Understanding the etiopathogenesis of both osteonecrosis and osteoporosis can remarkably minimize associated morbidity and mortality. An astute clinician should carefully assess the complexity of specific problems in formulating a working diagnosis of chronic back and hip pain in an elderly patient. Although degenerative conditions are more common, malignancy should not be missed. Careful evaluation of various manifestations complemented with appropriate ancillary procedures in these two conditions are integral in clinical management decisions. Evidence-based therapeutic modalities with foremost consideration to safety, efficacy and cost, are the mainstays in managing osteonecrosis and osteoporosis.