Avascular Necrosis of the Hip
Avascular necrosis of the femoral head, also called osteonecrosis, is the death of bone tissue in the ball of the hip joint when its blood supply is interrupted. At Modern Physio we focus on understanding the root-cause of your problem & personalizing your treatment for lasting results.
Understanding Avascular Necrosis of the Hip
Avascular necrosis of the femoral head, also called osteonecrosis, is the death of bone tissue in the ball of the hip joint when its blood supply is interrupted. The bone does not collapse immediately, which is why the condition is so often caught late: for a while the hip simply aches, particularly in the groin, and X-rays can look normal. If the process continues, the weakened bone can flatten and collapse, the joint surface becomes irregular, and arthritis follows. This matters far more in India than most patients realise. Avascular necrosis is the reason behind roughly half of all hip replacements performed in India, compared with a small fraction in the United States, where wear-related arthritis dominates instead. In north Indian patients, corticosteroid use is the most frequently identified cause, followed by chronic alcohol intake, and a body of published work since 2021 has documented cases developing after steroid treatment for COVID-19, sometimes appearing within a few months rather than the year or more classically expected. The honest position on physiotherapy is that it depends entirely on stage. Physiotherapy cannot restore blood supply to dead bone, and it cannot prevent a femoral head that is going to collapse from collapsing. What it can do is genuinely useful: protect the joint through offloading and gait aids in early disease, maintain hip movement and muscle strength, prepare you for surgery if surgery is coming, and rebuild function afterwards. At Modern Physio in Vaishali Nagar, Jaipur, we work to your orthopaedic surgeon's staging and weight-bearing instructions, because in this condition the single most valuable thing is early specialist assessment while the joint surface is still intact.
Common Symptoms
- Groin pain, often described as deep and aching, which is the most typical location rather than pain on the outside of the hip
- Pain that worsens with weight-bearing, walking and stairs and eases with rest in the earlier stages
- Pain that begins to occur at rest and at night as the condition progresses
- Gradual loss of hip movement, particularly turning the leg inwards and taking it out to the side
- A limp that develops without any injury to explain it
- Difficulty with squatting, sitting cross-legged, and getting in and out of vehicles
- A sensation of catching, giving way or grinding in the hip once the joint surface has become irregular
- Pain that can be felt in the thigh or knee rather than the hip itself
- Symptoms in both hips in a proportion of people, since the condition is often bilateral
- Progressive shortening of walking distance and reduced tolerance for standing
How Common Is It?
Avascular necrosis is far more prominent in India than in Western countries, and the contrast is striking. A comparative study of Indian and American joint replacement databases found avascular necrosis to be the indication for roughly half of primary hip replacements in India, against a small single-digit share in the United States, where osteoarthritis is the dominant reason. Within Indian series, steroid exposure is the leading identified cause, followed by chronic alcohol use. Published Indian case reports since 2021 have described avascular necrosis following corticosteroid treatment for COVID-19, in some instances appearing considerably sooner after treatment than the classically described interval. India does not maintain a national registry for avascular necrosis, so its true incidence in the population is not precisely known, and the figures above come from surgical databases and hospital series rather than population surveillance.
Causes & Risk Factors
- Corticosteroid treatment, particularly at higher cumulative doses, which is the most commonly identified cause in published north Indian series
- Steroid treatment given for severe COVID-19, which has been documented in Indian case series as preceding avascular necrosis, at times within months rather than years
- Chronic alcohol intake, the second most frequently identified cause in Indian data
- Fracture of the femoral neck or dislocation of the hip, which can directly disrupt the blood supply to the femoral head
- Sickle cell disease and other haemoglobin disorders
- Decompression sickness in divers
- Radiotherapy or chemotherapy affecting bone
- Conditions treated with long-term immunosuppression, including inflammatory and autoimmune disease
- Cases where no cause is identified at all, which are described as idiopathic
Our Diagnosis Process
- Orthopaedic assessment and imaging lead the diagnosis: MRI is the key investigation because it detects avascular necrosis before changes appear on X-ray
- Staging by your surgeon, commonly using the Ficat and Arlet or ARCO systems, which describes whether the femoral head is still intact or has collapsed
- X-rays to assess joint space, femoral head shape and any secondary arthritis
- Imaging of both hips, since the condition frequently affects both sides even when only one is painful
- A careful history of steroid treatment, including steroids given during COVID-19 illness, alcohol intake, previous hip injury and relevant medical conditions
- Physiotherapy assessment of hip range, muscle strength, walking pattern, walking distance and daily function to set a baseline
- Clear instruction from your surgeon on permitted weight-bearing before rehabilitation begins, since this differs completely between stages and after surgery
