Following a periacetabular osteotomy (PAO), it is important to adhere to your surgeon’s protocol for weight-bearing and return to activity. During recovery, you will encounter terms such as non-weight-bearing, touch-toe weight-bearing, foot-flat weight-bearing, partial weight-bearing, weight-bearing as tolerated, and full weight-bearing.
This resource will define those terms, explain the purpose of each type of weight-bearing, and review the risk of doing too much weight-bearing too soon.
This resource is for educational purposes. Patients should discuss their specific weight-bearing precautions with their surgeon or physical therapist, deferring any questions or concerns to their care team.
Definitions:
1. Non-weight-bearing (NWB): the affected leg does not touch the floor or support bodyweight
2. Touch-toe weight-bearing (TTWB): the toes of the affected leg may touch the ground to maintain balance; however, weight should not be pushed through the leg.
3. Foot-flat weight-bearing (FFWB): the foot of the affected leg may rest flat on the ground through gait; however, weight should not be pushed through the leg. This helps to protect the hip flexor as the leg is not being held up while crutching during the gait cycle.
4. Partial weight-bearing (PWB): the patient is allowed to put some weight through the affected leg (usually 25% body weight), gradually increasing as directed by surgeon protocol
5. Weight-bearing as tolerated (WBAT): the patient is cleared to bear up to 100% body weight through the affected leg as tolerated, adjusting based on symptoms and pain
6. Full weight-bearing: the patient’s total body weight can be supported on the affected leg
Why is it important to follow my weight-bearing precautions after surgery?
The post-surgical instructions you receive from your medical team are given to keep you safe during recovery, as well as optimize healing of the osteotomy sites and soft tissues.
Bone Healing and Weight-Bearing:
Modified weight-bearing is used to prevent post-operative complications such as stress fractures. A stress fracture is a small break in the bone that can develop after surgery due to abnormal stress. Studies show that full weight-bearing immediately after surgery leads to a higher incidence of stress fractures, whereas modified weight-bearing for approximately two months decreases that risk.
After a PAO, weight-bearing forces are directed differently throughout the hip socket compared to before the surgery. Prior to a PAO, most of the force from walking and movement normally travels through the upper part of the pubic bone (superior pubic ramus). However, due to the structural changes to the hip socket after a PAO, more of that force gets carried through the lower part of the pubic bone (inferior pubic ramus), as well as other areas like the ischium (your “sit bone”) and the back portion of the pelvic bone. This change can cause increased stress on the bones, which is why modified weight-bearing is important initially.
If you had a hip arthroscopy or additional procedure with your PAO, weight-bearing precautions may be different than standard PAO rehab recommendations to protect the joint capsule or other structures healing from the additional surgery.
Soft Tissue Healing and Weight-Bearing
Post-operative rehab guidelines are designed to minimize overloading the muscles that stabilize the hip joint early in recovery. A muscle called the iliopsoas, or the major “hip flexor,” sits in front of the femoral head and helps to stabilize the hip joint. With hip dysplasia, the iliopsoas can experience greater stress as it compensates for the decreased joint stability, leading to inflammation. After a PAO, sometimes the iliopsoas can become irritated by the osteotomy site on the pubic bone, possibly contributing to more irritation of the hip flexor tendon. Therefore, it is especially important to avoid excessive hip flexor activation early in recovery. Foot-flat weight-bearing may be less straining on the iliopsoas compared to toe-touch or full non-weight bearing (where the affected leg is being held up during crutching).
Question and Answer Section: Post-Operative Weight Bearing
What happens if I accidentally put weight through my leg too early?
Accidentally bearing weight briefly usually will not cause harm; however, repeated or excessive early weight-bearing can delay healing or lead to complications like stress fractures. If it happens, inform your care team, especially if you feel pain afterwards.
What is the difference between touch-toe and foot-flat weight-bearing?
With touch-toe weight-bearing, only your toes make light contact with the floor for balance. With foot-flat weight-bearing, your whole foot is allowed to rest on the ground to for balance and to reduce tension on your hip flexor, but you still should not press weight through the leg.
What if I feel ready to do more than my protocol allows?
It is normal to feel eager or even frustrated during recovery; however, bones take time to heal. Doing too much too soon can delay your progress, so it is critical to follow the protocol and your medical team’s guidance.
Can I sleep on my side?
Ask your medical team first, but many surgeons allow sleeping on your non-operative side with pillows between your knees for support. Avoid sleeping directly on the operated side early on unless given clearance by your doctor.
Will I need help at home after surgery?
Most patients benefit from having help at home during the first few weeks, especially with cooking, cleaning, laundry, or navigating stairs. If you live alone, talk with your care team about resources for support.
Why do I feel sore in my arms, shoulders, and non-operative leg while using my crutches or walker?
Using mobility devices like crutches or a walker shifts the workload to your upper body and non-operative leg, which can lead to soreness, especially early on. Make sure your mobility aids fit properly and consider asking your physical therapist or occupational therapist for some stretches to reduce strain. You can also check out our video by Alexis Duckworth-Briggs on self-management strategies for releasing upper back, arm, hand, and wrist strain while using assistive devices: https://youtu.be/m4uwUropNxw
For specific home safety tips while you have weight-bearing restrictions after surgery, refer to our resource: Hip Surgery Home Safety Tips – Miles4Hips
Author: Lauren Schoeller
References:
Anderson TB, Duong H. Weight Bearing. [Updated 2023 May 1]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2025 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK551573/
Disantis AE, Ruh E, Martin R, Enseki K, McClincy M. Rehabilitation Guidelines for Use Following a Periacetabular Osteotomy (PAO): A North American Based Delphi Consensus. Int J Sports Phys Ther. 2022 Oct 2;17(6):1002-1015. doi: 10.26603/001c.38043. PMID: 36237641; PMCID: PMC9528724.
Disclaimer: The information on the Miles4Hips website is meant for informational purposes only. While our goals are to promote understanding and knowledge of hip dysplasia and to empower patients and their families in healthcare decision making, we cannot guarantee accuracy or appropriateness of the information for your specific condition or circumstances. The information on this site is not meant to take the place of the professional judgment of your medical providers. Individuals should always seek the advice of your physician/surgeon, physical therapists, and other qualified health care provider with any questions you may have regarding a medical condition or treatment. Individuals should never disregard the advice of your medical providers or delay in seeking it because of something you have read on this website.