What Muscles Are Affected During a Posterior Hip Replacement?

Key Takeaways

• Posterior hip replacement usually splits the gluteus maximus along its fibres and releases selected short external rotator tendons and the posterior capsule to access the joint.
• The gluteus medius and minimus are generally preserved, while the released tendons and capsule are commonly repaired before the wound is closed.
• Temporary soreness, weakness, or limping can reflect healing, preoperative deconditioning, and altered gait rather than permanent muscle damage.
• Recovery guidance varies by technique, so patients should follow their surgeon’s precautions and ask which tissues were released, repaired, and need protection during rehabilitation.

If you’re preparing for a posterior hip replacement, you’ve probably heard some version of “the muscles get cut” — a phrase that’s technically not wrong, but vague enough to sound more alarming than it needs to be. Which muscles, exactly? Are they cut all the way through, or just moved aside? Do they grow back? Is this why some surgeons recommend avoiding certain movements afterward?

Here’s a clearer, more accurate picture: during a conventional posterior hip replacement, the gluteus maximus is usually split in line with its fibres, while selected short external rotator tendons and the posterior joint capsule are released to allow the surgeon to enter the hip. The gluteus medius and minimus — the main hip abductor muscles — are generally preserved. The released tendons and capsule are commonly repaired at the end of surgery, though the exact technique varies between surgeons. This article walks through exactly what’s involved, layer by layer, so you understand what’s actually happening rather than relying on an oversimplified phrase.

The short answer

Before getting into the details, here’s the key picture in summary.

• The gluteus maximus is usually split along its natural fibre direction, not cut across it
• Selected short external rotator tendons are released from their attachment on the femur
• The posterior joint capsule is opened to allow access to the hip
• The gluteus medius and minimus — your main hip abductors — are generally preserved
• The released capsule and tendons are commonly repaired before the wound is closed

Patients who want a broader understanding of posterior hip replacement may find it helpful to learn how the surgeon reaches the joint, repairs the affected tissues, and supports recovery afterward. This context can make the muscle anatomy easier to understand, particularly when comparing the procedure with anterior or lateral approaches and discussing which technique may suit an individual patient.

Why does the surgeon need to move or release these tissues?

Your hip joint sits deep within the pelvis, surrounded by layers of muscle, tendon, and fibrous tissue that exist for good reason — they stabilise and move your hip. To reach the joint safely and replace it, your surgeon needs a clear path to:

• Access and dislocate the femoral head
• Prepare the acetabulum, or socket, to receive the new implant
• Prepare the femur to receive the new stem
• Achieve stable, accurate placement of both components
• See enough of the joint to do all of this safely

The posterior approach achieves this by working through the back of the hip, moving through specific tissue layers in a deliberate, structured sequence.

The tissue layers involved

Understanding the operation as a series of layers, rather than one vague “cutting” event, makes it much easier to picture what’s actually happening.

• Skin and the underlying subcutaneous tissue
• The fascia, a fibrous layer overlying the gluteus maximus
• The gluteus maximus muscle itself
• The trochanteric bursa is a fluid-filled sac that allows tissues to glide smoothly over the greater trochanter
• The gluteus medius, which is identified and protected rather than divided
• The short external rotator muscles and their tendons
• The posterior joint capsule
• The sciatic nerve, which runs nearby and is carefully identified and protected throughout

What happens to the gluteus maximus?

The gluteus maximus is the largest muscle in your buttocks, and it plays an important role in hip extension and external rotation — it’s heavily involved in standing up from a chair, climbing stairs, and walking uphill.

During a standard posterior approach, this muscle is generally split along the natural direction of its fibres, rather than cut across its width or detached from its bony attachments at the pelvis and femur. This is a meaningfully different type of disruption to a transverse cut — think of it more like parting the fibres than severing them. At the end of surgery, this split layer is closed back together. It’s genuinely normal to experience soreness and some temporary weakness in this muscle afterward, and this doesn’t indicate permanent damage.

Which short external rotators may be affected?

The short external rotators are a group of small, deep muscles that sit behind the hip joint and contribute to fine rotational control. Depending on your surgeon’s specific technique, some or all of the following may be involved.

Piriformis

Often, one of the tendons is released to access the joint, though some modified posterior techniques specifically aim to preserve it.

Obturator internus

Commonly involved in the standard posterior approach.

Superior and inferior gemelli

These small muscles work alongside the obturator internus and may be affected depending on the technique.

Obturator externus

May or may not be directly involved, depending on the specific approach and exposure needed.

