Aseptic necrosis of the hip joint means that a part of the head of the thigh bone (femoral head) dies because its blood supply becomes too low or stops, but there is no infection. In simple words, the bone at the top of the thigh, inside the hip joint, does not get enough blood, the bone cells die, and the bone becomes weak and can collapse.
Aseptic necrosis of the hip joint, also called avascular necrosis or osteonecrosis of the femoral head, happens when the blood supply to the ball of the thigh bone (femoral head) slowly gets blocked or reduced. Without enough blood, the bone cells in this part of the hip start to die. Over time, the bone becomes weaker, can collapse, and the smooth round shape of the hip joint can flatten. This leads to pain, stiffness, and finally arthritis of the hip joint if it is not treated early. Common risk factors include long-term steroid use, heavy alcohol use, blood-clotting problems, sickle cell disease, hip injury, and some autoimmune and metabolic diseases.
This condition is also called avascular necrosis (AVN) of the femoral head, osteonecrosis of the femoral head, ischemic necrosis of the hip, or aseptic osteonecrosis. All these names describe the same basic problem: loss of blood flow to the bone, followed by bone death and joint damage.
The hip joint is a ball-and-socket joint. The “ball” is the head of the femur, and it has a delicate blood supply that can be easily blocked by injury, clots, fat, or pressure inside the bone. When the blood flow is reduced for a long time, the bone first becomes sick and then may break down and flatten, which causes pain and arthritis in the hip.
Types of aseptic necrosis of the hip joint
Traumatic aseptic necrosis
In traumatic aseptic necrosis, the blood supply to the femoral head is damaged by a clear injury, such as a fracture of the neck of the femur or a dislocation of the hip. The blood vessels can tear or become compressed, which suddenly cuts off blood flow to the bone and leads to bone death over time.
Non-traumatic aseptic necrosis
In non-traumatic aseptic necrosis, there is no big injury to the hip. Instead, long-term steroid medicines, heavy alcohol use, blood clotting problems, sickle cell disease, and some autoimmune diseases slowly damage the blood flow inside the bone. The reduction in blood flow is often gradual, and the cause may not be obvious at first.
Steroid-induced aseptic necrosis
This type is linked to long-term or high-dose use of corticosteroid medicines, such as prednisone. Steroids can change fat cells in the bone marrow, increase fat in the blood, and raise pressure in the bone. This can press on blood vessels and cause small clots, so blood cannot reach the bone cells properly.
Alcohol-related aseptic necrosis
Heavy and long-term alcohol intake can also change fat metabolism in the body and bone marrow. Fat can build up and block small vessels, and alcohol can damage blood vessel walls. This combination increases the risk that the femoral head will lose its blood supply and develop necrosis.
Disease-related aseptic necrosis
Some systemic diseases, such as sickle cell disease, systemic lupus erythematosus, antiphospholipid syndrome, Gaucher disease, and other blood or immune disorders, can increase the risk of AVN. These diseases often cause blood clots, sick or misshaped red cells, or inflamed blood vessels, which can all reduce blood flow to the femoral head.
Idiopathic (unknown cause) aseptic necrosis
In some patients, no clear cause is found even after careful testing. This is called idiopathic AVN. Doctors believe that hidden clotting problems, minor injuries, or subtle metabolic issues may still be present, but they cannot always be proven with current tests.
Causes of aseptic necrosis of the hip joint
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Traumatic fracture of the femoral neck
A break in the neck of the femur, especially when the pieces are displaced, can tear or compress the arteries that feed the femoral head. After such a fracture, the blood supply may never fully recover, and over months the bone cells in the head die, leading to aseptic necrosis. -
Hip dislocation
When the femoral head pops out of the socket in a dislocation, the blood vessels that wrap around the neck can stretch, kink, or tear. Even after the hip is put back in place, the previous loss of blood flow may trigger bone death later. -
Long-term high-dose corticosteroid therapy
Using corticosteroids in high doses or for a long time is one of the most common non-traumatic causes. Steroids increase fat inside the bone marrow and blood, raise pressure in the bone, and favor blood clot formation, which together reduce blood flow to the femoral head. -
Heavy alcohol consumption
Drinking several alcoholic drinks every day for years can change fat metabolism and cause fatty deposits inside blood vessels. These changes can narrow small arteries and veins in the femoral head and block micro-circulation, leading to AVN. -
Cigarette smoking and tobacco use
Smoking damages the lining of blood vessels and causes them to narrow. It also increases the risk of blood clots. These effects can further reduce the already delicate blood supply around the femoral head and increase the chance of aseptic necrosis. -
Sickle cell disease and other hemoglobin disorders
In sickle cell disease, red blood cells become stiff and sickle-shaped. These abnormal cells can block tiny blood vessels in many bones, including the femoral head. Repeated blockage leads to ischemia and bone death. -
Systemic lupus erythematosus (SLE)
People with SLE have a high risk of AVN, partly due to inflammation of blood vessels and partly because they often need long-term steroids. Immune complexes and vasculitis can damage the micro-circulation of bone, while steroids add metabolic and clotting stress. -
Antiphospholipid syndrome (APS)
APS is a clotting disorder where antibodies increase the tendency of blood to clot. These clots can block the small arteries that supply the femoral head, even without trauma. Over time, repeated small clots may cause idiopathic-looking AVN in young or middle-aged adults. -
Inherited thrombophilia and hypofibrinolysis
Some people inherit factors that make their blood more likely to clot or less able to break down clots. This state of hypercoagulability can silently compromise blood flow in the femoral head, especially when combined with steroids, alcohol, or other risks. -
High lipid levels (hyperlipidemia)
Very high levels of cholesterol and triglycerides in the blood can encourage fat emboli and plaque formation inside vessels. This can narrow or block the tiny arteries to the femoral head and lead to ischemic bone injury. -
