Pilates for Hip and Knee Arthritis - Before and After Joint Replacement
Updated: Oct 6
By Katherine, Lead Instructor, Certified Pilates Instructor
Pilates can be a reasonable, low-impact way to stay active with knee arthritis or after a joint replacement, but it is not proven to beat other exercise. For knee osteoarthritis the evidence is low to very low certainty, and we found no Pilates-specific review for the hip. After surgery, your surgeon sets the timing and any movement restrictions, not the studio.
Key takeaways
For knee osteoarthritis, a 2025 meta-analysis of 8 trials (322 people) found Pilates did better than no treatment but showed no significant difference from other exercise, and the certainty of the evidence was low to very low (Zhang et al., 2025).
For hip osteoarthritis, we did not find a dedicated Pilates review, so we make no claim about it. Exercise in general does have supporting evidence.
After a hip or knee replacement, follow the timeline and restrictions from your surgeon and physiotherapist. Those can differ with the surgical approach.
Kneeling and deep knee bending often need changes after a knee replacement.
Tell your Pilates instructor about your joint, your surgery date and any restrictions before the first session.
Does Pilates help knee arthritis?
Osteoarthritis (OA) is a long-term joint condition in which the cartilage gradually thins and the joint changes, which can cause pain, stiffness and reduced movement. The best Pilates-specific evidence for knee OA is a 2025 systematic review with meta-analysis of 8 randomized controlled trials involving 322 people (Zhang et al., 2025). Compared with no treatment, Pilates reduced scores on the WOMAC, a questionnaire that rates knee pain, stiffness and function. One trial compared Pilates with health education and found a drop in pain and WOMAC scores.
The most important finding is the third comparison. Against other types of exercise, Pilates showed no significant difference in pain, WOMAC scores or knee range of motion. In plain terms, Pilates appears to help compared with doing nothing, and to perform about as well as other exercise, not better.
The authors rated the certainty of the evidence as very low for pain and WOMAC scores, and low for range of motion. The trials were small, results varied widely between them, and the pattern suggested possible publication bias (positive studies being more likely to appear in print). No adverse events were reported, but only two of the eight trials said they actively monitored for them, so safety is still uncertain. The Pilates programs in these trials were short, typically 2 to 3 sessions a week for 6 to 8 weeks.
This sits inside a much larger body of research on exercise generally. A Cochrane review of 54 trials found that land-based therapeutic exercise reduces knee pain and improves function, with moderate effects right after treatment and smaller effects 2 to 6 months later (Fransen et al., 2015). A summary of the 2019 American College of Rheumatology and Arthritis Foundation guideline lists exercise as a first-line approach for knee and hip OA and notes that no particular type of exercise is superior (Buelt and Narducci, 2021). The best exercise for arthritic joints is the one you can do regularly and your joints tolerate.
This post is part of our healthy aging series. For the broader picture of strength, balance and safe progression, see our guide to Pilates after 50.
What about hip arthritis?
We did not find a Pilates-specific systematic review or meta-analysis for hip OA, so we cannot tell you that Pilates helps hip arthritis, and we will not pretend otherwise. What exists is evidence for exercise as a group. A Cochrane review of 10 trials of land-based therapeutic exercise in people with hip OA found it reduced pain and improved physical function, with benefits that lasted at least 3 to 6 months after supervised treatment ended. The review examined land-based exercise broadly, not Pilates in particular (Fransen et al., 2014).
If your hip pain is new, severe or getting worse, see your doctor or physiotherapist before starting any exercise program.
Should you do Pilates before a joint replacement?
Strengthening before surgery is often called prehabilitation, or "prehab." A 2022 meta-analysis of 5 trials (256 people having knee or hip replacement) found that progressive resistance training before surgery improved sit-to-stand performance, walking speed and knee extensor strength in the months afterwards. The certainty was low to very low, and the authors noted that the best loading, duration and training volume are still unknown (Jørgensen et al., 2022).
That review studied resistance training, not Pilates, so it does not show that Pilates works as prehab. If you are waiting for surgery, ask your surgeon or physiotherapist whether a prehab program is appropriate, what to avoid and whether Pilates can be part of it.
When can you start Pilates after a hip replacement?
There is no universal date, and your surgeon decides it. Recovery from a hip replacement takes many months, and the American Academy of Orthopaedic Surgeons advises checking with your therapist or surgeon before trying exercises, with early exercises progressing to more advanced ones as your strength improves (OrthoInfo, AAOS). Pilates usually belongs after your rehabilitation with your physiotherapist, once you have been cleared, rather than replacing it.
