Fundamental to rational, safe, and effective treatment for any orthopaedic condition is an accurate understanding of the etiology of the symptoms. The decades-old paradigm of a pure structural and biomechanical explanation for the genesis of patellofemoral pain is giving way to one in which biologic factors are being given more consideration. It is increasingly evident that a variable mosaic of possible pathophysiologic processes, often caused by simple overload, best accounts for the etiology of patellofemoral pain in most patients. Inflamed synovial lining and fat pad tissues, retinacular neuromas, increased intraosseous pressure, and increased osseous metabolic activity of the patella all have been documented as contributing to the perception of anterior knee pain. Considered together, these processes can be characterized as loss of tissue homeostasis and can be seen as providing a new and alternative explanation for the conundrum of anterior knee pain. Certain high loading conditions of the patellofemoral joint can be of sufficient magnitude to induce the symptomatic loss of tissue homeostasis so that, once initiated, they may persist indefinitely. From this new biologic perspective, it clinically matters little what structural factors may be present in a given joint (such as chondromalacia, patellar tilt or a Q angle above a certain value) if the pain free condition of tissue homeostasis is safely achieved and maintained.
Level of evidence: Level V (expert opinion). See the Guidelines for Authors for a complete description of levels of evidence.