Translating the knowledge gained from research of osteoporosis into a rational approach applicable to clinical practice is challenging. The availability of methods to quantify bone strength has enabled the diagnosis of osteoporosis before fractures occur. These methods are too costly for screening, and a case finding approach is usually recommended. An understanding of the epidemiology of osteoporosis and fractures has assisted in case finding and the development of clinical decision tools to direct diagnostic evaluation. Clinical suspicion is important in directing laboratory investigations for secondary causes of osteoporosis. There are increasingly available pharmaceutical options which are effective in reducing fracture rates among those with or without fractures. Although the use of treatment thresholds based on bone density to decide on therapy is supported by data from intervention trials, clinical assessment and an estimation of individual fracture risk to direct treatment decisions is increasingly being recognized as a more rational approach to the management of this disease.