Life-saving medicine, hidden hip risk

Steroids such as prednisone are one of the leading causes of avascular necrosis (AVN) of the hip, especially when given at high doses. They save lives in asthma, lupus, severe allergy and severe COVID-19, but in some people they starve the top of the thigh bone of blood.

What is AVN? Avascular necrosis, or osteonecrosis, means bone death from loss of blood supply. In the hip, the ball at the top of the thigh bone (femoral head) is fed by a few small, fragile vessels. When that supply fails, the bone beneath the cartilage dies, weakens and can eventually collapse, causing arthritis in young, active adults.

This article explains what causes AVN, how steroids are linked to it and who is most at risk. Treatment is covered in our separate guide on avascular necrosis hip treatment.

At Sports Orthopedics Institute, led by Dr Naveen Kumar L V, we have seen a steady rise in steroid-related hip problems since 2021.

What causes AVN of the hip?

AVN is either traumatic, when an injury tears the vessels, or non-traumatic, when a medical cause chokes the blood supply from within. Steroids and alcohol are the two leading non-traumatic causes. Their share varies by country: in a Japanese registry, steroids accounted for about 47% of non-traumatic cases and alcohol about 31% (Ikeuchi et al., 2015). In a large Chinese database, steroids caused 27% of all cases, alcohol 37% and trauma 16% (Zhao et al., 2020).

Cause	How it damages the blood supply
Corticosteroids (prednisone, dexamethasone, methylprednisolone)	Fat build-up in the marrow, raised pressure and clotting in small vessels (see below)
Alcohol (heavy, long-term drinking)	Raises blood fats and fat cells in the marrow, a mechanism similar to steroids
Trauma (hip fracture or dislocation)	Directly tears the vessels supplying the femoral head
Blood disorders (sickle cell disease, clotting disorders)	Abnormal cells or clots block small vessels
Autoimmune disease (lupus, antiphospholipid syndrome)	Vessel inflammation and clotting, often combined with steroid treatment
Decompression sickness (divers, tunnel workers)	Nitrogen bubbles block vessels
Radiation and chemotherapy	Damage to bone and small vessels
Other conditions (Gaucher disease, HIV, pancreatitis, organ transplant)	Mixed mechanisms; transplant patients also receive high-dose steroids
Smoking	Narrows vessels and adds to other risk factors
Idiopathic	No cause found despite investigation

Many patients have more than one risk factor, and careful questioning often reveals combined steroid and alcohol exposure (DKOU, 2017).

How steroids damage the femoral head

The exact mechanism is still being studied, but several processes work together:

Fat cells swell inside the bone. Steroids raise blood fat levels and make marrow fat cells multiply and enlarge. The femoral head is a rigid, closed space, so rising pressure squeezes the small vessels shut.
Fat particles block vessels. Tiny fat droplets can lodge in the small arteries feeding the bone.
Blood clots more easily. Steroids promote clotting in the small vessels.
Bone repair slows down. Steroids suppress the cells that build bone and speed up the death of existing bone cells.

The femoral head is especially vulnerable because its blood supply travels in one direction through a few narrow vessels, with little backup.

How much steroid is risky?

There is no single "safe" dose. Risk rises with the daily dose, the total (cumulative) dose and how quickly a large amount is given. The largest analysis, of 57 studies and 23,561 patients, found (Mont et al., 2015):

Exposure	Effect on AVN risk
More than 20 mg prednisone a day	About 9 times the odds of AVN compared with lower daily doses
Every extra 10 mg a day	About 3.6% higher rate of AVN
Cumulative dose above 10 g	About 2.4 times the odds
High-dose therapy overall	AVN in about 6.7% of patients, ranging from 0.3% to 52% across studies

Peak doses matter more than the total. Risk is concentrated in the first weeks to months of high-dose treatment, especially the first 3 months (review, 2017). The international ARCO criteria label AVN as steroid-associated when more than 2 g of prednisolone (or equivalent) was taken within 3 months and AVN is diagnosed within 2 years (ARCO, 2019). In lupus, pulse therapy and a starting dose above 60 mg a day raised risk significantly, while the cumulative dose did not (Frontiers in Immunology, 2026).

