The importance of addressing meniscal pathology associated with anterior cruciate ligament (ACL) insufficiency stems from the increased incidence of meniscal tears with chronic instability. The combined effect of instability and meniscal lesions can lead to the development of knee arthrosis. A predominance of lateral meniscal tears has been demonstrated with acute ACL rupture, whereas the incidence of medial meniscal tears increases significantly with chronic ACL insufficiency. The percentage of repairable meniscal tears is higher on the medial than the lateral side and decreases overall with the chronicity of ACL insufficiency. The likelihood of a successful meniscal repair is enhanced significantly when combined with ACL reconstruction. This review suggests that maximal meniscal preservation is best achieved with ACL reconstruction. This review suggests that maximal meniscal preservation is best achieved with ACL reconstruction shortly after injury and simultaneous repair of coexisting peripheral meniscus tears.