The major focus of the guideline is management of established pain and disability in patients with existing osteoarthritis. It raises several conundrums for clinicians. Firstly, it identifies as core treatments those that are low risk and low cost. However, these treatments are also generally low in efficacy with low or negligible effect sizes.1 Of the core treatments, only exercise therapy has a moderate effect size for treating pain in osteoarthritis, which is similar to the effect size of the more risky and costly oral non-steroidal anti-inflammatory drugs (NSAIDs). Although these core treatments should be integrated into osteoarthritis management, in clinical practice they are rarely sufficient as …