Lower Extremity Injury Rates on Artificial Turf Versus Natural Grass Playing Surfaces: A Systematic Review

Abstract

Background: No study has provided a comprehensive systematic review of sports injuries on artificial turf versus natural grass. Purpose: To comprehensively examine the risk of overall injuries and multiple types of lower extremity injuries across all sports, all levels of competition, and on both old-generation and new-generation artificial turf. Study Design: Systematic review; Level of evidence, 3. Methods: A systematic review of the English-language literature was performed according to PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines. All included articles compared overall injury rates or lower extremity (hip, knee, or foot and ankle) injury rates on artificial turf and natural grass. All sports, levels of competition, and turf types were included. Studies were excluded if they did not include overall injury rates or lower extremity injury rates. Because of the heterogeneity of the included studies, no attempt was made to aggregate risk ratios to conduct a quantitative meta-analysis. Results: A total of 53 articles published between 1972 and 2020 were identified for study inclusion. Most studies on new-generation turf (13/18 articles) found similar overall injury rates between playing surfaces. When individual anatomic injury locations were analyzed, the greatest proportion of articles reported a higher foot and ankle injury rate on artificial turf compared with natural grass, both with old-generation (3/4 articles) and new-generation (9/19 articles) turf. Similar knee and hip injury rates were reported between playing surfaces for soccer athletes on new-generation turf, but football players, particularly those at high levels of competition, were more likely to sustain a knee injury on artificial turf than on natural grass. Conclusion: The available body of literature suggests a higher rate of foot and ankle injuries on artificial turf, both old-generation and new-generation turf, compared with natural grass. High-quality studies also suggest that the rates of knee injuries and hip injuries are similar between playing surfaces, although elite-level football athletes may be more predisposed to knee injuries on artificial turf compared with natural grass. Only a few articles in the literature reported a higher overall injury rate on natural grass compared with artificial turf, and all of these studies received financial support from the artificial turf industry.