Back pain is a common problem in general practice, and is of enormous economic importance. A recent report urges general practitioners (GPs) to refer early for manual therapies, such as osteopathy. The key concept to understanding osteopathic principles is somatic dysfunction. This is a disorder of function, rather than pathology, of the musculoskeletal and related systems. Its characteristic features are asymmetry of anatomical landmarks, asymmetry of joint movement, tissue texture changes, and tenderness. The scientific basis of the tissue texture changes and tenderness can be explained in terms of the 'facilitated segment', but the cause of movement asymmetry remains elusive. Randomized controlled trials provide some support for the use of osteopathic treatment in acute low back pain. It is proposed that somatic dysfunction is the new paradigm for non-specific back pain.