High-level athletes have some distinct characteristics which distinguish them from other patients. They are typically highly driven individuals and they compete in an environment which can increase their risk of certain complications. Anterior cruciate ligament (ACL) rupture in this group is a potentially career altering injury. Therefore, treating high-level athletes with ACL injury brings certain challenges. This chapter outlines the specific risks and complications associated with ACL reconstruction (ACLR) in this patient population. It also provides recommendations on how to mitigate risk and avoid complications. The pathway from the initial injury to return to sport and the problems encountered along the way are discussed. Finally, the long-term consequences of ACL injury in this specific patient group are addressed. A patient-centred approach has been employed in answering explicit questions often asked by high-level athletes in this setting. The information contained in this chapter is based on the latest evidence and provides realistic expectations for both the patient and the treating surgeon on what to expect in the path to recovery.