Disruption of the distal syndesmosis of the lower extremity is most commonly associated with ankle fractures but can also occur without gross bone injury. Definitive management of these injuries remains controversial. The current indications for syndesmosis fixation are based on tibiotalar joint mechanics as determined in cadaveric and biomechanical studies, as well as radiologic evaluation and an understanding of the pertinent anatomy and the etiology of these injuries. Such data support the use of syndesmotic screws in selected fractures that include a disruption of the syndesmosis. However, definitive fixation recommendations for syndesmosis disruption with or without ankle fracture remain under investigation. Distal lower extremity syndesmosis sprains without fracture or subluxation consistently require longer recovery time than typical lateral sprains and can be associated with greater long-term disability.