Athletes sustain ankle syndesmosis injuries far less frequently than they do lateral ankle sprains;​ however, syndesmosis injuries are more challenging to detect and treat. Grade II injuries, which are occultly unstable, may be overlooked or treated too conservatively (nonsurgically), leading to latent diastasis, chronic instability, further injury, arthritic changes, chronic pain, osteochondral lesions, and other sequelae. Surgical intervention for chronic syndesmosis injuries produces mixed results and creates an uncertain future for athletes who desire to return to their sport. Optimal treatment starts with a comprehensive evaluation that includes a thorough physical examination as well as imaging studies to evaluate for instability (medial clear space widening and syndesmosis disruption). All acute unstable syndesmosis injuries (grades II and III) should be treated with surgery, which can include repair of the deltoid ligament with open reduction and internal fixation of the syndesmosis. Isolated deltoid sprains also are often repaired surgically in athletes. This more aggressive treatment helps avoid the chronic pain and instability and osteochondral abnormalities associated with chronic injury.