What about low doses? AVN on low doses is rare but documented, including after years of 4 to 5 mg a day (PMC case series). Rare cases have also followed long-term inhaled, nasal or injected steroids. A short course for a mild allergy carries very little risk.

Prednisone equivalents. Doses are compared as prednisone equivalents: 5 mg prednisone ≈ 4 mg methylprednisolone ≈ 0.75 mg dexamethasone. Dexamethasone is powerful, so 6 mg a day, as used in COVID-19, equals about 40 mg of prednisone.

Who is most at risk?

Two people on the same dose can have very different outcomes. Risk is higher with:

Conditions treated with high or repeated steroid doses: lupus, organ and bone marrow transplants, leukaemia, nephrotic syndrome, severe asthma, inflammatory bowel disease, severe skin disease and severe COVID-19
Pulse (intravenous) therapy and high starting doses
Alcohol on top of steroids: the two share mechanisms and add to each other's risk
Clotting tendency and high blood fats
Individual metabolism: people who break down steroids more slowly in the liver, through lower activity of an enzyme called CYP3A, appear more susceptible (BMC case report and review)

Steroid-related AVN typically affects younger adults, with a peak between 30 and 40 years (Liu et al., 2017). It is also often bilateral: in one series, 82% of steroid-induced cases involved both hips (KoreaMed). If one hip is affected, the other should be checked.

Post-COVID steroid AVN in India

During COVID-19, dexamethasone and methylprednisolone were used widely for moderate and severe disease, and saved many lives. Indian orthopedic centres have since reported a clear rise in AVN in young adults:

Study	Patients	Key findings
KIMS-Sunshine, Hyderabad (Cureus, 2025)	118 patients, 212 hips	Mean age 36.8 years; 87% men; most had both hips affected
P.D. Hinduja Hospital, Mumbai (Agarwala et al., 2022)	48 patients, 88 hips	Mean steroid dose about 841 mg prednisolone equivalent; AVN appeared on average 179 days after starting steroids
Earlier Mumbai series (Agarwala et al.)	Small series	AVN as early as about 2 months, after a mean of 759 mg prednisolone
Central Karnataka hip replacements (J Orthop Case Rep, 2025)	100 hips	AVN was the reason for 80% of hip replacements after the pandemic, compared with 13% before; patients were younger

Why so aggressive at relatively low doses? These total doses are below the classic thresholds above. Researchers suspect COVID-19 itself adds risk, by damaging blood vessels and making blood clot more easily, on top of the steroid effect (Agarwala et al., 2022).

If you received steroids for COVID-19 and now have hip, groin, thigh or buttock pain, even a year or more later, get it checked.

Warning signs and diagnosis

Early AVN is often silent. When symptoms appear, they usually include:

A deep ache in the groin, the most common first symptom
Pain spreading to the thigh, buttock or knee
Pain and stiffness putting on socks, sitting cross-legged or turning the hip
A limp, and later pain at rest or at night

Get an MRI, not just an X-ray. X-rays are often normal in early AVN. MRI detects it weeks to months earlier and shows whether the other hip is affected. Anyone with a steroid history and groin pain lasting more than 2 to 3 weeks should ask for one.

A note on treatment. Early detection decides the options. Before the femoral head collapses, joint-preserving treatment such as core decompression may save the hip; after collapse, hip replacement is usually needed. Our avascular necrosis hip treatment guide covers these options in detail.

Reducing your risk while on steroids

Never stop steroids suddenly. Abrupt withdrawal can be dangerous; always change doses with your doctor
Use the lowest effective dose for the shortest time, and ask about steroid-sparing medicines for long-term conditions such as lupus or rheumatoid arthritis
Avoid alcohol during and after high-dose courses
Tell your orthopedic doctor about any significant steroid course, including for COVID-19, even if you have no symptoms
Watch for groin pain for at least 2 years after a high-dose course, and get early MRI if it appears
Keep bones healthy with enough calcium, vitamin D and weight-bearing activity, and stop smoking

Frequently asked questions

Can prednisone cause AVN even at a low dose? Rarely. Most cases follow more than 20 mg a day or a large total over a few months, but AVN has been reported after years of 4 to 5 mg a day.

