Asian Journal of Case Reports in Medicine and Health

Avascular necrosis (AVN) of the femoral head is a progressive osteonecrotic condition often linked to corticosteroid therapy or excessive alcohol. Plain radiography is the most accessible initial tool, yet its accuracy is limited by technical factors, observer variability, and the inherent delay between ischaemia and bone density changes. We report a 42-year-old male with chronic alcohol intake who presented with bilateral groin pain and restricted internal hip rotation. Initial radiography revealed femoral head sclerosis, lucencies, and joint space narrowing—findings suggestive of bilateral AVN (radiographically consistent with Ficat-Arlet stage II). However, MRI was deferred, so the diagnosis was never definitively confirmed. The patient received conservative management including restricted weight-bearing, acupuncture, physiotherapy, and ozone therapy. A follow-up X-ray 51 days later, surprisingly, showed complete radiological "normalisation" without demonstrable lesions; nevertheless, the patient continued to have residual discomfort and an antalgic gait, creating a clinical-radiological paradox. This case highlights plain radiography pitfalls, particularly when MRI is unavailable. The apparent change is more plausibly explained by observer variability, technical acquisition differences, or alternative diagnoses (e.g., transient bone marrow oedema), rather than true healing of confirmed AVN. Critically, a normal plain radiograph never excludes AVN when clinical suspicion persists, and contrast-enhanced MRI remains the mandatory gold standard to establish an accurate diagnosis and prevent femoral head collapse.