Movement precautions are where instructions vary most. Surgeons often give restrictions (for example, limits on bending the hip past a certain angle or crossing the legs), and the right ones depend partly on how the surgery was done. Practice also differs between hospitals and between countries (Crompton et al., 2020). A systematic review of 7 studies and 6,900 people after posterior-approach hip replacement found dislocation in 2.2% of people with precautions and 2.0% of those without, which was not a significant difference. Only 2 of the studies were randomized, and the review covered only posterior-approach surgery, so it cannot speak to other approaches (Crompton et al., 2020). A 2023 review of 4 randomized and 5 non-randomized studies (8,835 people) similarly found the evidence does not support routinely prescribing precautions after posterior-approach surgery, while stating that results might change with high-quality studies. The certainty was low for randomized trials and very low for the others (Korfitsen et al., 2023).
These reviews inform your surgeon's decisions, not yours. Keep following the precautions you were given until your surgeon tells you otherwise, and tell your instructor what they are.
Pilates after a knee replacement: kneeling and deep bending
AAOS advice is that your orthopaedic surgeon and physical therapist supervise your exercise progression and that you should check with them before trying exercises (OrthoInfo, AAOS). The NHS adds that full recovery can take several months or longer, with a hospital follow-up around 6 weeks after the operation (NHS).
Two movement types need particular care:
Kneeling. The NHS advises that you do not kneel on your new knee until your doctor says you can (NHS). Kneeling often stays difficult: a meta-analysis of 36 studies found that 36.8% of patients could kneel at a minimum of one year after surgery and 47.6% at a minimum of three years, so many people still cannot kneel years later, although it tends to improve over time (Nadeem et al., 2021). Many Pilates exercises involve kneeling, so expect standing, side-lying, seated or lying-down alternatives.
Deep bending and impact. Deep squats, deep lunges and loaded end-range knee bending may be uncomfortable or restricted, and your surgeon can tell you your limits. The AAOS advises avoiding high-impact activities such as jumping, jogging or skiing, and continuing the exercises your physical therapist prescribes for at least 2 months after surgery (OrthoInfo, AAOS).
Reformer considerations for arthritic or replaced joints
On the reformer, springs can assist or lightly resist a movement, and you can work lying down with your weight supported; our guide to reformer Pilates covers how the equipment works. For hip and knee joints, these details matter and should be personalized:
Footbar work means pressing out and returning against spring resistance from bent hips and knees. With the carriage close to the footbar, the hips can bend past 90 degrees, which matters if you have hip precautions. Range, spring load and the depth of the bend can all be reduced.
Kneeling on the carriage is common in reformer repertoire and may need to be replaced or padded, depending on your clearance.
Deep hip bending and rotation, such as legs in straps drawing close to the chest or wide, turned-out positions, can conflict with hip precautions.
Getting on and off the carriage is a movement in itself, and your instructor can set up the machine to make it easier.
Pain, swelling or warmth at a joint during or after a session is a reason to pause, not push on.
We are not aware of trials comparing reformer and mat Pilates for arthritis or joint replacement, so the choice is individual, and our comparison of reformer and mat Pilates covers the general differences. In our sessions we adapt exercises to you, and we work alongside your health care provider.
Why a surgeon and physiotherapist come first
Your surgeon knows your approach, your implant and how your repair is healing. Your physiotherapist can assess your range, strength and walking and set goals for each stage. Pilates is best added once they have cleared you, and our comparison of Pilates and physiotherapy explains how the two fit together.
Bring any written instructions from your surgeon or physiotherapist to your first session so your instructor can build around them. Because restrictions and symptoms are individual, starting one-to-one often makes sense, and our guide to private versus group Pilates explains the trade-offs.
Safety note: This article is general information, not medical advice, and it does not replace an individual assessment. Talk to your family doctor, orthopaedic surgeon or physiotherapist before starting Pilates with arthritis, before surgery or at any stage of recovery from a joint replacement. Seek medical help promptly for signs of infection (fever, a wound that is increasingly red, swollen or draining) or of a blood clot (throbbing or cramping leg pain, or pain and swelling in the leg), as described by the NHS (NHS). Call 911 or go to the nearest emergency department for chest pain or sudden difficulty breathing. Stop exercising and contact your surgeon's team or your doctor if you have sudden sharp joint pain, a joint that feels unstable or gives way, new swelling or warmth, or if you cannot bear weight on the leg. Our instructors are not physiotherapists and do not diagnose or treat medical conditions.
