited weight bearing post-operatively.

The program for post osteochondroplasty was accompanied by an ongoing strength program which included exercises such as side plank raises, front planks, band walks, supine bridge, and single leg squat reaches.

Prior to each workout or run, a dynamic warm-up was required with the following exercises. (A) Knee hug to calf raise, (B) in/out heel taps, (C) swing kicks, (D) soldier walks, (E) glute kicks, (F) walking lunges with reach and rotation, (G) lunge twist, (H) quick steps and (I) Single-leg mini-squat to calf raise.

  • The first phase of this program was a walking program which was initiated on a treadmill and progressed to outdoor activities. The requirement was being able to walk 30 minutes at a speed of around 3.5 mph which corresponds to 5.6 km/h. 
  • Phase 2 was a quick response and plyometric activity. They state the following: “Quick muscle response and plyometrics are initiated in this phase, progressing to about 500–600 foot contacts between one and two legs. Thus, if a runner has an average turnover of 170–180 strides/min, then running for 5–7 min would be required to reach the necessary 500–600 single-foot contacts.”

Progression to the walk/run program was allowed when participants had successfully completed phase 1 and the level I plyometric program of phase 2, could walk without limping, and had no pain with daily activities. Here also, the advice was to initiate this program on a treadmill. The following rules had to be followed: (i) No hills or inclines, (ii) no speed work, (iii) work on form and (iv) run every other day. Ideally, they should continue the level II and III plyometric program.

  • Phase 3 returned the patient to distance running. During this last phase, patients had to find their baseline. This is the distance the patient can run without pain and again 48h later. Distance, time, and pace had to be carefully noted down to track progress.
    • During weeks 1–2, patients should run 2–3 times per week, with two shorter runs between 50% and 60% of their baseline distance and one longer run at the baseline distance. 
    • During weeks 3–6, patients should run three times per week at their baseline level, with a rest day between each run. Patients should increase their distance by 10% each week. 
    • Starting in week 5, patients should reassess their baseline and increase running distance accordingly.
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PREVENTING MUSCLE CRAMPS DURING EXERCISE AND COMPETITION – THIS IS HOW YOU DO IT BASED ON EVIDENCE!

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“Are you taking magnesium tablets?” “You need to make sure you drink water regularly!”
“Oh, I thought you were fit?!” “Make sure to eat a banana during the break!”
So much advice, but nothing seems to work for your muscle cramps during exercise or competition?! Then you NEED to read this blog post to learn what the latest evidence says about relieving and preventing muscle cramps!


Based on evidence from Nelson et al. in 2016 we mentioned that the only thing that really helps against cramps acutely is stretching. But anyone involved in competitive sports knows that cramps usually come back after a minute or so and it’s basically game over. That’s why in this post, we will look at the latest evidence that has come out in the last couple of years and get into details about what steps you can take for relieving and preventing muscle cramps in the first place.

My personal story: Fit, but often stopped by cramI wanna tell you my personal story first: As you might know, I played high-level amateur soccer in the past and I am playing competitive tennis now and although I would consider myself one of the fitness players on the team, I seem to be the only one that is regularly stopped by muscle cramps. In the past I’ve tried everything from taking magnesium, drinking large amounts of water before and during competition, adding electrolytes to my drink, and even taking medication, but nothing really seemed to help. That’s one reason why I dug deeper into the literature again to finally find something to help my situation. Amongst others, I ended up finding this article by Troyer et al. (2020) who published a review about exercise-associated muscle cramps in the tennis player.

Debunking common cramping myths

Let’s first debunk a couple of myths:
1) While stretching is the treatment of choice to relieve acute muscle cramping it does not have a preventative effect to reduce future cramping

2) Several prospective cohort studies could not show an association between dehydration and cramping. So, while drinking enough water to prevent dehydration is advisable for sports performance, it does not prevent cramps.

3) Eating bananas for their potassium content does not prevent cramping as hypokalemia is not associated with cramping, nor do potassium levels change quickly enough in the blood following digestion to stop cramps. What about magnesium? A Cochrane review by Garrison et al. (2012) concluded that it is unlikely that magnesium supplementation provides clinically meaningful cramp prophylaxis.

Drinking enough water and consuming magnesium or potassium does not prevent cramps

In general, the electrolyte and dehydration theory came forth from a study in 1923 (yes, 100 years ago) in which they observed cramping in coal miners in hot humid conditions. This study has shaped the way many people in the industry view muscle cramping until this very day. A survey among certified athletic trainers for example showed that the majority of them still believe that cramps occur due to dehydration and electrolyte loss.