Quadratus femoris

Sometimes involved, depending on how much exposure is required.

It’s worth understanding that the exact combination of tendons released genuinely varies between surgeons and techniques — not every posterior procedure affects every one of these structures identically, so it’s reasonable to ask your own surgeon which specific tendons their technique involves.

Are the gluteus medius and minimus cut?

Generally, no. In a standard posterior approach, the gluteus medius is identified and carefully protected during the procedure, rather than being detached from its attachment. This is an important distinction, because the gluteus medius and minimus are your primary hip abductor muscles — they’re what stabilise your pelvis during walking and single-leg standing.

This is one of the genuine differences between posterior and direct lateral hip replacement, since the lateral approach more commonly involves splitting or partially detaching this abductor mechanism. That said, preserving the attachment doesn’t guarantee these muscles will feel strong immediately after surgery — weakness can still occur for reasons unrelated to whether the tendon itself was cut, which is covered further below.

What happens to the posterior capsule?

The joint capsule is a fibrous envelope surrounding the hip joint that contributes significantly to its stability — it isn’t a muscle, but it’s an important structure in its own right. To access the joint, the posterior portion of this capsule is opened, a step called a capsulotomy. At the end of the procedure, this capsule is commonly repaired alongside the short external rotator tendons, and this repair contributes meaningfully to your hip’s overall stability during early healing. This is also part of the reason certain movement precautions may be recommended in the weeks after surgery — they’re protecting this healing repair, not just the implant itself.

How are the tendons and capsule repaired?

Once the new joint components are in place, your surgeon repairs the released structures using one of several possible techniques.

• Sutures passed through small bone tunnels drilled in the greater trochanter, sometimes called a transosseous repair
• Suture anchors are placed directly into the bone
• Direct tendon-to-tendon or tendon-to-capsule repair techniques
• A combined repair addressing both the capsule and the rotator tendons together

The specific method used depends on your individual surgeon’s preference and the quality of your tissue during surgery — not every patient receives an identical repair technique, and it’s a reasonable question to ask your surgeon directly.

Why are precautions sometimes recommended?

Some surgeons recommend avoiding certain hip positions in the weeks following surgery, and understanding why can make these instructions feel more meaningful rather than arbitrary.

• Hip flexion beyond a certain point, often around 90 degrees
• Internal rotation of the hip
• Adduction, or moving the leg across the midline of the body
• Combined positions, such as flexion together with internal rotation, which place particular stress on the repair

These precautions exist to protect the healing capsule and tendon repair while it develops biological strength. That said, protocols genuinely vary — some surgeons use fewer or no formal precautions, particularly where a secure repair has been achieved, and modern implant designs offer additional stability. Your own surgeon’s specific instructions should always take priority over generic guidance.

Does the repair reduce dislocation risk?

A well-performed repair of the posterior capsule and short rotator tendons does genuinely contribute to hip stability during recovery. However, dislocation risk depends on several factors working together, not the soft-tissue repair alone.

• The accuracy of component positioning
• The size of the femoral head used
• Your individual spinopelvic mechanics — how your pelvis and spine move together
• Any neuromuscular conditions affecting your movement control
• How well you follow any recommended precautions during early healing

No hip replacement, regardless of approach or repair quality, has zero dislocation risk — but a secure posterior repair is a meaningful contributor to overall stability.

Does posterior replacement cause permanent muscle weakness?

For most patients, no. Some degree of temporary weakness and soreness is expected as your body heals from the surgery itself, quite separate from any specific structural damage. This temporary inhibition typically improves steadily with time and structured rehabilitation. Persistent, non-improving weakness is not the usual course, and if you notice this, it’s worth raising with your surgeon or physiotherapist rather than assuming it’s simply how things will remain.

Why might you limp after surgery?

A lingering limp can be genuinely frustrating, and it’s worth understanding that it doesn’t automatically mean your abductor muscles were surgically affected — in a standard posterior approach, they generally weren’t.

• Ongoing pain can affect how confidently and normally you walk
• Gluteus maximus weakness, related to the muscle-splitting itself, can take time to resolve
• Longstanding weakness in the abductor muscles from years of arthritis and reduced activity before surgery, even though the tendon attachment itself was preserved
• Habitual gait patterns developed before surgery don’t disappear immediately just because pain has improved
• Balance concerns that haven’t fully resolved yet
• A perceived difference in leg length
• Progressing your walking distance or reducing walking aids more quickly than your muscles are ready for
• Pain or stiffness in another joint affecting your overall walking pattern

Posterior versus anterior versus lateral muscle effects

Each major hip replacement approach affects a different set of tissues, which is a more useful way to compare them than asking which one is simply “better.”