Working on your joints with us in Markham
If you have hip or knee arthritis, or you are cleared to exercise after a joint replacement, a one-to-one session lets your instructor adapt every exercise to your restrictions. Private 1:1 Pilates with Instructor (1 hr) and Private 1:1 Pilates with Lead Instructor (1 hr) are both available at our Markham studio, and we welcome clients from across York Region. Book a private session online.
Frequently asked questions
Do I have to wait for my surgeon's clearance before booking?
Yes. Please talk to your surgeon or physiotherapist first, because they know your approach, your implant and your healing. If they have given you written restrictions, bring them to your first session.
Is Pilates better than other exercise for knee arthritis?
No. In the 2025 meta-analysis, Pilates was not significantly different from other exercise types for pain, WOMAC scores or range of motion (Zhang et al., 2025). Choose the form of exercise you will keep doing.
Is some pain normal when I exercise with arthritis?
Some soreness can happen when you start. In the Cochrane reviews, the adverse events reported in trials of exercise for knee and hip OA were all related to increased pain, and no serious adverse event was reported in the knee review (Fransen et al., 2015; Fransen et al., 2014). Sharp pain, swelling, heat or a joint that feels unstable is different: stop and tell your instructor and your health care provider. For more on normal muscle soreness, see our post on being sore after Pilates.
Sources
Zhang K, Li Y, Zhao F, Xie X, Yan S, Kong D, Zhang W, Zhou J, Ma H (2025). The efficacy and safety of Pilates exercise in patients with knee osteoarthritis: a systematic review with meta-analysis of randomized controlled trials. Annals of Medicine, 57(1). https://pmc.ncbi.nlm.nih.gov/articles/PMC12337744/
Fransen M, McConnell S, Harmer AR, Van der Esch M, Simic M, Bennell KL (2015). Exercise for osteoarthritis of the knee. Cochrane Database of Systematic Reviews, CD004376. https://pubmed.ncbi.nlm.nih.gov/25569281/
Fransen M, McConnell S, Hernandez-Molina G, Reichenbach S (2014). Exercise for osteoarthritis of the hip. Cochrane Database of Systematic Reviews, CD007912. https://pubmed.ncbi.nlm.nih.gov/24756895/
Buelt A, Narducci DM (2021). Osteoarthritis Management: Updated Guidelines from the American College of Rheumatology and Arthritis Foundation. American Family Physician, 103(2), 120-121. https://www.aafp.org/pubs/afp/issues/2021/0115/p120.html
Jørgensen SL, Kierkegaard S, Bohn MB, Aagaard P, Mechlenburg I (2022). Effects of resistance training prior to total hip or knee replacement on post-operative recovery in functional performance: a systematic review and meta-analysis. Frontiers in Sports and Active Living, 4:924307. https://pmc.ncbi.nlm.nih.gov/articles/PMC9329591/
Crompton J, Osagie-Clouard L, Patel A (2020). Do hip precautions after posterior-approach total hip arthroplasty affect dislocation rates? A systematic review of 7 studies with 6,900 patients. Acta Orthopaedica, 91(6), 687-692. https://pmc.ncbi.nlm.nih.gov/articles/PMC8023879/
Korfitsen CB, Mikkelsen LR, Mikkelsen ML, et al. (2023). 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, 94, 141-151. https://doi.org/10.2340/17453674.2023.11958
American Academy of Orthopaedic Surgeons. Total Hip Replacement Exercise Guide. OrthoInfo. https://www.orthoinfo.org/en/recovery/total-hip-replacement-exercise-guide/
American Academy of Orthopaedic Surgeons. Total Knee Replacement Exercise Guide. OrthoInfo. https://www.orthoinfo.org/en/recovery/total-knee-replacement-exercise-guide/
American Academy of Orthopaedic Surgeons. Activities After Knee Replacement. OrthoInfo. https://www.orthoinfo.org/recovery/activities-after-knee-replacement/
NHS. Knee replacement: recovery. https://www.nhs.uk/conditions/knee-replacement/recovery/
NHS. Knee replacement: complications. https://www.nhs.uk/conditions/knee-replacement/complications/
Nadeem S, Mundi R, Chaudhry H (2021). Surgery-related predictors of kneeling ability following total knee arthroplasty: a systematic review and meta-analysis. Knee Surgery & Related Research, 33(1), 36. https://pubmed.ncbi.nlm.nih.gov/34600595/
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