Our Treatment Approach
- Working to your surgeon's stage and weight-bearing instructions, because what is appropriate for an intact femoral head is not appropriate for a collapsed one
- Protected weight-bearing using crutches or a walking frame where offloading has been advised, with training so the aid is actually used correctly
- Maintaining hip range of movement without forcing the joint, since stiffness compounds the functional loss
- Strengthening the muscles around the hip and pelvis, especially the abductors and extensors, to improve control and reduce load transmitted awkwardly through the joint
- Core and trunk work to support a more efficient walking pattern
- Cardiovascular conditioning through non-impact options such as cycling and pool-based exercise, to preserve fitness while impact is limited
- Prehabilitation before core decompression or joint replacement, since starting surgery stronger measurably eases recovery
- Structured rehabilitation after core decompression, which typically begins with a non-weight-bearing phase of ankle pumps, static muscle work and gentle range, progressing to weight-bearing as directed
- Full rehabilitation after total hip replacement, following your surgeon's precautions and protocol
- Advice on load management in daily life, including avoiding deep squatting and prolonged standing where these aggravate symptoms
Key Highlights
Rehabilitation matched to your Ficat or ARCO stage and your surgeon's weight-bearing instructions
Prehabilitation and structured recovery for core decompression and hip replacement
Awareness of steroid-related and post-COVID avascular necrosis, which is well documented in Indian practice
Honest framing: physiotherapy manages function and prepares you for surgery, it does not reverse bone death
Recovery & Prevention Tips
- Get assessed early if you have unexplained groin pain and a history of steroid treatment or significant alcohol intake, because the treatments that preserve the joint work best before the femoral head collapses
- Use the crutches or walking aid exactly as prescribed, since offloading is a deliberate treatment rather than a sign of weakness
- Understand that offloading alone does not stop the disease progressing, which is why it sits alongside medical or surgical treatment rather than replacing it
- Ask your doctor specifically about your stage, because it determines what is realistic and what your rehabilitation should look like
- Keep the hip moving within comfortable range rather than protecting it completely, as stiffness adds a second problem on top of the first
- Keep your fitness up with cycling or pool work while impact activity is restricted
- Avoid deep squatting, sitting cross-legged on the floor and heavy lifting while the joint surface is vulnerable
- If you are being considered for surgery, do the prehabilitation work, because strength going in shapes the speed of recovery coming out
- Tell your doctor if pain suddenly worsens or the hip starts giving way, as this can indicate collapse of the femoral head
- Have the other hip checked even if it is not painful, since this condition is frequently bilateral
Products That Can Help
Supports and equipment we fit at the clinic that patients with this condition commonly use alongside treatment, never instead of it.
Related conditions
People reading this page often want one of these next. Each has its own guide to symptoms, causes and what physiotherapy can and cannot do.
Evidence & Sources
A comparative analysis of Indian and American joint replacement data found that avascular necrosis accounted for a far larger share of primary total hip arthroplasty in India than in the United States, where osteoarthritis is the leading indication.
Yakkanti et al. - Relative frequency of avascular necrosis as an indication for primary total hip arthroplasty in the USA versus India (Journal of Orthopaedics, 2023)A study of the causes of osteonecrosis of the femoral head in north Indian patients identified corticosteroid administration as the most commonly observed cause, followed by chronic alcohol intake.
Etiology of osteonecrosis of the femoral head in North Indian patients (PMC)A published case series described avascular necrosis of the femoral head developing after corticosteroid treatment for COVID-19, at cumulative steroid doses lower than the level traditionally associated with the condition and at a shorter interval than classically described.
Agarwala et al. - Avascular necrosis as a part of long COVID-19 (BMJ Case Reports, 2021)Clinical literature on osteonecrosis notes that weight-bearing restriction on its own is insufficient to prevent disease progression, and is best regarded as a reasonable measure when combined with pharmacological treatment or surgery, with excessive compressive and shear forces avoided during physical therapy.
Avascular Necrosis - clinical overview (Physiopedia)Frequently Asked Questions
Can physiotherapy cure avascular necrosis or restore the dead bone?
No. We want to be completely clear about this, because it is the question that matters most. Once bone tissue in the femoral head has lost its blood supply and died, no exercise programme brings it back, and physiotherapy cannot prevent a femoral head that is going to collapse from collapsing. Treatments that genuinely aim to preserve the joint, such as core decompression, are surgical and work best before collapse occurs. What physiotherapy contributes is real but different: protecting the joint through offloading, keeping movement and strength, maintaining your fitness, preparing you for surgery, and rebuilding function afterwards. Anyone offering to reverse avascular necrosis with exercise is not being straight with you.