Gaucher disease and other storage disorders
In Gaucher disease, abnormal lipid storage in bone marrow cells increases pressure inside the bone and may compress blood vessels. This can reduce blood flow and cause AVN of the femoral head, sometimes at a young age. -
Radiation therapy to the pelvis or hip
Radiation used for cancer treatment can damage bone cells and the small blood vessels that feed them. When the hip area is exposed, this damage may weaken the femoral head and slowly lead to aseptic necrosis years after treatment. -
Cytotoxic chemotherapy and other marrow-toxic drugs
Some chemotherapy drugs suppress bone marrow and damage dividing bone cells. Combined with steroids or radiation, they can disturb bone repair and blood supply, making the femoral head more vulnerable to AVN. -
Organ transplantation (especially kidney transplant)
Patients who receive organ transplants often take long-term high-dose steroids and other immunosuppressive drugs. They may also have underlying clotting or metabolic problems, so their risk of femoral head AVN is higher than in the general population. -
Chronic kidney disease and dialysis
Kidney disease is linked to changes in bone metabolism, anemia, and clotting problems. Patients may also receive steroids and other drugs. These combined factors increase their risk of AVN of the hip. -
Decompression sickness (“the bends”)
In divers or people exposed to rapid pressure changes, nitrogen bubbles can form in the blood and bone. These bubbles may block bone vessels and cause ischemic damage in weight-bearing bones like the femoral head. -
Autoimmune vasculitis and inflammatory blood vessel diseases
In vasculitis, the blood vessel walls become inflamed and thickened. This can narrow the vessel lumen and limit blood flow to the femoral head, especially when combined with steroids used to treat the vasculitis itself. -
HIV infection and some antiretroviral therapies
People living with HIV have higher rates of AVN. The causes may include chronic inflammation, lipid changes, steroid use for other conditions, and possible direct effects of certain antiretroviral drugs on bone and blood vessels. -
Endocrine and metabolic disorders (for example Cushing’s syndrome)
Conditions with high cortisol levels, whether from the body or from medicines, can mimic the effects of steroid therapy on fat cells and blood clotting. This can create similar risk for aseptic necrosis of the hip. -
Idiopathic (no known cause)
In many patients, no single strong cause is found. Doctors call this idiopathic AVN. Even in these cases, research suggests that small inherited clotting problems or minor, repeated injuries may still play a role in reducing blood flow to the femoral head.
Symptoms of aseptic necrosis of the hip joint
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Deep groin pain
The most common symptom is a deep, aching pain felt in the groin area. The pain often feels “inside the joint” rather than on the skin and may be hard for the patient to point to exactly. -
Hip pain with weight-bearing
Pain usually gets worse when the person stands, walks, or runs, because the damaged femoral head must carry body weight. At first, the pain may only appear with long walks, but later it can happen with short distances or even standing still. -
Pain at rest or at night
As the disease progresses, pain can occur even when the person is resting or lying in bed. Night pain may disturb sleep and is a sign that the bone damage and joint inflammation are becoming more severe. -
Limping gait
Because of pain and weakness around the hip, many patients develop a limp. They may shift their weight to the other side or shorten the time they stand on the painful leg, leading to a visible change in the way they walk. -
Reduced hip range of motion
Movements like bending the hip (flexion), turning it inward or outward (rotation), or opening the leg to the side (abduction) may become limited and painful. Stiffness is often more noticeable when the person tries to squat, sit cross-legged, or tie their shoes. -
Morning stiffness or stiffness after rest
Many patients feel that the hip is stiff when they first get up in the morning or after sitting for a long time. The stiffness may improve a little with gentle movement, but pain can return with heavy use. -
Pain radiating to the thigh or knee
Hip joint pain can sometimes be felt in the front of the thigh or even near the knee. This referred pain may confuse patients and doctors, so careful examination is needed to identify the hip as the true source. -
Difficulty climbing stairs or walking uphill
Climbing needs more hip flexion and muscle effort. When the femoral head is weak and painful, going up stairs or hills becomes especially difficult and may cause sharp or catching pain. -
Difficulty sitting cross-legged or squatting
These positions require deep hip flexion and rotation. In AVN, these movements often trigger pain or are simply not possible because the joint is stiff and the muscles are tight. -
Clicking, catching, or grinding feeling in the hip
As the femoral head collapses and the joint surface becomes uneven, patients may feel or hear clicks or grinding when they move the hip. This often means that the joint cartilage is also being damaged. -
Feeling of instability or “giving way”
Some patients feel that the hip is not steady or that the leg may suddenly give way. This can happen when the muscles around the hip get weak from pain and disuse or when the joint surface becomes irregular. -
Muscle wasting around the hip and thigh
Long-lasting pain makes people avoid using the affected leg fully. Over time, the muscles, especially in the buttock and thigh, may shrink and become visibly smaller and weaker. -
Shortening of the affected leg (in advanced stages)
If the femoral head collapses and the hip joint develops secondary osteoarthritis, the affected leg may look shorter. This difference in leg length can further worsen limping and back discomfort. -
Bilateral hip symptoms
In many patients, both hips are involved, either at the same time or one after the other. The patient may notice pain on one side first and later feel similar pain on the other side. -
Reduced ability to do daily activities and sports
Over months or years, hip pain and stiffness can limit work, exercise, and household tasks. People may stop running, playing sports, or even walking long distances because of fear of pain and joint damage.
Diagnostic tests for aseptic necrosis of the hip joint
In real practice, doctors combine history, physical and manual tests, laboratory tests, and imaging to confirm aseptic necrosis of the hip and to rule out other causes of hip pain.
