Syndesmosis injury in the athlete presents a difficult and complex injury. Early and accurate diagnosis is the key to having good results. Establishing the severity of the injury is also of great importance to maximize treatment and minimize time lost for the athlete. We advocate aggressive rehabilitation after acute inflammation and swelling for minor sprain injuries. Athletes, coaches, and trainers must be educated regarding proper rehabilitation and expectations for return to activities. More severe injuries present a more difficult diagnostic and treatment problem. Injuries without overt diastasis or fracture can be managed by protection of the ankle followed by rehabilitation. Injuries managed in this fashion will require longer recovery time than less significant injuries. It may be advantageous to be aggressive with Grade 2 injuries. However, early accurate diagnosis of subtle instability can readily be made clinically and with the use of arthroscopic evaluation of the syndesmosis injury without frank diastasis. If dynamic instability is present, syndesmosis fixation gives the optimal chance for a good outcome and the return to sport. This controversial approach minimizes time lost for athletes as well as minimizing the possibility of chronic disability or pain. The rare high-grade injuries require early operative stabilization and prolonged rehabilitation. We also recommend accurate diagnosis and aggressive management of subacute and chronic injuries to the syndesmosis. Several authors have reported good results with reconstructive surgery. The need for operative intervention is dictated by the presence of instability. Although instability is not evident radiographically in these cases, it is the functional instability that is problematic and stabilization by trans-syndesmotic screw is necessary to allow stable healing in a reduced position. Operative stabilization allows early ROM, but weightbearing activity still must be delayed at least 6 to 8 weeks.