There is no shortcut to accurate diagnosis in the patellofemoral pain patient. Most important in the process is a desire and ability to specifically identify the structural and biomechanical origin of pain. This can be elusive and often requires a careful analysis of all factors affecting the patient, including documenting his or her specific history of pain origin and specific treatments to date, and acknowledging the patient's localization of the pain origin. Many patients can pinpoint the site of pain origin when given the time and encouragement to do so. Of all sources of anterior knee pain, intractable pain related to diffuse patella articular cartilage deficiency can be most troublesome, particularly in a young person. Rest and removal of inciting causes of pain must always be the first option. Surgery is usually unnecessary, but may be extremely helpful in recalcitrant cases. Releasing excessively tight, painful contracture, removing unstable fragments and impinging synovial tissue, and sometimes permanently unloading a well-documented painful distal or lateral articular lesion by anteromedial tibial tubercle transfer will eliminate resistant pain in even the most resistant anterior knee pain patient.