Physical examination tests
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General physical examination and vital signs
The doctor first checks the patient’s overall health, looks for signs of anemia, infection, or chronic disease, and measures vital signs such as temperature, pulse, and blood pressure. This helps to identify underlying diseases like sickle cell disease, lupus, or infection that may be linked to AVN risk. -
Inspection and palpation of the hip region
The doctor observes the way the hip and pelvis look while the patient stands and lies down. They gently press around the hip, groin, and buttock to find tender spots. Localized tenderness in the groin or over the front of the hip suggests joint or bone problems like AVN rather than simple muscle strain. -
Gait analysis (watching the way the patient walks)
The doctor asks the patient to walk across the room and may watch from different angles. A limp, short stance time on the affected leg, or a side-to-side sway can indicate pain or weakness in the hip, which is common in AVN and other hip diseases. -
Range of motion assessment of the hip
The hip is moved gently through flexion, extension, abduction, adduction, and rotation while the patient is lying down. Pain or restriction, especially in internal rotation and abduction, is often seen in early AVN and progresses as the disease worsens.
Manual special tests
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Trendelenburg test
In this test, the patient stands on one leg, and the doctor watches the level of the pelvis. If the pelvis drops on the opposite side, the Trendelenburg sign is positive, showing weakness of the hip abductor muscles, which may occur due to pain or damage in hip conditions including AVN. -
FABER (Patrick) test
FABER stands for flexion, abduction, and external rotation. The patient lies on their back, and the affected leg is placed in a “figure-4” position. The doctor presses gently on the knee. Pain in the groin suggests hip joint pathology, which could include AVN, arthritis, or labral problems. -
FADIR (hip impingement) test
FADIR stands for flexion, adduction, and internal rotation. The doctor bends the hip to 90 degrees, then moves it inward and across the body. Groin pain during this movement suggests intra-articular problems, such as impingement or early joint surface damage, and can be present in AVN. -
Log roll test
With the patient lying on their back, the doctor gently rolls the whole leg in and out. Pain in the groin with minimal movement suggests a problem inside the hip joint itself, such as AVN, rather than muscle or ligament strain. -
Straight leg raise test
The patient lies on their back, and the doctor lifts the straight leg. While this test is mainly used to check for nerve root or lumbar spine problems, pain deep in the hip during the maneuver may point to intra-articular hip pathology and prompt further imaging for AVN. -
Thomas test for hip flexion contracture
The patient lies on the table and hugs one knee to the chest. If the opposite leg cannot stay flat on the table, there is a hip flexion contracture. This may develop in advanced hip disease, including AVN with secondary arthritis, due to chronic pain and muscle shortening.
Laboratory and pathological tests
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Complete blood count (CBC), ESR, and CRP
These blood tests check for anemia, infection, and inflammation. While they do not diagnose AVN directly, they help rule out other causes of hip pain, such as infection or inflammatory arthritis, and can show anemia linked to sickle cell or chronic disease. -
Lipid profile
Tests for cholesterol and triglycerides help detect hyperlipidemia. High lipid levels support the suspicion that fat emboli and vessel blockage may have contributed to AVN, especially in patients with alcohol use or steroid therapy. -
Coagulation profile and thrombophilia screening
Tests such as PT, aPTT, and specialized assays for factors like factor V Leiden, prothrombin mutations, and protein C or S deficiency help detect clotting disorders. A positive result can explain idiopathic AVN by showing that the patient is prone to forming clots in the femoral head vessels. -
Autoimmune and inflammatory markers (ANA, anti-dsDNA, antiphospholipid antibodies)
These tests are used when diseases like SLE or APS are suspected. Detecting these antibodies links the hip problem to a systemic autoimmune disease that can increase AVN risk through vasculitis and thrombosis. -
Liver and kidney function tests
Blood tests for liver enzymes, bilirubin, creatinine, and urea help identify alcohol-related liver disease, steroid effects, or chronic kidney disease. These conditions are important associated factors and may influence treatment decisions and surgery risk. -
Bone biopsy and histopathology (rarely needed)
In uncertain or complex cases, a small piece of bone may be taken during surgery and examined under the microscope. Typical findings in AVN include dead bone cells (empty lacunae), collapse of trabeculae, and attempts at new bone formation at the edges. This confirms the diagnosis but is not usually needed when imaging is clear.
Electrodiagnostic tests
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Nerve conduction studies (NCS)
These tests measure how fast electrical signals travel along nerves in the leg. They are not used to diagnose AVN directly, but they can rule out nerve problems, such as peripheral neuropathy or lumbar radiculopathy, when hip or leg pain is confusing. -
Electromyography (EMG)
EMG records the electrical activity of muscles. It can help show whether weakness and wasting around the hip are due to nerve injury or long-term disuse from joint pain. This information can guide rehabilitation but is usually a supportive, not primary, test in AVN.
Imaging tests
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X-ray of the hips
Plain X-rays are usually the first imaging test. In early AVN, X-rays may look normal. Later, they can show areas of bone density change, a “crescent sign” (a line indicating subchondral fracture), flattening of the femoral head, and secondary osteoarthritis. Both hips are often imaged because AVN can be present on both sides. -
Magnetic resonance imaging (MRI) of the hip
MRI is the most sensitive test for early AVN. It can show bone marrow changes and small areas of dead bone long before X-rays become abnormal. MRI helps stage the disease, detect AVN in the other hip even if it does not hurt yet, and guide decisions about treatments such as core decompression or joint replacement. -
Computed tomography (CT) scan of the hip
CT gives detailed images of bone structure. It is useful to assess the shape of the femoral head, detect subtle fractures, and plan surgery when collapse of the bone has already occurred. CT is less sensitive than MRI for very early disease but helpful in later stages. -
Bone scan (radionuclide scintigraphy)
In a bone scan, a small amount of radioactive tracer is injected, and its uptake in the bones is imaged. AVN may show areas of reduced or increased tracer uptake depending on the stage of disease. Bone scans can screen both hips and other joints when multifocal AVN is suspected. -
Dual-energy X-ray absorptiometry (DEXA) for bone density
DEXA does not diagnose AVN itself but measures bone density. It helps identify osteoporosis or low bone mass in patients with long-term steroid use or chronic disease. Knowing bone density is important when planning weight-bearing limits, rehabilitation, and fracture prevention.
