PDB is the second most common metabolic bone disease characterised by increased but disorganised bone remodelling. Some patients are asymptomatic but others present with bone pain or other complications such as fracture and deformity. Major advances have been made in understanding the pathophysiology of PDB in recent years and highly effective agents are now available with which to suppress the abnormal bone turnover that causes the disease. In Chapter 1, an overview of the recent advances in the epidemiology, pathogenesis, clinical features and management of PDB is discussed. The clinical presentation of a cohort of patients with PDB and a systematic review and time trend analysis examining the way in which patients with PDB come to medical attention is discussed in Chapter 2. Chapter 3 provides a detailed analysis of randomised clinical trials examining and comparing the effects of various bisphosphonates used in the management of PDB. The long term effects of intensive treatment aimed at normalising ALP levels compared with a symptomatic approach using analgesia only initially is explored in Chapter 4. The change in ALP with bisphosphonate treatment and its relation to and impact on bone pain and quality of life scores as measured using the Short Form Survey 36‐Item (SF36) questionnaire will be discussed in Chapter 5. In Chapter 6, I finally reflect upon the future challenges that remain to be overcome to explain the unusual distribution of the disease and to favourably alter the natural history and prevent the development of complications.