Insufficiency fractures of the pelvis are being increasingly recognized as a major cause of low back pain in elderly women with osteoporosis. Fractures in the sacrum are difficult to diagnose, as plain radiographic findings are either unhelpful or misleading. Bone scintigraphy is very sensitive for the detection of fractures in the sacrum, with demonstration of the H-shaped (or butterfly) sacral pattern or the combination of concomitant sacral and parasymphyseal uptake being considered as characteristic of insufficiency fractures. Computed tomography (CT) is helpful for confirming the presence of fractures in cases with atypical scintigraphic patterns, particularly in those with a known primary malignant neoplasm. CT is especially useful in the further evaluation of parasymphyseal and pubic rami lesions. The majority of patients respond well to periods of enforced bed rest and administration of analgesics. Recognition of the spectrum of imaging findings for this entity should lead to its correct identification and the institution of appropriate treatment.