There are similarities in the imaging presentation of subchondral insufficiency fractures of the femoral head (SIF) and osteonecrosis of the femoral head (ON). Femoral head necrosis is characterized on imaging by subchondral bone collapse accompanied by subchondral fractures forming crescentic signs and sclerotic bands, but some subchondral incomplete fractures of the femoral head can also have the same imaging presentation. A recent study showed that SIF can be distinguished from ON by the presence of a low signal band on T1-weighted images on MRI, which is usually irregular, curved, and convex to the articular surface. In contrast, the low signal band of ON represents necrotic repair tissue that is morphologically smooth, opposite to the articular surface alignment and surrounds all necrotic segments. In reality, MRI is not available in every medical institution, and the presence of low signal bands in SIF, like ON and opposite to the articular surface alignment, has been reported in the literature. Ikemura conducted a clinical study on patients with subchondral collapse in Japan, hoping to find clinical features that distinguish ON from SIF. The results were published in the journal Arch Orthop Trauma Surg. Forty-four patients over 60 years of age with a total of 46 hip pains and subchondral collapse on imaging were included from May 1998 to July 2010, investigated for a history of hormone use and alcohol abuse, and had their body mass index (BMI) measured and calculated, and were defined as obese over 26.4. Sclerotic bands and/or crescentic signs on imaging were recorded in each patient. The femoral head was examined in all patients. According to the pathological examination, 22 patients (22 hips) were SIF and 22 patients (24 hips) were ON. It was found that the percentage of patients in the SIF group was significantly older and more female than in the ON group. 95.5% of the ON group (21/22) had hormone use or alcohol abuse, while only 22.7% (5/22) of the patients in the SIF group had hormone use and 1 patient had alcohol abuse (1/22). Thirteen patients in the SIF group had vertebral compression fractures compared with three in the ON group, a significant difference. If the patients were female and older than 70 years, the ratio of SIF occurrence relative to ON was 12.01 and 7.29, respectively. patients were much more likely to have SIF than ON if they were on hormones or alcohol abuse.