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Principles of Health: Occupational Therapy & Physical Therapy

Osteonecrosis

by Robin Kamienny Montvilo

Specialties and related fields: Orthopedics; Rheumatology

Definition: a disorder that occurs when the blood supply to bone is cut off, causing the death of bone tissue and leading to the collapse of joints in the affected areas

KEY TERMS

bisphosphonate: the most commonly prescribed group of drugs to prevent loss of bone density and treat osteoporosis

osteoporosis: a bone disease that develops when bone mineral density and bone mass decrease or when the structure and strength of bone changes, leading to a decrease in bone strength that increase the risk of fractures

osteotomy: the surgical cutting of a bone or removal of a piece of bone

CAUSES AND SYMPTOMS

Osteonecrosis—from osteo, meaning “bone,” and necro, meaning “death”—may be either post-traumatic or nontraumatic, in some cases with risk factors identified and in others with no known cause (idiopathic). Approximately twenty thousand new cases are diagnosed each year in the United States, most commonly between the ages of twenty and fifty, with the average age of onset at thirty-eight. Osteonecrosis is of equal prevalence in men and women.

Some risk factors seem to predispose people to osteonecrosis, including corticosteroids (to treat inflammatory conditions) and excessive alcohol ingestion. Both steroid and alcohol use may lead to a buildup of lipids in the blood vessels, decreasing blood flow to bones. Injury to a bone or joint (such as a fracture) may damage the blood vessels, decreasing the blood supply and causing bone death. Medical conditions which affect the bone (gout, osteoarthritis, osteoporosis) may predispose someone to osteonecrosis. Cancer treatments (radiation and chemotherapy) and organ transplantation also increase the risk of osteonecrosis, as do other medical conditions, including sickle cell disease and acquired immunodeficiency syndrome (AIDS).

Bisphosphonates are the first-line treatment for osteoporosis.

Osteonecrosis of the jaw (ONJ) has occurred in 1/50,000 osteoporosis patients who routinely take an oral bisphosphonate. The incidence of ONJ is higher in patients with cancer or immunosuppression treated with high-dose IV bisphosphonates. Other risk factors include dental extractions and periodontal infection.

Another osteoporosis treatment, denosumab (Prolia), is a fully humanized monoclonal antibody that inhibits the RANK ligand (RANKL) protein. RANKL is secreted by bone-building osteoblasts in bone when it undergoes damage. RANKL recruits precursor cells to become bone-destroying osteoclasts. By inhibiting RANKL, denosumab decreases bone destruction and increases bone density. Denosumab, injected subcutaneously every six months, also increases the risk of ONJ.

Often, few symptoms occur in the early stages of the disease. Initial symptoms include pain in the affected joint, followed by collapse of joint surfaces and increased pain. Pain occurs initially only when the joint is in use and later even at rest. The bones most commonly affected are the ends of the femur, the upper arm bone, and the knees, shoulders, and ankles. Within months to two years from the onset of symptoms, individuals may lose range of motion and suffer severe disability. Appropriate treatment must be undertaken to prevent the breakdown of joints. Therefore, immediate diagnosis is important. X-rays, magnetic resonance imaging (MRI), computed tomography (CT) scans, and bone scans serve as diagnostic tools when an individual is symptomatic.

Information on Osteonecrosis

Causes: Interruption of blood supply to the bone; may result from trauma, corticosteroid use, excessive alcohol consumption, bone disorders, cancer treatment

Symptoms: Chronic and progressive

Duration: Ranges from several seconds to minutes immediately after impact

Treatments: Nonsteroidal anti-inflammatory drugs (NSAIDs), anticoagulants, statins, exercises, electrical stimulation, surgery (core decompression, bone grafting, osteotomy, joint replacement)

TREATMENT AND THERAPY

Once the condition has been diagnosed, treatment should begin immediately. To decide on the most effective treatments, physicians consider the patient’s age, the disease’s progression, the location of the bones involved, and the underlying cause. Treatment can be either medical or surgical. Medical treatments include the use of NSAIDs to decrease pain, anticoagulants (blood thinners) to improve blood supply to the bone, and statins (cholesterol-lowering medications) to decrease lipid buildup in blood vessels, allowing improved blood flow to the bone. Other medical treatments involve a range of motion exercises, electrical stimulation to induce bone growth, and decreased weight-bearing on affected joints.