Non-pharmacological treatments
Below are common non-drug approaches that may be used, especially in early stages or together with surgery and medicines. Exact plans must be made by an orthopaedic specialist and physiotherapist.
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Activity modification and rest
In early disease, doctors often advise you to reduce activities that load the hip, such as running, jumping, or heavy lifting. This rest helps lower stress on the weak bone so it has a better chance to heal or at least not collapse quickly. You may need to limit standing time, avoid climbing many stairs, and take breaks during the day. This does not cure the disease but can reduce pain and slow down damage. -
Restricted weight-bearing with crutches or a walker
Using crutches, a walker, or sometimes a cane shifts body weight away from the injured hip. This can delay progression and give time for other treatments, such as medicines or surgery, to work. Doctors may advise “toe-touch weight-bearing” or “partial weight-bearing” for several weeks or months. Even though weight-bearing restriction alone is often not enough to stop the disease, it is a useful part of a combined plan. -
Structured physical therapy exercises
Physiotherapists design safe exercises to keep the hip joint moving and to strengthen the muscles around the hip, thigh, and core. Strong muscles help support the joint and can reduce pain by sharing the load. Therapy usually includes gentle stretching, isometric exercises, and later more active strengthening and balance work. The goal is to improve walking, sitting, and daily activities without pushing the hip into painful positions. -
Range-of-motion (ROM) exercises
Simple ROM exercises, such as gentle hip flexion, extension, abduction, and rotation, keep the joint from becoming stiff. These movements are done within a pain-free range and may be assisted at first by the therapist. Regular ROM helps maintain joint nutrition and reduces the risk of developing a frozen or very stiff hip. -
Low-impact aerobic exercise (cycling, swimming)
When the doctor allows, low-impact activities such as cycling on a stationary bike or swimming can help maintain heart fitness and muscle strength without putting high impact on the hip joint. These exercises keep you active, support weight management, and may improve mood and sleep, which indirectly helps with pain control. -
Hydrotherapy (water-based physiotherapy)
Exercising in warm water takes pressure off the hip because the body floats. This lets you move the joint more easily with less pain while still strengthening muscles. The warmth of the water can also relax tight muscles around the hip and lower back. -
Assistive devices and home modifications
Using higher chairs, raised toilet seats, grab bars in the bathroom, and shoe horns can reduce hip bending and strain. A cane or crutch in the opposite hand of the painful hip can reduce joint load. These changes make daily life safer and more comfortable while the hip is fragile. -
Weight management and nutrition counseling
Excess body weight increases the load across the hip joint with every step. Diet and lifestyle programs that promote gradual, healthy weight loss can reduce pain and slow joint wear. Good nutrition with enough protein, vitamins, and minerals also supports bone and muscle health. -
Stopping or reducing alcohol and smoking
Heavy alcohol intake and smoking are strong risk factors for avascular necrosis because they harm blood vessels and bone metabolism. Stopping these habits can slow further damage and lower the risk of AVN in the other hip or other bones. Doctors may refer patients to counseling or cessation programs. -
Changing steroid or other risky medicines (if possible)
Long-term high-dose steroid use is a major cause of aseptic necrosis. When safe, doctors may lower the steroid dose or switch to other medicines that are kinder to bone and blood supply. This must always be done carefully and under specialist supervision; never change these medicines by yourself. -
Pulsed electromagnetic field therapy (PEMF)
In some centers, PEMF devices are used around the hip to stimulate bone repair. Research suggests that electromagnetic fields may improve blood flow and bone cell activity in early stages of osteonecrosis, especially when combined with core decompression. Evidence is mixed, and availability varies by country. -
Extracorporeal shockwave therapy (ESWT)
ESWT uses focused sound waves applied from outside the body to stimulate healing in bone and soft tissue. Some studies report reduced pain and better function in early hip osteonecrosis when ESWT is used along with weight-bearing restriction and other treatments, but it is not yet standard everywhere. -
Hyperbaric oxygen therapy (HBOT)
HBOT involves breathing pure oxygen in a pressurized chamber. The higher oxygen level in the blood may improve oxygen delivery to damaged bone and promote healing in early disease. Evidence is still limited and mixed, and the treatment is costly and not widely available, so it is usually considered only in special cases. -
Occupational therapy and ergonomic training
Occupational therapists teach ways to do daily tasks—such as dressing, bathing, cooking, and work duties—while protecting the hip. They suggest practical tools and body positions that reduce bending and twisting, lowering pain and preventing falls. -
Heat and cold therapy
Warm packs or hot showers can relax tight muscles and ease stiffness around the hip, while cold packs may reduce sharp pain and swelling after activity. These methods do not change the disease, but they support comfort and reduce the need for pain medicines. -
Psychological support and pain-coping strategies
Long-lasting hip pain can cause stress, low mood, and sleep problems. Cognitive-behavioral therapy, relaxation breathing, mindfulness, and support groups can help patients cope better with pain and treatment decisions. Better mental health often improves how people feel their pain. -
Fall-prevention programs
Because the hip is weak, a fall can cause a fracture on top of the necrosis. Balance training, home safety checks, good lighting, proper footwear, and sometimes physical therapy for gait training all help reduce the risk of falls. -
Regular imaging and follow-up
Doctors use X-rays and especially MRI scans to monitor the size and stage of the necrotic area. Regular follow-up lets the team see if the lesion is stable or progressing so they can adjust non-surgical and surgical plans at the right time. -
Education about hip-protecting positions
Patients are taught to avoid deep flexion (very low chairs, deep squats), twisting on the leg, and high-impact sports. Learning safe ways to sit, stand, and turn can reduce daily stress on the damaged femoral head. -
Comprehensive rehabilitation after surgery
After operations like core decompression or hip replacement, early and structured rehab is vital. Physical therapy improves strength, mobility, and walking pattern, while education on hip precautions prevents dislocation and protects healing tissue.
