Artificial turf may increase risk of anterior cruciate ligament injury

1. Of ten studies analyzed, four studies comprising 753 anterior cruciate ligament (ACL) injuries found an increased risk of injury on synthetic playing surfaces compared to natural grass. 

2. Increased ACL injury risk on synthetic surfaces was only shown in American football cohorts.  No difference was seen in soccer cohorts. 

Evidence Rating Level: 2 (Good)

Study Rundown: The use of synthetic playing surfaces has steadily increased in recent years. However, despite the continued modification and improvements made to synthetic surfaces, concern remains regarding the risk of injury on such surfaces relative to natural grass. Biomechanical studies have largely supported such claims by demonstrating increased frictional forces on synthetic surfaces, potentially contributing to a higher injury risk. The authors attempted to evaluate this risk through a query of the literature. Of the 10 studies that fulfilled the criteria for analysis, 4 demonstrated an increased risk of ACL injury on synthetic surfaces, 3 of which demonstrated a significantly elevated risk.  One study found a decreased risk of ACL injury on synthetic field though this study did not account for potential confounders related to field moisture and exposure setting. While the concordance of 4 of these studies illustrating a higher incidence of ACL injuries perhaps suggests an increased risk for ACL injury on synthetic surfaces, many deficiencies prevent any definitive conclusions to be drawn. For example, grouping of data was precluded by the variability of what constituted an exposure which ranged from games played to practice hours logged. Thus, no pooled rates of incidence and risk of ACL injury were able to be determined. Other limitations include the relatively small number of studies analyzed and sports represented as well as reporting bias of injuries from the queried databases.

Click to read the study in Am J Sports Med

Relevant Reading: The effect of playing surface on the incidence of ACL injuries in National Collegiate Athletic Association American Football

In-Depth [systematic review]: Studies included in the systematic review were identified according the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA). A total of 10 Level II evidence studies encompassing 963 ACL injuries were included in the review. Three studies found a significantly elevated risk of ACL injury on synthetic playing surfaces (RR = 1.4, 1.7, 1.9, respectively).  One study found a mildly elevated risk.  These studies included professional and collegiate athletes playing on both early generation synthetic turf and 3^rd generation surfaces. A significantly reduced risk of injury was found in 1 football cohort (RR = 0.4). All 3 studies studied injury rates in football playing populations. 4 studies of ACL injuries in soccer players found a decreased risk of injury on turf fields although no observed differences were significant (RR = 0.3, 0.7, 0.8, 0.9).

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