How to Approach Yoga After a Total Hip Replacement

Editor's note: The below are intended to be general recommendations for yoga practitioners and teachers. They are not a replacement for the personal advice of a health professional. Yoga teachers should remain within their : This means not attempting to diagnose, treat, or offer medical advice to students.

In 2018, yoga teacher Cyndi Lee had one hip, then the other, replaced, in surgeries just months apart.

“My surgeon told me that I was the kind of person he worries about because he thought I might try to do too much activity too soon,” Lee says. “But honestly, in the end, that was not a good thing to say to me because it gave me an unrealistic expectation of recovery. The truth was, it was a difficult recovery that I would describe as raw, brutal, and very real.” 

Total hip replacement (THR) surgery, which involves replacing a damaged hip joint with a prosthetic joint, is so common as to be considered “the operation of the 21st century.” In the U.S., upward of 2.5 million people are living with hip replacements. Though, as Lee experienced, recovery can be challenging, only about 10 percent of patients report dissatisfaction with the results. Most often recommended for those with arthritis-related joint damage, THR surgery often improves movement and decreases pain.

As patients recover from surgery—sometimes in as few as three to six months—they are increasingly able to return to a wide variety of athletic activities, especially those deemed low impact, such as dancing, low-impact aerobics, and yoga. Naturally, those who have had hip replacements should consult their surgeons about returning to, or beginning, a yoga practice, but it may not always be clear how to ease back into practice safely.

If you or one of your students have undergone THR surgery and are wondering about the recovery process and how common movement precautions translate to yoga, read on for Lee’s experiences and a physical therapist’s perspective. 

Recovery

In the months immediately following surgery, an active yoga practice may not be possible. Recovery, for Lee, “was not easy in any way—physically, emotionally, mentally,” she says. After both surgeries, Lee’s movement was significantly circumscribed; she used a walker for ten days after each surgery, then a cane. And there was no running or driving for six weeks, and she had to go up and down stairs one foot at a time. “But the hardest part was not recognizing myself anymore,” says Lee, who, with a background in dance as well as yoga, was accustomed to leading an extremely active life. 

“Two surgeries so close together is more than a double whammy,” she says. “So my overall strength was completely gone, my flexibility was completely gone, and my physical confidence was completely gone. I waited too long to have the surgeries, and by the time I got to the first one, my hips were thoroughly degraded, and I had been in chronic pain and stress for nearly a year. I had a lot to recover from.”

During recovery, when movement is limited, the inner work of yoga, like mindfulness and pranayama, is still accessible and also beneficial. Lee says that “The most helpful thing for me in my recovery was my years of meditation. I was able to face the reality of what had happened to me. I didn’t like that I had titanium implants in my femurs. I didn’t like that I couldn’t move freely. But meditation helped me to stay with those feelings and face them and move beyond them, instead of going into anger and frustration.” 

Lee did gradually return to yoga again. “I started by exercising on my bed, lying on my back, then eventually sitting on the edge of the bed, then standing with one hand on the wall. Finally I got onto my mat.” But yoga was not her only healer: “The best thing was walking outside every single day.”

Approaching yoga slowly after surgery is allowed and important, according to longtime physical therapist Bill Reif, author of The Back Pain Secret: The Real Cause of Women's Back Pain and How to Treat It. Practicing yoga poses on your back and then seated in bed or on a chair, as Lee did, may be a good way to ease back into asana, as might some restorative poses, especially “restorative poses that are less demanding and allow you more time to enter and exit a pose,” Reif says. “Once you feel comfortable with these versions of yoga, you can progress to more standing and weight-bearing poses,” perhaps with a chair or wall nearby for support while getting up from and down to the floor.

Those recovering from hip replacement surgery are often advised to keep their hips neutral, toes and knees pointing forward, as they are in mountain pose (tadasana), for example. 

As students recover fully, they may be able to move farther away from neutral, but Reif cautions that “Extreme deviations from this neutral position may always put the prosthesis at risk.”

Like all surgeries, THR carries the risk of complications, one being dislocation, the loss of contact between the artificial ball of the femur and its cup. To avoid the slim but unwelcome chance of dislocation, it’s important to understand the movements that could increase risk. 

Preventing Dislocations After Hip Replacement Surgery

Once students have received the green light from their surgeons to resume a yoga practice—a few months to a year after the surgery—“The priority should be preventing dislocation,” Reif says. 

Dislocation occurs in perhaps two percent of patients in the year immediately after the procedure and is the most common reason for revision surgery.

While the risk of dislocation seems to be greatest in the first three months after surgery, it remains a long-term risk: The cumulative risk of dislocation rises by another one percent every five years thereafter, so someone who had surgery 25 years ago actually has a seven percent risk of dislocation.

