Vertebral compression fractures (VCFs) are the most common osteoporotic fractures. In the U.S., there are 1.5 million VCFs that occur annually and worldwide there is a vertebral fracture every 22 seconds. Overall, 25% of women over the age of 65 years and 40% of women over the age of 80 years will have a VCF. A detailed history and physical examination are essential to the diagnosis of a symptomatic VCF. There are many different pain generators in the spine including degenerative disc disease, facet arthropathy, spinal canal, or neural foraminal stenosis; and the characteristics of fracture pain must be separated from the pain produced by other spine pathology. Osteoporotic VCFs may be differentiated from malignant or metastatic fractures based on their MRI appearance.