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The pathology we discuss in the present monograph presents itself with a multifactorial etiology and a great pathogenic, diagnostic, and therapeutic complexity.

The consideration of anterior knee pain to be a self-limited condition in patients with an underlying neurotic personality should be banished from the orthopedic literature.

Our knowledge about anterior knee pain has evolved throughout the twentieth century. While until the end of the 1960s this pain was attributed to chrondromalacia patellae, a concept born at the beginning of the century, after that period it came to be connected with abnormal patellofemoral alignment. More recently, the pain was put down to a wide range of physiopathological processes such as peripatellar synovitis, the increment in intraosseous pressure, and increased bone remodeling. We are now at a turning point. New information is produced at breakneck speed. Nowadays, medicine in its entirety is being reassessed at the subcellular level, and this is precisely the line of thought we are following in the approach to anterior knee pain syndrome. Still to be seen are the implications that this change of mentality will have in the treatment of anterior knee pain syndrome in the future, but I am sure that these new currents of thought will open for us the doors to new and exciting perspectives that could potentially revolutionize the management of this troublesome pathological condition in the new millennium we have just entered. Clearly, we are only at the beginning of the road that will lead to understanding where anterior knee pain comes from.

This study is not intended to advocate for a particular surgical technique, but it does provide insight into improving our understanding of the pathophysiology of anterior knee pain syndrome. Our objectives were: to identify a relationship, or lack of one, between the presence of PFM and the presence of anterior knee pain and/or patellar instability; to analyze the long-term response of VMO muscle fibers to increased resting length; and to determine the incidence of patellofemoral arthrosis after IPR surgery. Our findings indicate (1) that not all PFM knees show symptoms; that is, PFM is not a sufficient condition for the onset of symptoms, at least in postoperative patients; (2) that the advancement of VMO has no deleterious effects on VMO; and (3) that IPR does not predispose to retropatellar arthrosis.

The observations reported here provide a neuroanatomic basis for anterior knee pain syndrome in the young patient and support the clinical observation that the lateral retinaculum may have a key role in the origin of this pain. Our findings, however, do not preclude the possibility of pain arising in other anatomical structures.

We hypothesize that periodic short episodes of ischemia could be implicated in the pathogenesis of anterior knee pain by triggering neural proliferation of nociceptive axons (SP positive nerves), mainly in a perivascular location. Moreover, we believe that instability in patients with anterior knee pain syndrome can be explained, at least in part, because of the damage of nerves of the lateral retinaculum that can be related with proprioception.

We report the clinical results of an anterior interval release for recalcitrant anterior knee pain associated with decreased patellar mobility after anterior cruciate ligament (ACL) reconstruction.

Thirty consecutive patients with recalcitrant anterior knee pain and decreased patellar mobility after ACL reconstruction underwent an arthroscopic lysis of adhesions and scar of the distal patella tendon from the proximal anterior tibia (anterior interval release). Anterior knee pain was initially treated nonoperatively. Failure of nonoperative treatment was defined by recalcitrant anterior knee pain and no improvement in functional outcome, assessed by Lysholm scores and patient questionnaires. Minimum clinical followup was 2 years. All anterior interval release procedures were also performed by the senior author using a high inferolateral viewing portal in order to arthroscopically evaluate the anterior interval between the patella tendon and tibia. Prior to anterior interval release, Lysholm score averaged 68 (range 18–90). Postoperative Lysholm score averaged 85 (range 68–100) (P < 0.0001). Postoperative range-of-motion did not change significantly. Postoperative instability examinations were all graded zero using the International Knee Documentation Committee (IKDC) system. Average patient satisfaction at follow-up was 8.0 (1 = very dissatisfied; 10 = very satisfied).

Early operative intervention with an anterior interval release has been shown in this series to result in significantly improved functional outcomes in the treatment of recalcitrant anterior knee pain after ACL reconstruction.

Acute patellar dislocation is a common injury that can lead to disabling knee pain and/or recurrent instability. In the past 10 years, research has begun to focus on the injuries associated with acute patellar dislocation, and the specific contributions the injured structures make to patellar stability in intact knees. The implication is that injury to specific structures may have important consequences in converting a previously asymptomatic, though perhaps abnormal, patellofemoral joint into one that is painful and/or unstable. These studies have been intended to improve the precision of surgical treatment for patellar instability, and their results are driving refinements in our surgical indications as well as technique.

There is no substitute for a thorough history and a complete and careful physical examination. The history and physical examination still remain the first step for making an accurate diagnosis of anterior knee pain and patellar instability above any technique of diagnostic image. Imaging studies are a second step and can never replace the former. Surgical indications should not be based only on methods of image diagnosis as there is a poor correlation between clinical and image data. Finally, arthroscopy should be used judiciously and no realignment surgery should be based solely on the arthroscopic analysis of the patellofemoral congruence.

This study is not intended to advocate for a particular surgical technique, but it does provide insight into improving our understanding of the pathophysiology of anterior knee pain syndrome. Our objectives were: to identify a relationship, or lack of one, between the presence of PFM and the presence of anterior knee pain and/or patellar instability; to analyze the long-term response of VMO muscle fibers to increased resting length; and to determine the incidence of patellofemoral arthrosis after IPR surgery. Our findings indicate (1) that not all PFM knees show symptoms; that is, PFM is not a sufficient condition for the onset of symptoms, at least in postoperative patients; (2) that the advancement of VMO has no deleterious effects on VMO; and (3) that IPR does not predispose to retropatellar arthrosis.

In the treatment of patellofemoral complications, the surgical treatment should address the primary pathology as well as the changes induced by the failed procedure. Cutting normal ligaments, removing articular cartilage, or transferring tendons to an abnormal position usually create new problems and should be performed cautiously.

We report the clinical results of an anterior interval release for recalcitrant anterior knee pain associated with decreased patellar mobility after anterior cruciate ligament (ACL) reconstruction.

Thirty consecutive patients with recalcitrant anterior knee pain and decreased patellar mobility after ACL reconstruction underwent an arthroscopic lysis of adhesions and scar of the distal patella tendon from the proximal anterior tibia (anterior interval release). Anterior knee pain was initially treated nonoperatively. Failure of nonoperative treatment was defined by recalcitrant anterior knee pain and no improvement in functional outcome, assessed by Lysholm scores and patient questionnaires. Minimum clinical followup was 2 years. All anterior interval release procedures were also performed by the senior author using a high inferolateral viewing portal in order to arthroscopically evaluate the anterior interval between the patella tendon and tibia. Prior to anterior interval release, Lysholm score averaged 68 (range 18–90). Postoperative Lysholm score averaged 85 (range 68–100) (P < 0.0001). Postoperative range-of-motion did not change significantly. Postoperative instability examinations were all graded zero using the International Knee Documentation Committee (IKDC) system. Average patient satisfaction at follow-up was 8.0 (1 = very dissatisfied; 10 = very satisfied).

Early operative intervention with an anterior interval release has been shown in this series to result in significantly improved functional outcomes in the treatment of recalcitrant anterior knee pain after ACL reconstruction.

Management of patellofemoral pain is no longer a conundrum if the therapist can determine the underlying causative factors and address those factors in treatment. It is imperative that the patient’s symptoms are significantly reduced. This is often achieved by taping the patella, which not only decreases the pain, but also promotes an earlier activation of the VMO and increases quadriceps torque. Management will need to include specific VMO training, gluteal control work, stretching tight lateral structures, and appropriate advice regarding the foot, be it orthotics, training, or taping.