Posterior ankle impingement syndrome (PAIS) results in posterior ankle pain during ankle plantarflexion and is commonly encountered in the athletic population. First-line treatments include activity modification, oral analgesics/NSAID (nonsteroidal anti-inflammatory drugs), and intra-articular corticosteroid injections. However, when non-surgical management strategies fail, symptomatic posterior ankle impingement requires surgical intervention. Historically treated with open debridement and soft tissue and/or bony resection, there is now a shift towards minimally invasive posterior two-portal hindfoot arthroscopy to address posterior ankle impingement, which offers lower complication rates and faster recovery. However, this technique presents challenges, including technical complexity and a potential for neurological injury. This chapter aims to provide a comprehensive assessment and analysis of the etiology of posterior ankle impingement, its clinical manifestations, and current arthroscopic treatment strategies.