The field of stem cell biology continues to evolve with the ongoing characterization of multiple types of stem cells with their inherent potential for experimental and clinical application. Mesenchymal stem cells (MSC) are one of the most promising stem cell types due to their availability and the relatively simple requirements for in vitro expansion and genetic manipulation. Multiple populations described as "MSCs" have now been isolated from various tissues in humans and other species using a variety of culture techniques. Despite extensive in vitro characterization, relatively little has been demonstrated regarding their in vivo biology and therapeutic potential. Nevertheless, clinical trials utilizing MSCs are currently underway. The aim of this review is to critically analyze the field of MSC biology, particularly with respect to the current paradox between in vitro promise and in vivo efficacy. It is the authors' opinion that until this paradox is better understood, therapeutic applications will remain limited.