Painful bone metastases are a clear indication for the use of radiotherapy, with reported response rates of up to 85% of patients treated. In an attempt to define the optimal use of palliative radiotherapy when used in this situation, the data for the efficacy, toxicity and choice of dose and fractionation are reviewed. Although there have been some recent trials demonstrating the value of hypofractionated radiation therapy, half-body irradiation and 89-strontium, in general there is a lack of information in this clinical area, particularly on the duration of beneficial effect and on treatment toxicity. The available data suggest that single-fraction radiation is as effective as short-course fractionated treatment, and may be isotoxic when 5HT3 antagonists are used. Future implications for research are discussed.