Eight randomized trials (Level 1) including 566 patients undergoing primary anterior cruciate ligament reconstruction (ACLR) were pooled to compare local infiltration analgesia (LIA) versus femoral nerve block (FNB). Pooled outcomes included pain at 0–4, 4–8, 8–12, and 12–24 h; 24‑h intravenous morphine-equivalent consumption; time to first analgesic request; and 24‑h complications. FNB yielded lower pain scores at 8–12 h, but there were no differences at 0–4, 4–8, or 12–24 h; morphine use; or analgesic duration. LIA was associated with higher odds of nausea within 24 h. Overall, FNB confers better analgesia during the 8–12 h window and less nausea, while broader 24‑h analgesic effectiveness and opioid requirements are comparable—suggesting choice should be individualized to early pain control needs and emetogenic risk.