• Posterior — commonly affects the gluteus maximus, which is split along its fibres, along with selected short external rotator tendons and the posterior capsule, both of which are released and then repaired. The main hip abductor attachment is generally preserved.
• Anterior — works through an interval between anterior muscle groups, still involves capsular work and tissue retraction, and may require selective deeper releases depending on exposure. It generally preserves the posterior rotators and the gluteus maximus.
• Lateral — commonly involves part of the gluteus medius and minimus mechanism, while generally preserving the posterior rotators.

None of these approaches is free of soft-tissue involvement — they simply involve different structures, in different ways, each with their own genuine considerations.

Are minimally invasive posterior approaches different?

Yes, to varying degrees. Several modified posterior techniques exist, aiming to reduce the amount of tissue disrupted during surgery.

• The mini-posterior approach, using a more limited incision and dissection
• The direct superior approach, which aims to further limit soft-tissue disruption
• Piriformis-sparing techniques, which specifically try to preserve this particular tendon
• SuperPATH and other branded modifications
• Various capsule-sparing adaptations

These modifications may genuinely preserve more tissue than a conventional posterior approach, but they are not all identical to one another, and the evidence supporting each specific variant differs. It’s worth asking your surgeon directly whether they use a conventional posterior technique or one of these modified approaches, and what that means specifically for your surgery.

Are primary and revision surgery different?

Yes, often meaningfully so. Revision hip replacement — addressing a previous hip replacement rather than a first-time procedure — commonly requires more extensive soft-tissue work, including:

• Broader exposure of the gluteus maximus
• Removal of scar tissue from the previous surgery
• More extensive release of the rotator tendons and capsule
• Greater femoral exposure to remove and replace existing components
• Bone reconstruction in cases involving bone loss

The standard description of a primary posterior hip replacement doesn’t necessarily apply in the same way to a revision procedure, which is worth understanding if you’re facing a second surgery.

Rehabilitation after posterior hip replacement

Recovery of these specific tissues follows a fairly predictable general pattern, though the exact pace varies between individuals.

Hospital phase

Early walking with an aid, safe bed and chair transfers, gentle gluteal muscle activation, and practising safe turning technique.

First several weeks

Protecting the repair according to your specific instructions, gradually increasing your walking distance, working on restoring hip extension and balance, and avoiding compensatory limping patterns where possible.

Later strengthening

Progressive gluteus maximus and abductor strengthening, functional sit-to-stand practice, stair work, balance training, and a structured return to work and recreational activities.

When should weakness or pain be assessed?

Certain patterns are worth raising with your surgical team rather than assuming they’ll simply resolve on their own.

• Symptoms that are genuinely worsening, rather than gradually improving over time
• A new loss of function you hadn’t experienced before
• New numbness or weakness in the foot or leg
• Severe buttock pain
• A new inability to bear weight
• A limp that is persistent and not showing any improvement over a reasonable period

Patient scenarios

These examples show how understanding the actual anatomy involved can change how you interpret your own recovery.

An active adult concerned about muscle cutting

This patient learns that the gluteus maximus is split along its fibres and the tendons are repaired afterward — a considerably less alarming picture than the entire buttock muscle being severed, which is what “muscles are cut” had implied to them beforehand.

Older patient with longstanding weakness

Recovery takes longer here largely because the muscles were already weak before surgery, not because the surgical repair has failed in any way.

Patient with a persistent limp

This patient may still need a gait and abductor strength assessment, even though the abductor muscles themselves were never directly detached during their surgery.

Revision patient

This patient’s surgery may have involved considerably more extensive soft-tissue disruption than a standard first-time posterior replacement, which is worth factoring into recovery expectations.

Patient with previous gluteal tendon disease

Pre-existing abductor tendon damage, unrelated to the hip replacement itself, may genuinely affect this patient’s recovery independently of the surgical approach used.

Patient with buttock pain

Pain here could reasonably arise from the incision itself, the gluteus maximus, the deeper rotator muscles, or even referred symptoms from the spine — proper clinical assessment helps identify which is actually responsible.

Athlete returning to rotation-heavy sport

This patient genuinely needs progressive rotational strength and control work, rather than simply being cleared to return based on time alone.

Questions to ask the surgeon

These questions can help you understand exactly what your own surgery will involve, rather than relying on general descriptions.

