On April 24, 2018, the Rams exercised the fifth-year option on Gurley's contract.
On July 24, 2018, Gurley signed a four-year, $60 million contract extension with the Rams with $45 million guaranteed, making him the highest-paid running back in the NFL.

Gurley scored the Rams' first touchdown of the season, taking a short pass from quarterback Jared Goff and going 19 yards to the end zone in a 33–13 victory against the Oakland Raiders on Monday Night Football.
In Week 2, in the 34–0 victory over the Arizona Cardinals, Gurley recorded three rushing touchdowns for the second time in his professional career.
In Week 3, Gurley had 23 carries for 105 rushing yards and a rushing touchdown to go along with five receptions for 51 receiving yards in the 35–23 victory over the Los Angeles Chargers.
Gurley scored on an eight-yard pass from Goff for the Rams' first touchdown in 38–31 victory over the Minnesota Vikings in Week 4.

In Week 5, Gurley had 77 rushing yards and three rushing touchdowns in the 33–31 victory over the Seattle Seahawks.
In Week 6, Gurley ran for a career-high 208 yards and two touchdowns in a 23–20 win over the Denver Broncos, earning him NFC Offensive Player of the Week.
In Week 7, against the San Francisco 49ers, he recorded two rushing touchdowns and a receiving touchdown.
Gurley was named the NFC Offensive Player of the Month for the month of October after rushing for 462 yards and seven touchdowns and catching 16 passes for 157 yards and two touchdowns through four games.

With a 17-yard touchdown run during a Week 10 victory over the Seattle Seahawks, Todd Gurley set a new team record by scoring a touchdown in 13 straight games, breaking the mark set by Elroy "Crazy Legs" Hirsch.
During a Week 12 matchup against the Detroit Lions, Gurley rushed for 132 yards and two touchdowns in the fourth quarter to help the Rams clinch their second straight NFC West title and was named NFC Offensive Player of the Week for the second time in 2018.

Gurley scored two rushing touchdowns in a 30–23 loss to the Philadelphia Eagles in Week 15.
He was then held out of the final two regular season games due to knee inflammation and finished the 2018 season with 256 carries for 1,251 yards and 17 touchdowns rushing, along with 59 receptions for 580 yards and four touchdowns receiving.
Gurley was also named to his third Pro Bowl in his four professional seasons.
He was also named first-team All-Pro.

In the NFC Divisional Playoff against Dallas Cowboys, Gurley ran 23 times for 115 yards and a touchdown in the Rams' 30–22 victory.

In the NFC Championship Game against the New Orleans Saints, Gurley struggled as he ran four times for 10 yards and a touchdown and had one catch for three yards in a 26–23 overtime victory to advance and play the New England Patriots in Super Bowl LIII.
Leading up to the Super Bowl, Gurley's injury status was heavily discussed with reports claiming he was healthy while other reports claimed his knee was significantly more hurt than thought.
In the Super Bowl, Gurley had ten carries for 35 rushing yards in the 13–3 loss to the Patriots.
On March 2, 2019, it was reported that Gurley has arthritis in his left knee.
On April 24, 2018, the Rams exercised the fifth-year option on Gurley's contract. On July 24, 2018, Gurley signed a four-year, $60 million contract extension with the Rams with $45 million guaranteed, making him the highest-paid running back in the NFL.
Gurley scored the Rams' first touchdown of the season, taking a short pass from quarterback Jared Goff and going 19 yards to the end zone in a 33–13 victory against the Oakland Raiders on Monday Night Football. In Week 2, in the 34–0 victory over the Arizona Cardinals, Gurley recorded three rushing touchdowns for the second time in his professional career. In Week 3, Gurley had 23 carries for 105 rushing yards and a rushing touchdown to go along with five receptions for 51 receiving yards in the 35–23 victory over the Los Angeles Chargers. Gurley scored on an eight-yard pass from Goff for the Rams' first touchdown in 38–31 victory over the Minnesota Vikings in Week 4.
In Week 5, Gurley had 77 rushing yards and three rushing touchdowns in the 33–31 victory over the Seattle Seahawks. In Week 6, Gurley ran for a career-high 208 yards and two touchdowns in a 23–20 win over the Denver Broncos, earning him NFC Offensive Player of the Week. In Week 7, against the San Francisco 49ers, he recorded two rushing touchdowns and a receiving touchdown. Gurley was named the NFC Offensive Player of the Month for the month of October after rushing for 462 yards and seven touchdowns and catching 16 passes for 157 yards and two touchdowns through four games.
With a 17-yard touchdown run during a Week 10 victory over the Seattle Seahawks, Todd Gurley set a new team record by scoring a touchdown in 13 straight games, breaking the mark set by Elroy "Crazy Legs" Hirsch. During a Week 12 matchup against the Detroit Lions, Gurley rushed for 132 yards and two touchdowns in the fourth quarter to help the Rams clinch their second straight NFC West title and was named NFC Offensive Player of the Week for the second time in 2018.
Gurley scored two rushing touchdowns in a 30–23 loss to the Philadelphia Eagles in Week 15. He was then held out of the final two regular season games due to knee inflammation and finished the 2018 season with 256 carries for 1,251 yards and 17 touchdowns rushing, along with 59 receptions for 580 yards and four touchdowns receiving. Gurley was also named to his third Pro Bowl in his four professional seasons. He was also named first-team All-Pro.
In the NFC Divisional Playoff against Dallas Cowboys, Gurley ran 23 times for 115 yards and a touchdown in the Rams' 30–22 victory.
In the NFC Championship Game against the New Orleans Saints, Gurley struggled as he ran four times for 10 yards and a touchdown and had one catch for three yards in a 26–23 overtime victory to advance and play the New England Patriots in Super Bowl LIII. Leading up to the Super Bowl, Gurley's injury status was heavily discussed with reports claiming he was healthy while other reports claimed his knee was significantly more hurt than thought. In the Super Bowl, Gurley had ten carries for 35 rushing yards in the 13–3 loss to the Patriots. On March 2, 2019, it was reported that Gurley has arthritis in his left knee.
Todd Gurley