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Syndesmotic injuries or high ankle sprains in athletes can occur in elite and recreational athletes. They typically require a longer recovery and a significant delay in return to play compared with routine ankle sprains. Avoiding a misdiagnosis is important and is dependent on being aware of the mechanism of injury, a thorough physical examination, and careful interpretation of imaging studies. Management is guided by the severity of injury and the demands of the athlete. Many mild or stable injuries can be treated nonoperatively; however, acute surgical repair or stabilization in high-grade injuries can provide excellent results and an earlier return to play in selected cases.