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Pigmented villonodular synovitis is a synovial proliferative process. In the majority of cases, it is monoarticular; however, in the foot and ankle, it can affect more than 1 joint. It may be a challenge to diagnose and treat successfully. Nine patients with foot and ankle pigmented villonodular synovitis synovial disease were reviewed from a tertiary Oncology Unit during a 12-year period. Seven of the patients had ankle involvement and 2 had foot involvement; all of the patients were women. The mean follow-up time was 3.4 years. Seven patients had localized disease and 2 had diffuse disease. All of the patients with localized disease had wide surgical excision and none had recurrence. Both patients with diffuse disease had multiple recurrences after attempted total synovectomy and adjuvant radiotherapy. A review of the diagnosis, imaging strategies, and treatment options is provided.