Subchondral insufficiency fracture (SIF) of the femoral head is one of the predominant etiologies of rapidly progressive osteoarthritis of the hip (RPOH). SIF is a rare disease that causes acute pain in the hip joint. It is most frequently found in elderly women with osteoporosis. It is often underdiagnosed or misdiagnosed as osteonecrosis of the femoral head. SIF is currently a well-established cause of RPOH; however, the deeper etiology of SIF is not clear. Good clinical outcomes have been reported for hip preservation therapy and hip replacement. SIF is not obvious radiologically in the early stage, and a T1-weighted magnetic resonance imaging shows a discontinuous low-intensity band under the articular cartilage convex to the articular surface as its characteristic manifestation. Some patients will lose the opportunity to preserve the hip joint due to symptoms such as progressive joint space narrowing and subchondral collapse within a very short period. Patients with progressive hip space narrowing and subchondral collapse on X-ray should be converted to total hip arthroplasty. Based on the characteristics of the disease, surgeons need to master the clinical and radiological characteristics of SIF and strive for early diagnosis and treatment.