This commentary critically examines the foundational assumptions, practices and claimed distinctiveness upon which osteopathy was built and continues to be structured. Five areas which are considered to be highly problematic for osteopathy, namely its weak theoretical basis, inherent biomedicalism, monointerventionism, default practitioner-centredness and predilection for implausible mechanisms. It is argued that these areas require considerable reflection and action as if not remedied, they constitute a major threat to the development, unity and legitimacy of the osteopathic profession. Ongoing reconceptualisation of underpinning theories, assumptions and associated skills informed by current evidence and knowledge from disciplines outside of the osteopathic domain is necessary for professional maturation. Implications for practice•Osteopathy's weak theoretical basis, biomedicalism, monointerventionism, practitioner-centredness and implausible mechanisms are problematic.•These constitute a major threat to the development, unity and legitimacy of osteopathy.•Ongoing critical reflection, practice reconceptualisation and research are needed for professional maturation.•Osteopaths should draw on theory and evidence from outside the osteopathic domain.