Aminoacyl-tRNA synthetases (ARS) are ubiquitously expressed, essential enzymes that charge tRNA with cognate amino acids. Variants in genes encoding ARS enzymes lead to myriad human inherited diseases. First, missense, nonsense, and frameshift alleles cause recessive multi-system disorders that differentially affect tissues depending on which ARS is mutated. Second, missense alleles cause dominant peripheral neuropathy. A preponderance of evidence has shown that both phenotypic classes are associated with loss-of-function alleles, suggesting that tRNA charging plays a central role in disease pathogenesis. However, it is currently unclear how perturbation in the function of these ubiquitously expressed enzymes leads to tissue-specific or tissuepredominant phenotypes. Here, we review our current understanding of ARS-associated disease phenotypes and explore potential explanations for the observed tissue specificity.