Hypophosphatasia — a form of metabolic bone disease characterized by low serum alkaline phosphatase activity — results from loss-of-function mutations in the gene encoding the tissue-nonspecific isoenzyme of alkaline phosphatase (TNSALP). Here, Michael Whyte discusses the aetiology, nosology, pathogenesis, diagnosis and treatment of hypophosphatasia, which is particularly timely given the recently reported successes and approvals of treating the disease using asfotase alfa, a bone-targeted, recombinant TNSALP.