The mosaic of pathophysiology causing patellofemoral pain:: Therapeutic implications

Before embarking on a therapeutic program to treat patients with patellofemoral pain, including surgical intervention, it is crucial to have an understanding of the pathophysiology causing the symptoms. Our view of the genesis of patellofemoral pain is that the loss of homeostasis of innervated patellofemoral tissues often unimagable by standard radiographic studies, including magnetic resonance imaging, is a more important factor than the presence of abnormal structural characteristics. The most likely sources of nociceptive output in patients with patellofemoral pain are the innervated peripatellar soft tissues, including synovium, and the intraosseous environment of the patella. The goal of treatment of patients with patellofemoral pain should be the restoration of tissue homeostasis rather than the achievement of a "normal" patellofemoral position. Conservative measures, including scrupulous load restriction, anti-inflammatory therapy, and rehabilitation, should be tried first in most cases. Failing an appropriate conservative therapeutic course, a cautious and analytical approach to surgical treatment may be warranted.