Clinical experience of good results without reconstructing a torn ACL initiated the first randomised controlled trial comparing treatment options for acute ACL tears: ACL reconstruction followed by extensive exercise therapy versus exercise therapy alone, with the option for surgery later if needed. Results largely show that exercise therapy is a better treatment alternative than previously thought, while surgery, unfortunately, is not as effective as we would like it to be. This presentation will focus on the evidence underpinning the current shift in ACL treatment and present arguments for why an 'exercise first' approach is a reasonable option for many patients with an acute ACL tear.