Surgical techniques for osteonecrosis include core decompression, bone grafting, osteotomy, and joint replacement. In core decompression, the inner core of the bone is removed, thus reducing pressure within the bone. Core decompression is often followed by bone grafting to the decompressed area to support the joint. Osteotomy is a surgical reshaping of the bone to decrease stress on affected areas. Joint replacement is the surgical treatment of choice in advanced cases. Treatment may be an ongoing process for years as the disease progresses. Adequate treatment allows afflicted individuals to continue to live reasonably normal lives.

SIGNIFICANCE

Occupational therapy can play a role in managing and rehabilitating individuals with osteonecrosis.

Here are some ways in which occupational therapy can help:

  • Pain management: Occupational therapists can employ various techniques to help individuals cope with osteonecrosis-related pain. Such pain abatement strategies may include heat or cold therapy, transcutaneous electrical nerve stimulation (TENS), or other modalities to alleviate pain and discomfort.

  • Adaptive equipment: In cases where osteonecrosis affects weight-bearing joints such as the hips or knees, occupational therapists can assess the individual’s functional needs and recommend appropriate adaptive equipment. Such equipment may include assistive devices like canes, walkers, or crutches to help with mobility and reduce joint stress.

  • Joint protection techniques: Occupational therapists can teach individuals with osteonecrosis techniques to protect their affected joints during daily activities. Joint protection strategies may involve educating them on proper body mechanics, ergonomics, and energy conservation strategies to minimize stress on the affected joints and prevent further damage.

  • Activity modification: Occupational therapists can help individuals modify their daily activities to accommodate their condition. They can guide alternative techniques or equipment to make tasks easier and less demanding on the affected joints. These modifications may involve recommending modifications at home, work, or other environments to promote independence and reduce the risk of exacerbating symptoms.

  • Range of motion exercises: Maintaining joint mobility is crucial in managing osteonecrosis. Occupational therapists can prescribe range of motion exercises and develop individualized exercise programs to help maintain joint flexibility and prevent joint stiffness or contractures.

  • Self-care training: Osteonecrosis can affect a person’s ability to perform self-care tasks independently. Occupational therapists can provide training in activities of daily living (ADLs), such as dressing, bathing, grooming, and toileting. They can offer strategies to simplify tasks, use adaptive equipment, and conserve energy during self-care routines.

  • Work-related interventions: For individuals with osteonecrosis who are still working, occupational therapists can assess their work environments and recommend modifications or ergonomic adjustments to minimize stress on affected joints. They can also guide pacing activities, scheduling breaks, and implementing assistive devices or adaptive strategies to support their ability to continue working.

Occupational therapy interventions and techniques vary depending on the individual’s needs, the severity and location of osteonecrosis, and other factors. Therefore, patients should consult a qualified occupational therapist who can provide a comprehensive evaluation and develop a tailored treatment plan.

Further Reading

1 

Bianchi, Giancarlo I., and Pascual C. Giordano. Osteonecrosis: Diagnosis, Treatment, and Management. Nova Science, 2013.

2 

Icon Health. Osteonecrosis: A Medical Dictionary, Bibliography, and Annotated Research Guide to Internet References. Author, 2004.

3 

Mont, Michael A., et al. Osteonecrosis of the Hip. Springer, 2010.

4 

National Institute of Arthritis and Musculoskeletal and Skin Diseases. Osteonecrosis: Questions and Answers About Osteonecrosis (Avascular Necrosis). US Department of Health and Human Services, 2011.

5 

National Osteonecrosis Foundation, www.nonf.org.

6 

Soucacos, Panayotis N., and James R. Urbaniak, editors. Osteonecrosis of the Human Skeleton. W. B. Saunders, 2004.

7 

Urbaniak, James R., and John Paul Jones, editors. Osteonecrosis: Etiology, Diagnosis, and Treatment. American Academy of Orthopaedic Surgeons, 1997.

Citation Types

Type
Format
MLA 9th
Montvilo, Robin Kamienny. "Osteonecrosis." Principles of Health: Occupational Therapy & Physical Therapy, edited by Michael A. Buratovich, Salem Press, 2023. Salem Online, online.salempress.com/articleDetails.do?articleName=POHTherapy_0064.
APA 7th
Montvilo, R. K. (2023). Osteonecrosis. In M. A. Buratovich (Ed.), Principles of Health: Occupational Therapy & Physical Therapy. Salem Press. online.salempress.com.
CMOS 17th
Montvilo, Robin Kamienny. "Osteonecrosis." Edited by Michael A. Buratovich. Principles of Health: Occupational Therapy & Physical Therapy. Hackensack: Salem Press, 2023. Accessed December 14, 2025. online.salempress.com.