How soon after steroids can AVN develop? Usually within months. In Indian post-COVID patients, AVN appeared on average about 6 months after starting steroids, and sometimes within 2 months. Most steroid-related AVN is diagnosed within 2 years of exposure.

Does stopping prednisone reverse AVN? No. Reducing steroids, when it is medically safe, helps prevent new damage, but bone that has already died does not recover on its own.

Is AVN after COVID-19 caused by the steroids or the virus? Probably both. Steroids are the main driver, but COVID-19 may add risk by damaging blood vessels and increasing clotting.

Does alcohol cause AVN? Yes. Heavy, long-term drinking is one of the two leading causes of non-traumatic AVN, and it adds to the risk from steroids.

Can steroids cause AVN in other joints? Yes. The hip is affected most often, but the shoulder, knee and ankle can also be involved.

I took steroids but have no pain. Should I get checked? Mention it to your doctor. After a large or prolonged course, especially with other risk factors, an MRI may be advised even without symptoms.

The bottom line

AVN has several causes, but steroids and alcohol lead the list. Steroid risk rises with high daily doses (more than 20 mg of prednisone a day), large amounts over a few months and pulse therapy, and it varies from person to person. Since COVID-19, Indian centres have seen many young adults with AVN in both hips after relatively short steroid courses. If you have taken steroids and develop groin pain, ask for an MRI early, because early diagnosis keeps hip-saving options open.

For an assessment, book a consultation with Orthopedic Surgeons at Sports Orthopedics Institute, HSR Layout, Bengaluru.

This article is for general information and does not replace a personal consultation with a qualified orthopedic surgeon. Do not stop or change prescribed steroids without speaking to your doctor.

References

Mont MA, et al. High-dose corticosteroid use and risk of hip osteonecrosis: meta-analysis and systematic literature review. J Arthroplasty. 2015.
Yoon BH, et al. ARCO etiologic classification criteria for osteonecrosis of the femoral head, 2019, as summarised in this ONFH evidence review.
Corticosteroid-induced osteonecrosis of the femoral head: risk factors, diagnosis and treatment review. 2017.
Glucocorticoid dosage and risk factors for ONFH in systemic lupus erythematosus: systematic review and meta-analysis. Front Immunol. 2026.
Avascular necrosis with low-dose glucocorticoids: case report and review. PMC.
Ikeuchi K, et al. Epidemiology of nontraumatic osteonecrosis of the femoral head in Japan. Mod Rheumatol. 2015;25(2):278–281.
Zhao D, et al. Epidemiological study based on China Osteonecrosis of the Femoral Head Database. Orthop Surg. 2021;13(1):153–160.
Liu F, et al. An epidemiological study of etiology and clinical characteristics in patients with nontraumatic osteonecrosis of the femoral head. J Res Med Sci. 2017;22:15.
Uncertainty of classification of potential causative factors for nontraumatic ONFH. DKOU 2017.
Corticosteroid dose increase and contralateral ONFH: case report. BMC Musculoskelet Disord. 2019.
Osteonecrosis of the femoral head in adults: etiology and bilaterality. KoreaMed.
Outcomes of hip avascular necrosis following COVID-19 infection: 212 hips with minimum two-year follow-up. Cureus. 2025. doi:10.7759/cureus.87230
Agarwala S, Vijayvargiya M, et al. Bisphosphonates for post-COVID osteonecrosis of the femoral head. JBJS Open Access. 2022. doi:10.2106/JBJS.OA.22.00060
Dose–response meta-analysis of corticosteroid effects in SARS: model for ONFH screening after COVID-19. Life. 2023;13(4):907.
Aishwarya R, et al. Is there an increase in total hip arthroplasty due to ONFH after COVID-19? J Orthop Case Rep. 2025;15(1):247–253.

Groin Pain After Steroids? How Prednisone and Other Causes Lead to AVN of the Hip