Podostemum ceratophyllum, commonly called Hornleaf Riverweed, occurs in mid-order montane and piedmont rivers of eastern North America, where the plant grows submerged and attached to rocks and stable substrates in swift, aerated water. Multiple studies, mostly conducted in the southern portions of the plant’s range, have shown that Podostemum can variously influence benthic communities in flowing waters. However, a synthetic review of the biology and ecology of the plant is needed to inform conservation, particularly because P. ceratophyllum is reported to be in decline in much of its range, for mostly unknown reasons. We have thus summarized the literature showing that Podostemum provides substantial habitat for invertebrates and fish, may be consumed by invertebrates, turtles, and other vertebrates, removes and sequesters dissolved elements (i.e., nitrogen, phosphorus, calcium, zinc, etc.) from the water column, and contributes organic matter to the detrital pool. Podostemum may be tolerant to some forms of pollution but appears vulnerable to sedimentation, epiphytic over-growth, and hydrologic changes that result in desiccation, and possibly increased herbivory pressure. Much remains unknown about Podostemum, including aspects of morphological variation, seed dispersal, and tolerance to changes in temperature and water chemistry. Nonetheless, Podostemum may be considered a foundation species, whose loss from eastern North American rivers is likely to affect higher trophic levels and ecosystem processes.