Why is avascular necrosis so much more common in India?
The pattern is striking and well documented. A comparative study of Indian and American hip replacement databases found avascular necrosis behind roughly half of primary hip replacements in India, against a small single-digit share in the United States, where wear-related arthritis dominates. Indian series point to corticosteroid use as the leading identified cause, followed by chronic alcohol intake. Corticosteroids are widely prescribed in India across many conditions, and there is a documented set of Indian cases following steroid treatment for severe COVID-19. It also tends to affect younger people here, which is part of why it accounts for so many hip replacements.
I took steroids during COVID. Should I be worried about my hip?
You should not panic, but you should not ignore unexplained groin pain either. Indian case reports published since 2021 have documented avascular necrosis developing after corticosteroid treatment for COVID-19, in some instances at lower cumulative doses and shorter intervals than were classically expected. That does not mean everyone who received steroids will develop it, and the great majority will not. What it does mean is that new, persistent groin or hip pain in someone who had significant steroid treatment deserves proper assessment rather than being dismissed as a strain. MRI detects this condition well before X-rays do, and early detection is what keeps joint-preserving options open.
What does my stage mean for what physiotherapy can achieve?
It changes the goals substantially, which is why we ask for it. Where the femoral head is still intact, the priorities are protecting the joint through offloading, keeping range and strength, and supporting whatever medical or surgical treatment is planned to preserve it. Once the femoral head has collapsed and secondary arthritis has developed, the joint-preserving window has passed, and rehabilitation becomes about function: managing pain, keeping you walking, maintaining strength, and preparing you for joint replacement if that is the plan. Both are worthwhile, but they are different jobs, and it would be misleading to describe them as the same thing.
Will using crutches stop the disease getting worse?
Not on its own, and the literature is explicit about this. Weight-bearing restriction is a reasonable measure and it reduces load on a vulnerable joint surface, but as a standalone treatment it is not sufficient to prevent progression. It works as part of a plan that includes medical or surgical treatment, not as a substitute for either. That is worth knowing, because people sometimes use crutches diligently for months in the belief that offloading alone is treating the disease, while the window for joint-preserving surgery quietly closes. Use the aid as advised, and keep your orthopaedic follow-up.
Is physiotherapy useful before hip surgery, or only after?
Both, and the work beforehand is undervalued. Going into core decompression or hip replacement with better hip and pelvic muscle strength, reasonable range and a confident walking technique measurably eases the early recovery, because you are rebuilding from a higher baseline. It also gives you time to learn the exercises and, where relevant, the movement precautions before you are sore and recovering from an operation. After core decompression, rehabilitation typically starts with a protected non-weight-bearing phase using ankle pumps, static muscle work and gentle range, then progresses to weight-bearing as your surgeon directs.
Why does my other hip need checking when it does not hurt?
Because avascular necrosis is frequently bilateral, and the second hip is often silent in its early stages, which is exactly when it is most treatable. The causes that affect one femoral head, such as steroid exposure or alcohol, act on the body as a whole rather than on one side, so it would be surprising if only one hip were exposed. Many surgeons will image both hips at diagnosis for this reason. If your other hip has not been assessed, it is a fair question to raise at your next orthopaedic appointment.
What activities should I avoid?
The general principle is to reduce high impact and deep loaded positions while the joint surface is vulnerable, so running, jumping, deep squatting, sitting cross-legged on the floor and heavy lifting are usually restricted, and long periods standing often aggravate symptoms. Your surgeon's weight-bearing instruction takes precedence over any general advice, because it is based on your imaging. What we would rather you did not do is stop moving altogether: cycling, pool-based exercise and upper body work keep your fitness and muscle strength intact without loading the joint, and that matters a great deal if surgery is on the horizon.
Medically Reviewed
This content was reviewed for medical accuracy by Dr. Surabhi Bansal, BPT, MPT (Ortho) with 14+ years of clinical experience.
At Modern Physio, all medical content undergoes a thorough review process to ensure accuracy and alignment with current physiotherapy standards. Our content is created to educate and should not replace professional medical advice. Learn more about our review process.
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Post-Surgical Rehabilitation
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Hip and pelvic strengthening and non-impact conditioning matched to your stage and weight-bearing status.
Assessment & Education
Baseline measurement of range, strength, walking distance and function, with clear explanation of what your stage means.
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