NEITHER STRETCHING, NOR HYDRATION OR ADDING POTASSIUM OR MAGNESIUM TO YOUR DRINK CAN PREVENT EXERCISE-INDUCED MUSCLE CRAMPS

The most important electrolyte: NatriuNow let’s look at what DOES work based on the latest evidence and what I personally have in my tennis bag in order to prevent and relieve cramps. Now I want to stress beforehand that we need a strategy that covers as many bases as possible. With different possible underlying mechanisms for cramping, every athlete will have different requirements. A good idea to figure out what works for you is to create a cramping diary and note details like how you slept, the duration of your match, what you ate, how much and what you drank, and how much cramping you experienced. Now let’s get to the part that everyone was waiting for!


Troyer et al. recommend adding 3g of salt to half a liter of a carbohydrate/electrolyte solution when generalized muscle cramping occurs, but I personally find this approach very reactive. To be proactive I personally add 3g of salt to my bottle which is 750ml.
Another advantage of added salt is that it increases thirst and retains more water in the system that you would instead lose through urination.
Ideally, you should drink 1-2L of fluid per hour or between 200 and 400ml each changeover (USTA Texas Heat and Hydration for Tennis Players)

Prevent glycogen store depletion with isotonic drinks

Now a possible risk factor for muscle fatigue is decreased muscle energy. So a good idea 2-3 hours before competition is to consume a carbohydrate-rich meal or snack, such as pasta or rice to fill up your glycogen stores. During exercise between 30-60g of carbohydrates per hour are recommended. You should add between 6-8 grams of carbs per 100ml to make your drink isotonic. Isotonic means that the drink has the osmolarity or concentration as your blood and the carbs can thus be quickly absorbed into your bloodstream.

You can just add sugar to your drink, or you can opt for a sports drink which is usually isotonic. If you google “self-made isotonic sports drink”, there are many options to create your own delicious sports drink. Personally, I would mix orange juice and water in a ratio of 1:1. Obviously you can also consume carbohydrates in other forms such as gels or snacks. A normal-size banana contains about 25g of carbs, so 1 banana might be insufficient.

Provide cramp relief with TRP agonists

There are a couple of substances that can be ingested in order to provide rapid relief of muscle cramps by altering chemoreceptors in the oropharynx, so you don’t have to wait until they are absorbed into the bloodstream. Among others – you guessed it – it’s pickle juice. While having a glass of pickle juice in your bag is not really handy, I carry a tube of mustard in my bag.

A study by Craighead et al. (2017) suggests that the ingestion of transient receptor potential channel agonists abbreviated as TRP agonists can attenuate muscle-induced cramps by decreasing alpha motor neuron hyperexcitability. These TRP agonists are ginger, peppers, wasabi, and cinnamon. So you might want to add a bit of cayenne, ginger, or cinnamon to your sports drink or have one of those little wasabi packages in your bag to provide relief. In the study, participants consumed up to 500mg of cinnamon, 38mg of capsicum, or 750mg of ginger.

Decreasing EMG activity of the affected muscles

If you still experience a cramp, then next to consuming mustard and wasabi, you can decrease EMG activity by stretching and massaging the affected muscles. Antagonist contraction and icing or cooling the affected muscles can help by increasing the inhibitory afferent of the Golgi tendon organ. So I would suggest adding a cooling gel, ice spray, or cooling towel to your bag.
Compression stockings might be a good option, but scientific evidence is lacking at the moment

Something that has helped me personally with calf cramps during soccer matches was compression stockings. Be aware though, that this is personal anecdotal evidence and that no studies have evaluated the effects of compression stockings on exercise-induced muscle cramps yet.

Regulate your muscle receptors with plyometric training

Plyometric training can improve neuromuscular control, delay neuromuscular fatigue and induce beneficial adaptations to muscle fibers and the Golgi tendon firing receptors

And our last and probably most important advice is conditioning focusing on increased endurance intensity and resistance training of the affected muscle groups as well as other stabilizing muscles of the kinetic chain. The message is simple, the fitter you are, the less your muscles are prone to cramping. While general heavy lifting did not help me with cramping personally, I switched to mainly plyometric training of the legs about 2-3 times a week in an attempt to prepare specifically for the demands of tennis. On top of that, plyometrics are said to improve neuromuscular control and delay neuromuscular fatigue by inducing beneficial adaptations to muscle fibers and the Golgi tendon organ firing receptors.

If none of these tips can help you, you might want to get evaluated by a physician to exclude an underlying disease.  Feel free to reach out to us if our tips helped you with preventing muscle cramps or what other measures you are taking personally.