patellar impingement is 99,9% of the time due to patella infera/baya and fat pad fibrosis, with a catching of the low pole of the patella that remains stuck down bending from an extended position keeping the patella inclined inwards/down and creating a click/release at a certain moment during flexion.
Now an opposite view of the question: what if (for the record I'm sure of it in some cases like mine) part of the patellar impingement (not saying is the only cause but part of it, even up to 50%) is due to elevation/thickening of the structures that slide under the top of the patella extending the knee as they are scarred, fibrotic and consequently simply higher than they shoud be?
Once the knee is straightened and the quad is thight, the patella progressively slides up covering anatomical parts that if thickened will obviously keep the patella inclined inwards so more prone to fat pad impingement.
I'm talking of thickening in the part of the supra-patellar pouch that slides under the patella extending + medial/lateral areas thickened too (bend your knee 90° and take a look that medial/lateral parts too that are then exposed and that become completely covered by the patella once you reach an extended position, the patella slided up so much that these medial/lateral parts arrive to be even around under half of the patella once the knee is extended!).
Are these parts intra-articular, extra-articular or could be the joint capusule itself?
I know very well supra-pat. pouch is intra-articular, but these elevated parts clearly go under the kneecap even after the supra-patellar pouch was surgically extensively investigated/fixed, so where are they?
Maybe the right question is about the joint capsule: does it just envelope the whole knee or the patella is out of the joint caspsule with some kind of insertion on the medial/lateral side of the patella?
Any feedback is truly appreciated - thank you in advance