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. 2020 Jul 22;8(7):2325967120934434.
doi: 10.1177/2325967120934434. eCollection 2020 Jul.

Epidemiology of Anterior Cruciate Ligament Injury on Natural Grass Versus Artificial Turf in Soccer: 10-Year Data From the National Collegiate Athletic Association Injury Surveillance System

Mark Howard  1 , Samantha Solaru  2 , Hyunwoo P Kang  1 , Ioanna K Bolia  1 , George F R Hatch  1 , James E Tibone  1 , Seth C Gamradt  1 , Alexander E Weber  1
Affiliations

Epidemiology of Anterior Cruciate Ligament Injury on Natural Grass Versus Artificial Turf in Soccer: 10-Year Data From the National Collegiate Athletic Association Injury Surveillance System

Mark Howard et al. Orthop J Sports Med. .

Abstract

Background: Anterior cruciate ligament (ACL) injury is prevalent among National Collegiate Athletic Association (NCAA) soccer players. Controversy remains regarding the effect of the surface type on the rate of ACL injury in soccer players, considering differences in sex, type of athletic exposure, and level of competition.

Hypothesis: Natural grass surfaces would be associated with decreased ACL injury rate in NCAA soccer players. Sex, type of athletic exposure (match vs practice), and level of competition (Division I-III) would affect the relationship between playing surface and ACL injury rates.

Study design: Cohort study; Level of evidence, 3.

Methods: Using the NCAA Injury Surveillance System (ISS) database, we calculated the incidence rate of ACL injury in men and women from 2004-2005 through 2013-2014 seasons. The incidence was normalized against athletic exposure (AE). Additional data collected were sex, athletic activity at time of injury (match vs practice), and level of competition (NCAA division) to stratify the analysis. Statistical comparisons were made by calculating incidence rate ratios (IRR). Statistical significance was set at an alpha of .05.

Results: There were 30,831,779 weighted AEs during the study period. The overall injury rate was 1.12 ACL injuries per 10,000 AEs (95% CI, 1.08-1.16). Women comprised 57% of the match data (10,261 games) and 55% of practice data (26,664 practices). The overall injury rate was significantly higher on natural grass (1.16/10,000 AEs; 95% CI, 1.12-1.20) compared with artificial turf (0.92/10,000 AEs [95% CI, 0.84-1.01]; IRR, 1.26 [95% CI, 1.14-1.38]) (P < .0001). This relationship was demonstrated consistently across all subanalyses, including stratification by NCAA division and sex. The injury rate on natural grass (0.52/10,000 AEs; 95% CI, 1.11-1.26) was significantly greater than the injury incidence during practice on artificial turf (0.06/10,000 AEs; 95% CI, 0.043-0.096). Players were 8.67 times more likely to sustain an ACL injury during practice on natural grass compared with practice on artificial turf (95% CI, 5.43-12.13; P < .0001). No significant difference was found in injury rates between matches played on grass versus turf (IRR, 0.93; 95% CI, 0.84-1.03; P = .15).

Conclusion: NCAA soccer players who practice on natural grass have increased risk of ACL injury compared with the risk of those practicing on an artificial surface, regardless of sex or NCAA division of play. No difference in risk of ACL injury between playing surfaces was detected during matches. Further research is necessary to examine the effect of multiple factors when evaluating the effect of the surface type on the risk of ACL injury in soccer players.

Keywords: ACL; artificial; injury; natural; soccer; surface.

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Conflict of interest statement

One or more of the authors has declared the following potential conflict of interest or source of funding: H.P.K. has received educational support from Arthrex. G.F.R.H. has received educational support from Arthrex and Micromed, consulting and nonconsulting fees from Arthrex, and honoraria from Fidia Pharma. J.E.T. has received educational support from Arthrex and Micromed, nonconsulting fees from Arthrex, royalties from Arthrex, and hospitality payments from Pacira Pharmaceuticals and Stryker. S.C.G. has received educational support from Arthrex, consulting fees from Zimmer Biomet, and nonconsulting fees from Arthrex. A.E.W. has received educational support from Arthrex and Smith & Nephew, nonconsulting fees from Arthrex, and hospitality payments from Stryker. AOSSM checks author disclosures against the Open Payments Database (OPD). AOSSM has not conducted an independent investigation on the OPD and disclaims any liability or responsibility relating thereto.

Figures

Figure 1.
Figure 1.
Flow chart presenting the data collection process using the National Collegiate Athletic Association (NCAA) Injury Surveillance System (ISS) database.
Figure 2.
Figure 2.
Forest plot of incidence rate ratios based on competition type given surface type.
Figure 3.
Figure 3.
Forest plot of incidence rate ratios based on National Collegiate Athletic Association division, given both competition type and playing surface.
Figure 4.
Figure 4.
Forest plot of incidence rate ratios and 95% CIs based on sex, given both competition type and playing surface.
See this image and copyright information in PMC

References

    1. Adkison JW, Requa RK, Garrick JG. Injury rates in high school football: a comparison of synthetic surfaces and grass fields. Clin Orthop Relat Res. 1974;99:131–136. - PubMed
    1. Balazs GC, Pavey GJ, Brelin AM, Pickett A, Keblish DJ, Rue J-PH. Risk of anterior cruciate ligament injury in athletes on synthetic playing surfaces: a systematic review. Am J Sports Med. 2015;43(7):1798–1804. - PubMed
    1. Beynnon BD, Vacek PM, Newell MK, et al. The effects of level of competition, sport, and sex on the incidence of first-time noncontact anterior cruciate ligament injury. Am J Sports Med. 2014;42(8):1806–1812. - PMC - PubMed
    1. Calloway SP, Hardin DM, Crawford MD, et al. Injury surveillance in Major League Soccer: a 4-year comparison of injury on natural grass versus artificial Turf Field. Am J Sports Med. 2019;47(10):2279–2286. - PubMed
    1. Csintalan RP, Inacio MC, Funahashi TT. Incidence rate of anterior cruciate ligament reconstructions. Perm J. 2008;12(3):17. - PMC - PubMed

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