Traumas like falls and car accidents can displace the prosthesis, and so can movements that are “dislocation-promoting.” Those with hip replacements are often given precautions to restrict certain movements in order to keep the prosthesis in place.

Though some studies challenge the necessity of post-surgical precautions and not all doctors give them—Lee’s doctor, for instance, did not tell her to restrict any movements—it’s important to recognize that yoga is unique in the demands it places on the hips. 

Since many poses move the hips into extreme ranges, Reif favors erring on the side of caution: “In the case of a major surgery such as THR, it’s better to be safe than sorry. Neither the student nor the instructor knows who might ‘get away’ with a more extreme movement. Don’t push past your limits, as the risks far outweigh any rewards.”

Reif says, “Some of these restrictions may last just a few months, some forever.” How much range of movement is restricted, and how long those restrictions last, depends on many, many variables, according to Reif, such as “the patient’s age, pre-surgical condition and activity level, and the surgeon’s perspective on post-op activity. The surgical approach also matters.” So it’s important that students get personalized medical advice.

Exactly which movements entail the most risk depends on the type of THR surgery. The two most common surgical methods are the posterior—or “Southern”—approach, in which the incision is made at the side of the hip behind the greater trochanter, and the anterior approach, in which an incision is made at the front of the hip. Each requires different yoga modifications. 

Yoga Adaptations: Posterior Approach

Hip replacement via a posterior approach may carry a slightly higher risk of dislocation than that via the anterior approach, so the restrictions are often a bit stricter. The movements that could be troublesome, according to Reif, are “extremes of flexion, adduction, and internal rotation.” 

Here’s how to translate certain precautions for a yoga practice:

Avoid hip flexion of 90 degrees or greater.

“This means no forward folds so deep that you round the lower back,” Reif says. For those who have received this advice, it’s important to keep a right angle (or greater) between the thighs and the torso.

More yoga poses than you might realize bring the thighs and torso closer than this recommended maximum: deep squats, figure four pose, humble warrior, many standing and seated twists, crow/crane pose (kakasana/bakasana), plow pose (halasana), happy baby pose (ananda balasana), hugging one or both knees into the chest, and child’s pose (balasana). 

Transitions can be risky, too: For one 43-year-old woman who had had THR via the posterior approach 17 years previously, the plow-like transition into shoulderstand (sarvangasana) caused a hip dislocation, and transitions into other inversions, like headstand (sirsasana) and forearm balance (pincha mayurasana), may necessitate that the legs and spine come closer together than is safe. Likewise, stepping a foot forward from downward facing dog (adho mukha svanasana) into a lunge can be risky.

Instead: When forward-folding, stop at the halfway point, choosing a half standing forward bend (ardha uttanasana) instead of a full one (uttanasana), and staff pose (dandasana) over a seated forward fold (paschimottanasana). If your knees are higher than your hips and your back rounds in any seated position, sit on support so your knees can drop below them. Stay up high in squats and pick puppy pose (anahatasana) over child’s pose. Practice supine figure four with the bottom foot on the floor, instead of bringing your knees toward your chest. Transition into inversions like shoulderstand by walking your feet up a wall instead of swinging your legs overhead, and transition into standing poses from mountain pose rather than from downward facing dog.

Don’t adduct your hips past the midline.

This precaution means “No crossing the leg that was operated on over the other leg,” says Reif. Skip eagle pose (garudasana), twists with eagle pose legs, and cow face pose (gomukhasana). The legs also cross in side plank (vasisthasana) if you step one foot in front of the other for support, and in the seated twistardha matsyendrasana. Also avoid drawing your leg across the midline if you’re lying down and using a strap to extend one leg to the ceiling or out to the side in reclining big toe pose (supta padangusthasana).

Instead: Practice eagle by just doing the arms, keeping your legs in chair pose (utkatasana) position, and do cow face arms while seated in a comfortable version of thunderbolt pose (vajrasana).

Limit hip internal rotation.

For those who have had hip replacement surgery via the posterior approach, deep internal rotation—turning the legs inward into a pigeon-toed stance—is often contraindicated. 

Examples of potentially undesirable internal rotation, according to Reif, include W sitting, or hero pose (virasana), and windshield-wipering the knees with the feet wide apart. 

Instead: Instead of hero pose, sit in thunderbolt pose, placing a bolster across your calves if that makes the pose more comfortable, or substitute a seated pose that works better for you, like easy seat (sukhasana), staff pose, or sit in a chair if you prefer. When windshield-wipering your legs, keep your feet and knees close together, so that the bottom leg prevents the top leg from dropping so close to the floor.

