We present a rational, scientific, low-risk approach to patellofemoral pain (anterior knee pain) based on an understanding of tissue homeostasis. Loss of tissue homeostasis from overload and/or injury produces pain. Bone overload and synovial inflammation are common sources of such pain. Chondromalacia and malalignment are findings that almost always do not need to be "corrected" to relieve pain. Patience and persistence in nonoperative care results in consistent success. Surgery should be rare and done only after extensive nonoperative management and in the setting of clearly defined pathology. Rational surgical treatment is explained in the context of restoring tissue homeostasis to relieve pain.