Osteoporosis (OP) is a metabolic bone disease characterized by reduced bone mass and destruction of bone microstructure, posing a serious threat to the health of the elderly population. Studies in osteoimmunology have revealed that an imbalance between Th17 cells and regulatory T cells (Treg) is a core immunopathological mechanism underlying OP: overactivation of Th17 cells promotes osteoclast differentiation and accelerates bone resorption, while impaired Treg function weakens bone protection, ultimately leading to disrupted bone metabolism. Traditional Chinese medicine (TCM), with its advantages in multi-target and holistic regulation, shows broad application prospects in restoring Th17/Treg balance and reshaping the bone immune microenvironment. This article systematically reviews the molecular mechanisms by which TCM compounds (e.g., Yishen Juanbi Pills, Jintiange Capsules) and active components (e.g., icariin, astragaloside IV) regulate T cell differentiation, with a focus on the involvement of signaling pathways such as NF-κB and Wnt/β-catenin, as well as the gut microbiota–short-chain fatty acids axis in mediating immune regulation. In addition, it summarizes preclinical and clinical research evidence supporting the use of TCM in treating OP. In response to current challenges, including insufficient target analysis and a lack of high-quality clinical evidence, this paper proposes that future efforts should integrate cutting-edge approaches such as multi-omics technologies, nano-delivery systems, and artificial intelligence to systematically elucidate the molecular network through which TCM regulates bone immunity. Such advances will facilitate the transition of TCM from experience-based to evidence-based medicine, providing safer and more effective immune-targeted therapeutic strategies for the prevention and management of OP.