Background: Surgical treatment of symptomatic posterior ankle impingement consists of resection of the bony impediment and/or debridement of soft tissue. Historically, open techniques were used to perform surgery with good results. However, since the introduction of endoscopic techniques, advantages attributed to these techniques are shorter recovery time, fewer complications, and less pain. Purpose: The primary purpose was to determine whether endoscopic surgery for posterior ankle impingement was superior to open surgery in terms of functional outcome (American Orthopaedic Foot & Ankle Society [AOFAS] score). The secondary aim was to determine differences in return to full activity, patient satisfaction, and complications. Study Design: Systematic review and meta-analysis. Methods: MEDLINE, EMBASE (Classic), and CINAHL databases were searched. Publication characteristics, patient characteristics, surgical techniques, AOFAS scores, time to return to full activity, patient satisfaction, and complication rates were extracted. The AOFAS score was the primary outcome measure. Data were synthesized, and continuous outcome measures (postoperative AOFAS score and time to return to full activity) were pooled using a random-effects inverse variance method. Random-effects meta-analysis of proportions using continuity correction methods was performed to determine the proportion of patients who were satisfied and who experienced complications. Results: A total of 32 studies were included in this review. No statistically significant difference was found in postoperative AOFAS scores between open surgery (88.0; 95% CI, 82.1-94.4) and endoscopic surgery (94.4; 95% CI, 93.1-95.7). There was no difference in the proportion of patients who rated their satisfaction as good or excellent, 0.91 (95% CI, 0.86-0.96) versus 0.86 (95% CI, 0.79-0.94), respectively. No significant difference in time to return to activity was found, 10.8 weeks (95% CI, 7.4-15.9 weeks) versus 8.9 weeks (95% CI, 7.6-10.4 weeks), respectively. Pooled proportions of patients with postoperative complications were 0.15 (95% CI, 0.11-0.19) for open surgery versus 0.08 (95% CI, 0.05-0.14) for endoscopic surgery. Without the poor-quality studies, this difference was statistically significant for both total and minor complications, 0.24 (95% CI, 0.14-0.35) versus 0.02 (95% CI, 0.00-0.06) and 0.14 (95% CI, 0.09-0.20) versus 0.03 (95% CI, 0.01-0.05), respectively. Conclusion: We found no statistically significant difference in postoperative AOFAS scores, patient satisfaction, and return to preinjury level of activity between open and endoscopic techniques. The proportion of patients who experienced a minor complication was significantly lower with endoscopic treatment when studies of poor methodological quality were excluded.