This article highlights recent studies, particularly those with an emphasis on magnetic resonance imaging, that are providing unique insights into the relation between structures identified on imaging and the symptoms and genesis of osteoarthritis. These insights are changing the way disease prevalence is viewed and providing new insights into disease genesis. Furthermore, it is becoming increasingly apparent that the subchondral bone, periosteum, periarticular ligaments, periarticular muscle spasm, synovium, and joint capsule are all richly innervated and are the likely source of nociception in osteoarthritis. In addition, it is apparent that local tissue alterations in the bone and meniscus and alignment of the lower extremity are important in terms of disease genesis. The article is consistent with the literature in that much of the focus and understanding is knee-centric with less focus on the hip and hand.