Yoga Adaptations: Anterior Approach

An anterior approach is less invasive and generally requires fewer precautions, but limits are often advised in hip hyperextension (moving the hip back in space, as in a backbend), and hip external rotation or “hip opening.”

Here’s how to translate the common precautions for hip replacements via the anterior approach for a yoga practice:

Limit hip hyperextension.

Hip hyperextension occurs when the femur moves behind the pelvis; the back leg hyperextends slightly during walking, but many yoga poses ask for much more hip hyperextension than that.

For someone who had a hip replacement via the anterior approach, “It would be difficult to know how far back the rear leg could safely go in a yoga pose, but no more than normal walking gait stride would be a good guide,” Reif says.

Poses that may not be a good idea include backbends like wheel (urdhva dhanurasana), as well as cobra (bhujangasana), upward facing dog (urdhva mukha svanasana), dancer pose (natarajasana), and bow pose (dhanurasana), though low sphinx and bridge pose (setu bandha) would probably work for many. Likewise, according to a movement analysis, warrior I (virabhadrasana), warrior II (virabhadrasana II), crescent lunge, pigeon pose (eka pada raja kapotasana), and triangle pose (trikonasana) all place stress on extended hips. An upright lunge with the back knee on the floor also could extend the hip as the pelvis moves forward in front of the back knee.

Instead: Warrior poses, and other standing poses that bring one leg back, can be shortened to limit the extension. When in a lunge with your back knee down, keeping your pelvis above your bottom knee will prevent too much extension.

Limit hip external rotation.

“Skip or modify poses in which the toes and legs turn out to an extreme,” Reif says. While students may regain enough hip mobility after the surgery to turn the toes out somewhat, deep squats, lotus pose (padmasana), fire log pose (agnistambhasana), easy seat, pigeon pose, figure four, head to knee pose (janu sirsasana), and bound angle pose (baddha konasana) are all poses that, in their fullest expression, require external rotation that Reif would deem “extreme.” Even warrior II and similar poses practiced with strict heel-to-arch alignment and without allowing the back foot to turn in would require a deep external rotation of the front leg (in order to point the front knee toward the center of the front foot). 

Instead: When squatting, take your feet wide, and point your feet outward only slightly. In seated poses like head to knee pose or bound angle, “Move your feet farther forward, away from your hips, and pad your knees to lift them away from the floor,” Reif advises. When hugging the knees to the chest, keep the knees close together instead of letting them open to the sides. Lessen the external rotation required by warrior II by turning the back foot in and stepping it forward toward the long side of the mat.

Safe Practices

Reif says that for those with hip replacements, “The goal is to safely stay within allowed ranges while building core strength and gaining hip mobility.”

A practice that could work for both types of hip replacements is one that skips extreme hip movements, risks of falling are minimized, and hip abduction—the movement of the legs out to the sides—is emphasized. Abduction seems to carry little risk for those who have had THR surgery and is in fact a regular part of some postoperative recovery programs. Strength in the abductors may be worth cultivating because deficiency in these muscles may be a factor in dislocation of the hip prosthesis.

“A movement that abducts the hips is lying down on the floor or in bed and making snow angels, keeping the toes pointing up,” Reif says. 

A gentle practice that accommodates various hip precautions could include lying on your back for the abovementioned snow angels, supine leg stretches with the help of a strap (being mindful to avoid extremes), then coming to all fours for cat/cow and core-strengtheners like bird dog and plank. 

From mountain pose and chair pose, you could do arm and shoulder work, then practice “short-stance versions” of poses like warrior I. You could work on balancing—with support nearby—by marching in place. Calming poses could include staff and fish pose (matsyasana), and, of course, savasana. 

Resilience in Practice

Though far from an enjoyable experience, Lee’s hip replacement has not been without its compensations. “Compassion is something that naturally grows from one’s own pain and is a great thing to transmit as a yoga teacher,” she says. “Also, impermanence, interdependence, patience, letting go—these are all things that have been very vibrant in my hip replacement saga.”

Lee has also adapted to a changed reality. “I am never going to be the way I was before,” she says. “This is just the truth. We sometimes get this thought, that if/when I get back to how I was, then things will be better. But every day we age and grow, and we are never going to be the way we were before.” Now Lee is able to say, “At this point, I don’t wish to be as I was before. I wish to be my most awesome now.”

And her practicing is still evolving and expanding. “Every week I am finding myself in another pose that I haven’t done for eons and that is fun and feels great. Yoga is opening back up to me, in my own time or, you could say, in the fullness of my healing time.”