Acute ankle sprains are common, and if inadequately treated may result in chronic instability. Lateral ankle injuries are most common, with deltoid injuries rare and associated with ankle fractures/dislocation. Medial ankle instability is rare. Functional management of acute lateral ankle sprains is the treatment of choice, with acute ligament repair reserved for athletes. Chronic lateral ankle instability is initially managed conservatively, however, failure of rehabilitation is an indication for surgical management. Nonanatomic tenodesis reconstructions have poor long-term results, sacrifice peroneal tendons, and disrupt normal ankle and hindfoot biomechanics. Anatomic repair of the anterior talofibular and calcaneofibular ligaments is recommended when the quality of the ruptured ligaments permits. Anatomic reconstruction with autograft or allograft should be performed when ligaments are attenuated. The role of arthroscopic reconstruction is evolving. Ankle arthroscopy should be performed at the time of repair or reconstruction and should address any other intra-articular causes of pain.