Treatment options for acute acromioclavicular joint (ACJ) instability include several surgical and non-surgical approaches. Recent trends indicate a shift towards nonoperative treatment, even for severe Rockwood type V injuries, which traditionally required surgery. Despite this shift, some patients may still benefit from surgical stabilisation, particularly if significant pain and disability persist. Modern surgical techniques focus on cortical button systems and restoration of the coracoclavicular ligaments, emphasising the importance of the posterosuperior acromioclavicular capsuloligamentous complex in managing horizontal instability. Clavicular hook plates offer rigid stability but present risks, such as damage to the subacromial structures and acromial erosion. Although anatomical repair techniques have gained prominence due to their biomechanical advantages and have been endorsed by international societies, non-anatomic methods may also provide acceptable outcomes with lower costs. The use of tendon grafts in chronic ACJ instability has shown promise, although evidence for their use in acute cases remains limited. This review discusses various treatment strategies, including operative and nonoperative management, focusing on patient outcomes, complication rates, and return-to-sport scenarios. Ultimately, the choice between surgical and non-surgical treatment must consider individual patient needs and the potential for long-term recovery.