Drug treatments
Medicines for aseptic necrosis of the hip mostly aim to control pain, protect bone, improve blood flow, or manage risk factors like lipids and clotting. None of them should be used without medical supervision, and many are off-label for this condition. Evidence for each group comes from small trials, observational studies, and experience, not from large, simple cures.
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Ibuprofen (NSAID pain reliever)
Ibuprofen is a nonsteroidal anti-inflammatory drug (NSAID) used to ease hip pain and reduce inflammation around the joint. Typical adult label dosing is every 4–6 hours as needed, with the smallest effective dose used to lower side-effects such as stomach bleeding, kidney strain, and increased blood pressure. It helps patients stay active and complete physiotherapy but does not cure the necrosis itself. -
Naproxen / naproxen sodium (NSAID)
Naproxen is another NSAID used for longer-lasting pain control in hip AVN. It is usually taken in scheduled doses with food, one or two times a day depending on the product. It is helpful for moderate pain but can cause stomach ulcers, kidney problems, and heart risks in some people, especially with long-term use, so doctors monitor dose and duration carefully. -
Celecoxib (selective COX-2 NSAID)
Celecoxib is a COX-2 selective NSAID that may cause fewer stomach ulcers than some older NSAIDs, though it can still raise the risk of heart and kidney problems. It is given once or twice daily for chronic hip pain. It allows some patients with sensitive stomachs to tolerate pain treatment better while they undergo other therapies like weight-bearing restriction and physiotherapy. -
Paracetamol (acetaminophen)
Paracetamol is used for mild to moderate hip pain when NSAIDs are not safe (for example, in some patients with ulcers or kidney disease). It has little anti-inflammatory effect but can reduce background pain and may be combined carefully with other medicines. High doses can damage the liver, so total daily dose must not exceed the limit set on the product label and by the physician. -
Short-term weak opioids (for severe pain)
Tramadol or similar weak opioids may be prescribed for short periods when pain is very strong and other medicines are not enough. They act on the brain and spinal cord to change pain signals. Side-effects include dizziness, nausea, constipation, drowsiness, and risk of dependence, so doctors use the lowest dose for the shortest time and usually combine them with non-drug treatments. -
Alendronate (bisphosphonate)
Alendronate is a bisphosphonate that blocks bone-resorbing cells (osteoclasts). It is licensed for osteoporosis and taken once weekly or daily in specific doses under fasting conditions. In early AVN, studies suggest bisphosphonates may reduce pain and delay femoral head collapse, but evidence is mixed, and there is no official approval specifically for AVN. Long-term use can cause rare complications like jaw osteonecrosis and atypical femur fractures. -
Other bisphosphonates (zoledronic acid, etc.)
Intravenous zoledronic acid is a powerful bisphosphonate approved for osteoporosis and bone disease in cancer. It is given once yearly or at different schedules for other conditions. In AVN, it has been explored to protect bone structure, but routine use is not established. It can cause flu-like symptoms, low calcium, kidney effects, and rare jaw problems, so it is reserved for selected cases. -
Teriparatide (parathyroid hormone analog – bone anabolic)
Teriparatide is an injectable form of parathyroid hormone fragment (PTH 1-34). It stimulates bone-forming cells (osteoblasts) and increases bone volume. It is licensed for severe osteoporosis, given once daily under the skin. Studies in hip osteonecrosis suggest it may reduce femoral head collapse and improve healing, especially in pre-collapse stages, but this is off-label use. High calcium levels and other side-effects need monitoring. -
Enoxaparin (low-molecular-weight heparin anticoagulant)
Enoxaparin is a blood thinner that reduces clot formation. It is injected under the skin at doses chosen by the doctor. In early steroid-related AVN, studies show enoxaparin may prevent progression of necrosis and lower the need for hip replacement by improving blood flow in small vessels. It increases bleeding risk, so careful monitoring and correct dosing are essential. -
Warfarin and other anticoagulants
In selected patients with clotting disorders or idiopathic AVN, warfarin or similar anticoagulants may be used to prevent tiny blood clots that block vessels in the femoral head. Doses are adjusted to blood-test targets. The benefit must be weighed against bleeding risk, drug interactions, and the need for frequent monitoring. Evidence is limited and use is highly individualized. -
Statins (for lipid and fat-cell control)
Statins such as pravastatin lower cholesterol by blocking the HMG-CoA reductase enzyme. Animal and clinical studies suggest statins may reduce steroid-induced AVN by limiting fat buildup and improving blood vessel health, but results are mixed and there is no strong guideline for routine use in AVN alone. They are mainly used when patients also have high cholesterol or cardiovascular risk. -
Iloprost (prostacyclin analog – vasodilator)
Iloprost is a prostacyclin-like medicine given by intravenous infusion. It dilates blood vessels and reduces platelet clumping. Studies in bone marrow edema and early osteonecrosis show that iloprost can reduce pain, improve function, and shrink bone marrow edema on MRI, especially in early stages. It is usually used in hospital under close monitoring because it can cause low blood pressure, headache, and flushing. -
Calcium and vitamin D (supportive bone health)
Calcium and vitamin D are not cures for necrosis, but adequate levels are needed for healthy bone remodeling and to support other treatments like bisphosphonates. Doctors may prescribe them if diet and sun exposure are not enough. Doses are adjusted based on blood tests to avoid kidney stones or high calcium. -
Lipid-lowering and blood-pressure medicines (indirect support)
Medicines that control high blood pressure, diabetes, or other vascular risk factors help protect blood vessels that feed the hip. Good control can reduce future damage and is important in people with metabolic syndrome or cardiovascular disease. -
Anti-resorptive agents other than bisphosphonates (e.g., denosumab)
Denosumab is a monoclonal antibody against RANKL used for osteoporosis. By blocking RANKL, it reduces bone resorption. In theory, this may help protect weakened femoral heads, but data in AVN are limited, and use is off-label. It is given by injection every six months and can cause low calcium and rare jaw problems, so strict medical supervision is needed. -
Analgesic adjuvants (antidepressants, anticonvulsants)
Medicines like duloxetine or gabapentin may help people who have chronic pain with nerve-like features or central sensitization. They work on pain pathways in the nervous system rather than on the bone itself. Side-effects can include drowsiness, dizziness, and mood changes, so doses must be carefully titrated. -
Short courses of corticosteroid injections (very carefully)
Although systemic steroids can cause AVN, some doctors may use very limited local steroid injections around the joint for severe inflammation. This is generally avoided in established AVN of the hip, because repeated injections and steroid exposure can worsen bone death. If used at all, it is with great caution and clear discussion of risks. -
Bisphosphonate plus core decompression protocols
Some centers combine bisphosphonate therapy with core decompression surgery, hoping to support bone stability after surgically lowering the internal pressure in the femoral head. Studies show this combination can sometimes delay the need for total hip replacement, but it is not a guaranteed cure and still considered an evolving strategy. -
Combination pharmacologic protocols (statin + anticoagulant, etc.)
