Treatment of athletes with ligamentous injuries of the tibiofibular syndesmosis can be problematic. The paucity of historic data on this topic has resulted in a lack of clear guidelines to aid in imaging and diagnosing the injury, assessing injury severity, and making management decisions. In recent years, research on this topic has included an abundance of epidemiologic, clinical, and basic science investigations of syndesmotic injuries that are purely ligamentous or associated with ankle fracture. Several classification systems can be used to classify ligamentous injury to the syndesmosis. These systems integrate clinical and radiographic findings but do not address the location of the injury or its severity. Injury to the syndesmosis can be purely ligamentous; however, many unstable syndesmotic injuries are associated with fractures. Nonsurgical management can be used for stable ligamentous injuries without frank diastasis, but surgical management, including screw or suture-button fixation, is indicated for fractures with unstable syndesmotic injuries.