• Which short external rotator tendons do you routinely release?
• Do you specifically try to preserve the piriformis?
• How do you repair the capsule and tendons at the end of surgery?
• Do you use bone tunnels, suture anchors, or another repair method?
• Are my hip abductor muscles preserved with your technique?
• Which movement precautions do you recommend for me?
• How long should I actively protect the repair?
• When should I begin more focused strengthening work?
• What symptoms would suggest the repair needs review?
• Is your technique a conventional posterior approach, or one of the modified variants?

Australian recovery pathway

Understanding the support typically available in Australia can help you plan your rehabilitation.

• Hospital physiotherapy supports your early transfers, walking and gluteal activation
• Outpatient physiotherapy continues this work once you’re home, particularly valuable if a limp or weakness persists
• Your GP and surgeon both play a role in ongoing follow-up
• Medicare typically covers only part of specialist and allied health costs, and private health insurance extras may contribute toward physiotherapy, depending on your policy
• Work certificates and graduated return-to-work planning can be arranged through your surgeon or GP
• Regional patients should plan for community rehabilitation support closer to home, where available

Frequently Asked Questions (FAQs)

1. Which muscles are cut during posterior hip replacement, and is the gluteus maximus completely cut?

The gluteus maximus is generally split along its natural fibre direction, and selected short external rotator tendons are commonly detached from the femur to expose the posterior capsule and hip joint. No, the gluteus maximus is not completely cut — it’s split in line with its fibres rather than transected across the whole muscle, which is a meaningfully different and less disruptive type of tissue handling.

2. Which short rotator muscles are involved, and is the piriformis always cut?

Depending on the specific technique used, the release may involve the piriformis, obturator internus, the gemelli muscles and other deep external rotators — the exact tendons affected should be confirmed with your own surgeon. No, the piriformis isn’t always cut; some posterior techniques release it, while piriformis-sparing and direct superior modifications specifically aim to preserve it.

3. Are the gluteus medius and minimus cut, and is the tensor fascia lata affected?

No, they’re generally identified and preserved in a standard posterior approach, rather than being detached from their main insertion — this is different from the direct lateral approach, which more commonly does involve this abductor mechanism. The tensor fasciae latae muscle is also not usually one of the primary muscles divided during a standard posterior approach, despite some simplified comparison articles suggesting otherwise.

4. What happens to the posterior capsule, and are the muscles reattached afterward?

The posterior capsule is opened to reach the joint and is commonly repaired at the end of surgery, alongside the released short external rotator tendons. Yes — the released rotator tendons and capsule are generally repaired using sutures, bone tunnels or anchors, while the split gluteus maximus layer is simply closed back together as part of standard wound closure.

5. Why do I need hip precautions after surgery, and can the repair fail?

Some precautions are designed specifically to avoid positions that could stress the healing posterior repair or increase dislocation risk while the tissues regain their strength. Repair failure is possible, but it isn’t the usual explanation for ordinary postoperative weakness or soreness — worsening pain, a sense of instability, or a genuine loss of function are the signs that would warrant proper assessment.

6. Does posterior surgery permanently weaken the gluteus maximus, and why am I still limping if my abductors weren’t cut?

Persistent weakness isn’t expected for most patients, though strength genuinely takes time to recover after surgery and any preoperative deconditioning. Your abductor muscles can remain weak from years of arthritis, pain, and reduced activity even when their tendon attachment was fully preserved during surgery — a limp doesn’t prove they were surgically cut, it often just reflects muscles that need time and targeted strengthening to recover their full capacity.

7. Is posterior replacement more muscle-damaging than anterior or lateral replacement?

Not more damaging exactly — each approach affects different tissues. Posterior surgery splits the gluteus maximus and releases selected posterior tendons, anterior surgery involves retraction and capsular work through a different tissue plane, and lateral surgery more commonly affects the abductor mechanism directly. None of the three is free of soft-tissue involvement; they simply involve different structures in different ways.

The Bottom Line 

“The muscles are cut” is technically true but genuinely imprecise as a description of posterior hip replacement. A more accurate picture is that the gluteus maximus is split along its fibres, selected short external rotator tendons and the posterior capsule are released to allow safe access to the joint, your main hip abductor muscles are generally preserved, and the released tissues are commonly repaired before you leave the operating theatre. This layered, repairable process is quite different from the alarming image “cutting through the muscles” might conjure.

If you’re feeling uncertain about what your own surgery will specifically involve, it’s genuinely worth asking your surgeon to walk you through their particular technique — which tendons they release, how they repair them, and what precautions they recommend. A clear answer to these questions can turn a vague worry into a much more manageable, concrete understanding of your own recovery ahead.