PURPOSE OF REVIEW: Syndesmotic injuries are common football injuries. The unique demands of football athletes create large magnitude rotational moments about the ankle, even during low impact maneuvers. This review explores the structure and function of the syndesmosis, assesses recent data in football athletes at the professional and collegiate levels regarding epidemiology, describes available treatment options, and provides example cases from the authors' institution. The review concludes with clinical and surgical pearls for the evaluation and treatment of syndesmotic injury. RECENT FINDINGS: In general, flexible syndesmotic fixation has demonstrated similar clinical outcome scores as rigid fixation. Flexible fixation has demonstrated benefit over rigid fixation in terms of implant failure, hardware removal, and local irritation. Both flexible and rigid fixation remain viable options for treatment of syndesmotic injuries yet the indications for selecting a construct are often subjective. Certain cases of high-risk football players such as linemen may warrant careful consideration of rigid fixation options despite the clinical advantages of flexible fixation. During fixation, direct visualization techniques with open or arthroscopic assistance for reduction of the syndesmosis remain superior and enable diagnosis of chondral defects. Flexible and rigid syndesmotic fixation techniques are viable for treatment of unstable syndesmotic injuries in athletes. Recent literature favors flexible fixation. However, at-risk football athletes or those with length unstable fibula fractures may benefit from rigid or supplemental flexible fixation as opposed to traditional flexible fixation. We recommend direct visualization of reduction at the syndesmosis during surgical treatment of unstable ankle injuries.