In high-risk patients, doctors may combine drugs that target different mechanisms, such as a statin plus an anticoagulant, under close monitoring. The idea is to improve blood flow, reduce fat-cell problems, and stabilize bone. These regimens are tailored to each person’s risk factors and have not been standardized. -
Experimental agents in clinical trials
Other experimental medicines, such as PPARγ inhibitors combined with statins, are being studied in animal models and early research for steroid-induced osteonecrosis. They try to reduce cell death and improve bone repair, but they are not yet available as routine treatments.
Dietary molecular supplements
Supplements can support general bone and joint health but cannot replace core treatments or surgery when needed.
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Calcium supplements
Calcium is the main mineral in bone. When diet does not provide enough, doctors may recommend calcium tablets divided through the day with meals. Adequate calcium helps bone cells rebuild stronger tissue, but too much can lead to kidney stones or blood-vessel calcification. Doses must be matched to age, diet, and kidney function. -
Vitamin D3 supplements
Vitamin D helps the gut absorb calcium and helps bone cells mineralize properly. People with low vitamin D may have weaker bones and poorer healing. Typical daily doses range from moderate maintenance amounts to higher correction doses decided by the doctor based on blood levels. Too much vitamin D can raise calcium too high, so monitoring is needed. -
Vitamin K2 (menaquinone)
Vitamin K2 activates proteins such as osteocalcin that guide calcium into bone rather than soft tissues. Studies suggest K2 may improve bone quality and reduce fracture risk, especially in post-menopausal women. It is usually taken once daily with a meal containing fat. People on blood thinners like warfarin must not start K2 without specialist advice because of strong interactions. -
Omega-3 fatty acids (fish-oil EPA/DHA)
Omega-3 fats from fish oil or algae have anti-inflammatory effects and may modestly support bone health by reducing bone resorption and improving calcium handling. They may also help with general joint pain and cardiovascular risk. Usual doses are divided capsules with meals. Side-effects include fishy after-taste and a small increase in bleeding tendency at high doses. -
Curcumin (from turmeric)
Curcumin is a plant compound with anti-inflammatory and antioxidant properties. It may help reduce musculoskeletal pain and inflammatory markers, sometimes with fewer side-effects than NSAIDs, though evidence is still limited and mixed. It is often taken with black pepper (piperine) and fat to improve absorption. High doses can upset the stomach and may interact with blood thinners. -
Collagen peptides
Collagen supplements provide amino acids that form part of cartilage and connective tissue. Some studies in joint diseases suggest modest improvements in pain and function. They are usually taken as powders dissolved in water once or twice a day. Collagen is not a cure, but it may support overall joint health when combined with healthy diet and exercise. -
Magnesium supplements
Magnesium is important for bone mineralization and muscle function. Low magnesium levels can disturb calcium handling and bone quality. Supplements are sometimes used when blood levels are low or diet is poor. Too much magnesium can cause diarrhea or, rarely, heart rhythm problems in people with kidney disease, so dosing must be cautious. -
Antioxidant vitamins (C and E)
Vitamins C and E help control oxidative stress, which may contribute to bone and cartilage damage. Vitamin C is also vital for collagen formation. In AVN, they are mainly supportive and are best obtained from fruits, vegetables, nuts, and seeds, with supplements used only if diet is clearly insufficient. Very high doses may cause side-effects, so balanced intake is preferred. -
Protein supplements (whey, plant protein)
Adequate protein is crucial for muscle repair and bone matrix formation. When food intake is low, protein powders can help patients maintain strength, especially during rehabilitation and after surgery. Excessive protein without enough fluids can strain kidneys, so guidance from a dietitian is helpful. -
Combined bone-support formulas
Some products mix calcium, vitamin D, vitamin K, magnesium, and trace minerals like zinc and manganese. They aim to support overall bone health in one pill. Quality and exact ingredients vary widely, so patients should choose trusted brands and check with their doctor to avoid duplicating nutrients from other medicines or foods.
Immunity-booster and regenerative / stem-cell-related drugs
These approaches focus on supporting bone repair and, in some cases, using cells or biologic drugs. Many are still under study and are not standard care everywhere. They should only be considered by specialists in experienced centers.
