Inhibition of matrix metalloproteases (MMPs) for the treatment of diseases, such as cancer, arthritis and other diseases associated with tissue remodeling, has become an area of intense interest in the pharmaceutical industry in recent years. Despite tremendous efforts over the last decade to explore individual members of this target family, along with multiple inhibitor classes, simple and effective drugs for inhibiting individual MMPs have not yet emerged. This review highlights the major developments in research into MMPs and their inhibitors, from the recent medicinal chemistry literature, with a focus on structure-based design, selectivity and pharmacokinetic (PK) properties. The increasing availability of high-resolution X-ray crystal structures for many members of this protein family makes MMPs ideally suited for structure-based design approaches, which are now routinely used in this area. The most challenging aspect of lead optimization for MMP inhibitors is in finding candidates having acceptable pharmacological, PK and selectivity profiles. Clinical trials in cancer giving disappointing results have led to discussions on how to gain adequate MMP selectivity in order to minimize side effects. Unfortunately, careful analysis of X-ray crystal structures has not suggested any simple solutions. These areas collectively constitute the main challenges in the current search for orally available MMP inhibitors, and will be discussed in this review.