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The underlying principle of treatment for patients with patellofemoral pain from a tissue homeostasis perspective is to maximize the range of painless loading for a given symptomatic joint (envelope of function) as safely and predictably as possible. Current therapeutic approaches aimed at surgical correction of chondromalacia and malalignment often are neither safe nor predictable. A tissue homeostasis approach involves addressing the pathokinematics—primarily through temporary but scrupulous load restriction, anti-inflammatory therapy, and a gentle painless rehabilitation program. Failing this, a careful and analytical surgical approach may be warranted to include a possible gentle peripatellar synovectomy.