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Teriparatide (bone-forming hormone analog)
As described above, teriparatide stimulates bone-forming cells and increases bone turnover in a controlled way. In hip AVN, it has shown promise in reducing collapse and improving healing in early stages, including after certain osteotomies or fractures with early necrosis. It may also indirectly support immune and repair processes in bone marrow. Treatment duration is limited (often up to two years for osteoporosis), and careful monitoring is needed. -
Zoledronic acid and related bisphosphonates as structure protectors
Strong bisphosphonates such as zoledronic acid help preserve bone mineral and reduce excessive bone breakdown. By keeping the bone scaffold stronger, they may give the body more time to repair necrotic areas and may work in combination with core decompression and biologic therapies. They do not directly boost immunity but influence bone remodeling cells that also interact with the immune system. -
Bone marrow aspirate concentrate (BMAC) with mesenchymal stem cells
In some centers, surgeons take bone marrow from the patient’s pelvic bone, concentrate the cells (including mesenchymal stem cells), and inject them into the necrotic area, often combined with core decompression or iloprost. These cells may help form new blood vessels and bone, supporting regeneration of the femoral head. Results are encouraging in some studies, but the technique is complex, not standardized, and still being researched. -
Other mesenchymal stem-cell grafts and tissue-engineering constructs
Researchers are testing lab-grown mesenchymal stem cells, sometimes seeded onto scaffolds, to fill necrotic cavities in the femoral head. These scaffolds may release growth factors slowly and support new bone formation. Such therapies are still mostly in clinical trials or specialized centers. Risks include infection, graft failure, and uncertain long-term outcomes, so they are not yet routine treatments. -
Biologic agents that improve micro-circulation (such as iloprost)
Intravenous iloprost and similar prostacyclin-like drugs not only dilate blood vessels but may also positively influence endothelial and immune cells in bone marrow, helping resolve bone marrow edema and improving conditions for bone repair. Their role in advanced AVN is limited, but in early disease they can be an important part of regenerative strategies alongside cell-based treatments. -
Future targeted therapies (e.g., statin-based and PPARγ-modulating combinations)
New experimental therapies combine statins with agents that block PPARγ signaling to reduce fat-cell expansion and bone-cell death in steroid-induced AVN. Early studies show improved bone healing in animal models. These treatments act at the level of bone marrow cells and inflammation, which are closely linked to the immune system. They are not yet available as standard clinical treatments but show where future regenerative medicine may go.
Surgeries (Procedures and why they are done)
Surgery is often needed, especially once the femoral head has begun to collapse or when pain is severe despite conservative care.
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Core decompression
In core decompression, the surgeon drills one or more channels into the femoral head to relieve pressure, improve blood flow, and remove some dead bone. Sometimes bone graft or stem-cell-rich marrow is added. It is mainly used in early (pre-collapse) stages to reduce pain and delay or prevent collapse, often in younger patients. -
Bone grafting (non-vascularized or vascularized)
Bone grafting involves filling the necrotic area with healthy bone taken from another part of the body or from a donor. Vascularized grafts bring their own blood supply, which may help re-establish circulation in the femoral head. This surgery is more complex but can preserve the natural hip joint in selected younger patients. -
Corrective osteotomy of the proximal femur
In an osteotomy, the surgeon cuts and re-angles the upper femur so that weight is shifted away from the necrotic area toward healthier bone. This can reduce pain and slow arthritis in some patients with localized damage. It is usually reserved for younger, active patients with specific lesion shapes. -
Hip resurfacing
Hip resurfacing replaces only the surface of the femoral head and the acetabulum (socket) with metal components, keeping more of the patient’s own bone compared with total hip replacement. It may be considered for certain young, active patients, but concerns about metal wear and ion release mean careful patient selection is needed. -
Total hip replacement (total hip arthroplasty)
When the femoral head has collapsed and arthritis is advanced, total hip replacement is often the best option. The surgeon removes the damaged femoral head and socket and replaces them with artificial components. This can greatly reduce pain and improve walking, but the artificial joint can wear out over time, especially in very young or very active patients, so surgeons aim to delay it when safe.
Preventions
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Avoid long-term high-dose steroids whenever possible and use the lowest effective dose for the shortest time under specialist guidance.
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Limit or avoid heavy alcohol use, since alcohol is a major risk factor for avascular necrosis.
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Do not smoke; smoking damages blood vessels and reduces bone healing.
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Control blood lipids, blood pressure, and diabetes to protect the small vessels that feed the femoral head.
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Use protective equipment and safe habits to prevent serious hip injuries in sports, work, and traffic.
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If you must be on steroids or other high-risk drugs, get regular check-ups and report hip pain early.
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Treat underlying blood-clotting disorders or autoimmune diseases carefully to reduce risk of vessel blockage.
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Maintain a healthy body weight to lower mechanical stress on the hip joints.
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Keep good general bone health with balanced diet, safe sunlight exposure, and appropriate exercise.
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Follow up promptly on any imaging or specialist referrals if hip discomfort appears after steroid treatment, alcohol abuse, diving accidents, or injuries.
When to see doctors
You should see a doctor, ideally an orthopaedic specialist, if you:
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Have dull or sharp pain in the groin, buttock, or thigh that worsens with walking or standing and improves with rest.
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Notice stiffness, limping, or reduced ability to move the hip (for example difficulty putting on socks, using stairs, or getting into a car).
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Have a history of high-dose steroid use, heavy drinking, sickle cell disease, HIV, organ transplantation, or other conditions known to increase AVN risk and then develop hip pain.
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Hear or feel grinding or catching in the hip.
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Have pain in both hips or other joints at the same time.
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Experience sudden worsening pain, inability to bear weight, or suspected fracture after a minor fall. This is an emergency.
Early diagnosis with X-ray and especially MRI can show AVN before the bone collapses, which gives more options like core decompression and regenerative treatments.
Diet: what to eat and what to avoid
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Eat plenty of calcium-rich foods such as low-fat dairy, fortified plant milks, tofu set with calcium, and leafy greens to support bone health.
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Eat foods rich in vitamin D (fatty fish, egg yolks, fortified foods) if allowed by your doctor, and consider supplements if levels are low.
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Eat foods with vitamin K2 (fermented foods like natto, some cheeses) and plenty of colorful fruits and vegetables for antioxidants that support bone and vessel health.
