When the Hip Bone Loses Its Blood Supply

What are the first symptoms of avascular necrosis in the hip?

In its earliest stage, avascular necrosis frequently causes no symptoms at all — the bone tissue can be dying before an X-ray shows anything unusual and before pain begins. The first symptom most people notice is a deep, aching pain in the groin, sometimes spreading to the thigh or buttock, that shows up with walking, standing for a while, or climbing stairs and eases with rest. A mild, intermittent ache with activity does not mean the hip is collapsing — this early pattern is exactly why the condition can go unrecognized for a stretch, particularly when it is mistaken for a muscle strain or ordinary hip stiffness.

The symptoms below tend to look similar regardless of osteonecrosis causes — steroid treatment, heavy alcohol use, trauma, or no identifiable trigger at all — because what drives the symptoms is the state of the bone itself, not what damaged its blood supply.

How the pain changes as the disease progresses

Pain in avascular necrosis typically follows a recognizable arc: activity-related pain first, pain at rest next, and pain that disturbs sleep as the disease advances. Early on, the ache appears only with weight-bearing and settles with rest. As more of the femoral head is affected, pain can start appearing after shorter periods of activity, then during ordinary daily movement, and eventually at night, when lying still no longer relieves it. Night pain that wakes someone from sleep is generally a sign that the disease has moved past its earliest stage, not a stage in itself.

Where the pain is felt: groin, thigh, buttock, and referred pain to the knee

Most people describe the pain as centered deep in the groin, though it commonly radiates to the front or side of the thigh and sometimes into the buttock. A notable pattern worth knowing: hip disease, including avascular necrosis, can refer pain all the way down to the knee, because the nerves supplying the hip joint also supply the knee. This is one reason knee pain in an adult with hip risk factors is sometimes traced back to the hip itself rather than to the knee joint.

Limp, stiffness, and reduced motion

As avascular necrosis progresses, most people develop a limp, guarding the hip to avoid loading it fully, along with stiffness that limits how far the hip rotates and bends. Internal rotation — turning the leg inward — is often the first and most noticeably restricted movement. A sudden worsening hip pain and limp, especially appearing after a period of milder symptoms, is one of the clearest signals that the femoral head may be collapsing and deserves prompt evaluation rather than a wait-and-see approach.

How clinicians evaluate these symptoms

A clinician evaluating these symptoms usually starts with a physical exam, checking how far the hip rotates internally and whether that motion reproduces the ache, along with how much weight-bearing the hip currently tolerates. Imaging follows the exam rather than replacing it: a plain X-ray is often normal in the earliest stage, even though the bone is already affected, because X-rays are better at showing a collapsed shape than at showing dying bone before it changes shape. An MRI is far more sensitive at this early stage and can identify the affected area of the femoral head well before an X-ray would, which is part of why persistent groin pain with a known risk factor is often referred for MRI rather than an X-ray alone. Because the disease frequently involves both hips, the opposite hip is typically imaged at the same time even if it isn't yet causing symptoms.

Can avascular necrosis affect both hips?

Yes, and it does so often enough that both hips are typically imaged once one is diagnosed. It's common for one hip to be causing symptoms while the other has early, silent disease that only shows up on imaging. That pattern is part of why clinicians tend to check the opposite hip even when only one side hurts — catching quiet disease on the other side, before it becomes symptomatic, is one of the few genuine advantages of early imaging in this condition.

How these symptoms differ from hip osteoarthritis

Hip osteoarthritis symptoms groin pain and stiffness build up gradually, typically over years, and are driven by cartilage wearing down with age 2Ref 2American Academy of Orthopaedic Surgeons (OrthoInfo) (2024).Osteoarthritis of the Hip.That hip osteoarthritis causes progressive groin/hip pain and stiffness, contrasted with the faster course of osteonecrosis.3Ref 3National Institute of Arthritis and Musculoskeletal and Skin Diseases (NIAMS) (2023).Osteoarthritis.That osteoarthritis is a degenerative joint disease more common with age, distinguishing its gradual course from osteonecrosis.. Avascular necrosis can produce a similar-feeling ache in the same location, but it tends to progress over months rather than years and often strikes younger adults with a specific risk factor rather than simply age. Researchers who study hip conditions often use structured questionnaires to capture symptoms systematically; the Hip disability and Osteoarthritis Outcome Score, for instance, separately rates pain, other symptoms, daily function, sport and recreation, and hip-related quality of life 1Ref 1Nilsdotter AK, Lohmander LS, Klässbo M, Roos EM (2003).Hip disability and osteoarthritis outcome score (HOOS)—validity and responsiveness in total hip replacement.That the HOOS is a validated patient-reported measure with five subscales — pain, symptoms, ADL, sport/recreation, and hip-related quality of life — used to describe how hip symptoms are tracked systematically.. Initial management of an arthritic hip is usually nonsurgical 4Ref 4American Academy of Orthopaedic Surgeons (AAOS) (2023).Management of Osteoarthritis of the Hip — Clinical Practice Guideline.That initial management of hip osteoarthritis is nonsurgical, a comparison point against osteonecrosis management., and with more than 58 million US adults living with some form of arthritis 5Ref 5Theis KA, Murphy LB, Guglielmo D, et al. (CDC/MMWR) (2021).Prevalence of Arthritis and Arthritis-Attributable Activity Limitation — United States, 2016-2018.The US prevalence estimate of about 58.5 million adults with doctor-diagnosed arthritis, used to give scale for how much more common arthritis is than osteonecrosis., osteoarthritis is by far the more common explanation for hip pain generally — but the faster pace and younger age typical of osteonecrosis are worth flagging to a clinician specifically.

When to see a clinician about these symptoms

Groin, thigh, or buttock pain that persists for more than a couple of weeks, especially alongside a known risk factor such as steroid treatment, heavy alcohol use, or a past hip injury, is worth having evaluated rather than waited out. Because avascular necrosis can progress from mild symptoms to advanced disease faster than typical arthritis, earlier imaging tends to preserve more options. Once symptoms and imaging together suggest advancing disease, the conversation usually turns to avascular necrosis hip treatment surgery, which is chosen based on how far the femoral head has progressed, and for hips that reach collapse, many of the same considerations behind hip replacement indications for arthritis apply once secondary joint damage has set in. If replacement eventually becomes necessary, its recovery follows a separate, well-mapped timeline of its own.