In the last few decades, the amount of physical activity and sports has dramatically increased in elderly patients. Longer life expectancy and a more active lifestyle have brought about a proportional increase in anterior cruciate ligament (ACL) injuries and the need to reconstruct them in this age range. Today, ACL injuries in elderly patients force us to look at treatment options in a new light. We know that joint instability in patients over 50 years of age, with active lifestyles, may be devastating for the knee and that overall results in ACL reconstruction are similar to those obtained in younger patients. This kind of surgery is the ideal choice for elderly patients who plan on continuing with an active lifestyle and who do not want to change their style and quality of life. Age is no longer a predictive factor for results and ACL reconstruction in this kind of patient does increase both functional and satisfaction levels. Conservative treatment should be reserved for patients who have a contraindication for reconstruction and for those who would prefer modifying their lifestyle rather than undergo a surgical procedure.