Rheumatology (ACR) last published recommendations for the management of hip and knee OA in 2000 (2), with an addendum posted on the site in February 2005 (3). Since 2000, other professional societies have published recommendations for the management of hand, hip, and knee OA, including those developed by the European League Against Rheumatism (EULAR) (4-6), the Osteoarthritis Research Society International (OARSI) (7), and the American Academy of Orthopaedic Surgeons (AAOS) (8). Past ACR recommendations for the management of hip and knee OA were derived by a small group using an informal consensus approach following an extensive literature review. Since then, the methodology used to develop clinical practice guidelines has matured with the use of systematic literature reviews and the implementation of the Delphi method for development of consensus agreement on propositions (4-7) or the RAND/University of California, Los Angeles Appropriateness Method for determining when the use of certain therapeutic modalities is appropriate in a given clinical scenario (9). The current recommendations were developed using the Grades of Recommendation Assessment, Development and Evaluation (GRADE) approach, a formal process to develop recommendations that are as evidence based as possible. The GRADE approach has been adopted by the World Health Organization, the Cochrane Collaboration, the Agency for Healthcare Research and Quality (AHRQ) (10-14), and numerous professional organizations including, among others, the American College of Physicians and, most recently, the ACR. Since 2000, new therapies for OA and additional information on the safety and tolerability of existing therapies for OA have become available and, as noted above, the methodology for developing clinical practice guidelines has evolved. These factors combined to contribute to the decision of the ACR to revise and update recommendations for the management of OA of the hip and knee as well as create new recommendations for the management of OA of the hand. Applying these recommendations in clinical practice requires individualized assessment of the patient and consideration of the values and judgments of both the practitioner and the patient. The recommendations provided here are not intended to be used in a “cookbook” fashion, but rather to provide guidance based on clinical evidence and expert panel input. Unlike previous ACR recommendations for the management of OA, these recommendations do not recommend the sequence of subsequent interventions for those failing to have an adequate response to recommended initial therapies, as there are few, if any, high-quality studies that were designed to examine the benefit and safety of specific modalities under such assumptions. Although disseminated under the aegis of the ACR, we hope that these recommendations will have relevance to practitioners throughout the world. We specifically did not make recommendations regarding the use of pharmacologic agents that are not approved in the US and Canada, however, or regarding the use of surgical interventions, as this was beyond the scope of the charge to the committee. Systematic literature searches were conducted by a working group at the University of Ottawa, which also organized the summary evidence profiles and supporting documents. Systematic literature searches were performed for more than 50