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Eat healthy fats from fish, nuts, seeds, and olive oil to provide omega-3 fatty acids and support heart and bone health.
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Eat enough lean protein (beans, lentils, eggs, poultry, fish) to build and repair muscle that supports the hip.
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Avoid or limit heavy alcohol intake, which harms bone and blood supply and is a strong risk factor for AVN.
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Avoid smoking and vaping nicotine, which harm blood vessels and slow healing.
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Avoid very high-salt processed foods, which can increase calcium loss in urine and worsen high blood pressure.
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Avoid sugary drinks and ultra-processed snacks that contribute to weight gain and inflammation.
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Avoid extreme crash diets that cause rapid weight loss and malnutrition; instead aim for steady, balanced changes with guidance from a dietitian.
Frequently asked questions (FAQs)
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Is aseptic necrosis of the hip joint the same as osteonecrosis or avascular necrosis?
Yes. These names all describe the same problem: bone tissue in the femoral head dies because it does not get enough blood. “Aseptic” means it is not caused by bacteria or infection. “Avascular” means no blood, and “osteonecrosis” means bone death. -
Can aseptic necrosis of the hip heal on its own?
Very small early lesions sometimes stabilize or improve, especially with risk-factor control and careful treatment. However, many cases progress and cause collapse of the femoral head if not treated. This is why early detection and close follow-up with imaging are so important. -
What are the first symptoms I might notice?
Early on, you may feel a deep ache in the groin, buttock, or thigh that appears when you stand or walk and eases with rest. Stiffness, mild limp, and difficulty with stairs or tying shoes are also common. Some people have no symptoms until the bone is already damaged. -
How is aseptic necrosis diagnosed?
Doctors start with your medical history, a physical exam, and X-rays. However, standard X-rays can be normal in early disease. An MRI scan is the most sensitive test and can see early changes in bone marrow and necrosis before collapse. Sometimes CT scans and functional tests are also used. -
Is surgery always needed?
No. Treatment depends on the stage, size, and location of the lesion, as well as your age and health. In early stages, non-surgical options like weight-bearing restriction, medicines, and core decompression may be tried. Surgery becomes more likely if the bone is collapsing or pain is severe and long-lasting. -
Can medicines like bisphosphonates or teriparatide cure AVN?
These medicines can support bone strength and may delay or reduce collapse in some patients, especially early in the disease, but they do not reverse advanced damage. Evidence is mixed, and they are usually used as part of a combined approach rather than as stand-alone cures. -
Are treatments like iloprost or stem-cell therapy safe?
Iloprost infusions and stem-cell-based treatments can help some people with early AVN or bone marrow edema, but they require hospital-level monitoring and experienced teams. They have possible side-effects like low blood pressure, infection risk, or unknown long-term outcomes. They are generally used only in specialized centers or research settings. -
Can lifestyle changes really make a difference?
Yes. Stopping heavy alcohol use, not smoking, controlling weight and cholesterol, protecting the hip from trauma, and following physiotherapy can slow progression, reduce pain, and improve surgical outcomes. These steps also protect the other hip and overall health. -
Does every person with AVN need a total hip replacement?
No. Some people remain stable for years with conservative treatments and early surgeries like core decompression, especially if the lesion is small and caught early. However, many patients eventually need a hip replacement when pain and collapse become severe. Modern implants can work very well for many years. -
Is aseptic necrosis of the hip common in both hips?
Yes, AVN often affects both hips, especially when caused by steroids, alcohol, or blood disorders. Even if only one hip hurts now, doctors usually check the other hip with imaging to catch silent disease early. -
Can children or teenagers get aseptic necrosis of the hip?
Yes, there is a related condition called Legg–Calvé–Perthes disease in children, and adolescents can develop AVN after trauma, steroid use, or other conditions. Treatment plans and outcomes can be different in growing bones, so care by a pediatric orthopaedic specialist is important. -
How long does recovery take after core decompression?
Recovery varies. Many patients need several weeks of limited weight-bearing with crutches, followed by months of gradual rehabilitation. Pain relief may appear within weeks, but full functional improvement can take 6–12 months or more, depending on disease stage and other treatments such as bisphosphonates or teriparatide. -
What happens if I ignore hip pain and do not get checked?
If AVN is the cause and it is not treated, the femoral head can gradually collapse, the joint surface becomes uneven, and painful arthritis develops. This greatly limits walking and daily activities and usually leads to the need for total hip replacement. Early diagnosis offers more options and can delay or prevent these outcomes. -
Are there exercises I should avoid?
High-impact activities like running, jumping, football, and heavy squats usually put too much stress on a necrotic femoral head. Deep hip flexion (very low chairs, deep squats) and twisting on the leg should also be avoided. A physiotherapist can design a safe program focusing on low-impact exercises and hip-protecting movements. -
Is this information enough to plan my treatment?
No. This article gives a detailed overview, but each person’s case is unique. Stage of disease, age, other illnesses, medicines, and life goals all affect the best plan. Only your own doctors, using your scans and tests, can design a safe and effective treatment for you.
Disclaimer: Each person’s journey is unique, treatment plan, life style, food habit, hormonal condition, immune system, chronic disease condition, geological location, weather and previous medical history is also unique. So always seek the best advice from a qualified medical professional or health care provider before trying any treatments to ensure to find out the best plan for you. This guide is for general information and educational purposes only. Regular check-ups and awareness can help to manage and prevent complications associated with these diseases conditions. If you or someone are suffering from this disease condition bookmark this website or share with someone who might find it useful! Boost your knowledge and stay ahead in your health journey. We always try to ensure that the content is regularly updated to reflect the latest medical research and treatment options. Thank you for giving your valuable time to read the article.
The article is written by Team RxHarun and reviewed by the Rx Editorial Board Members
Last Updated: February 09, 2025.
