Skip to main page content
U.S. flag

An official website of the United States government

Dot gov

The .gov means it’s official.
Federal government websites often end in .gov or .mil. Before sharing sensitive information, make sure you’re on a federal government site.

Https

The site is secure.
The https:// ensures that you are connecting to the official website and that any information you provide is encrypted and transmitted securely.

Access keys NCBI Homepage MyNCBI Homepage Main Content Main Navigation
Review
. 2022 Aug 12;10(8):23259671221114353.
doi: 10.1177/23259671221114353. eCollection 2022 Aug.

Increased Risk of ACL Injury for Female but Not Male Soccer Players on Artificial Turf Versus Natural Grass: A Systematic Review and Meta-Analysis

Michelle Xiao  1 , Jacie L Lemos  1 , Calvin E Hwang  1 , Seth L Sherman  1 , Marc R Safran  1 , Geoffrey D Abrams  1
Affiliations
Review

Increased Risk of ACL Injury for Female but Not Male Soccer Players on Artificial Turf Versus Natural Grass: A Systematic Review and Meta-Analysis

Michelle Xiao et al. Orthop J Sports Med. .

Abstract

Background: Both natural grass (NG) and artificial turf (AT) are popular playing surfaces for soccer. Biomechanical studies have found increased frictional forces on AT that may lead to anterior cruciate ligament (ACL) injury. The increased risk of ACL injury during soccer in female participants may amplify this effect.

Purpose: To systematically review the literature for studies comparing ACL injury risk in soccer players on AT versus NG and to specifically determine whether there were differences in injury risk in male versus female players when considering the playing surface.

Study design: Systematic review; Level of evidence, 3.

Methods: A systematic review was performed using PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines. Three databases were searched for studies with evidence level 1 to 3 that compared the incidence of ACL injuries on AT versus NG in soccer players. Data recorded included study characteristics, sex, competition level, exposure setting (games or practices), turf type, and ACL injury information. Study methodological quality was analyzed using the methodological index for non-randomized studies (MINORS) score, and incidence rate ratios (IRRs) were calculated.

Results: Included were 7 articles (3 studying professional soccer, 3 collegiate soccer, 1 youth-level soccer; 4 male cohorts, 2 female cohorts, and 1 male and female cohort; mean MINORS score, 20 ± 0.8). Pooled ACL injury IRRs demonstrated no significant differences in overall ACL injury risk when playing soccer on AT compared with NG (IRR = 0.57 [95% CI, 0.21-1.53]; P = .31). A significantly increased risk of ACL injury in games played on AT compared with NG was detected for female (IRR = 1.18 [95% CI, 1.05-1.31]; P = .004) but not for male players (IRR = 1.18 [95% CI, 0.97-1.42]; P = .09). Subgroup analyses showed no significant differences in injury risk for games (IRR = 1.07 [95% CI, 0.97-1.18]; P = .20) or practices (IRR = 0.21 [95% CI, 0.04-1.23]; P = .09).

Conclusion: Findings indicated that female soccer players had a significantly higher risk of ACL injury when playing games on AT versus NG, whereas no significant difference was seen in male players. No differences were found for the combined male/female cohort or for soccer games or training sessions played on AT compared with NG.

Keywords: ACL; artificial turf; female; gender; injury risk; natural grass; playing surface; sex; soccer.

PubMed Disclaimer

Conflict of interest statement

One or more of the authors has declared the following potential conflict of interest or source of funding: S.L.S. has received research support from Arthrex and DJO; education payments from Elite Orthopedics and Evolution Surgical; consulting fees from Arthrex, Bioventus, Ceterix, ConMed Linvatec, Flexion Therapeutics, GLG Consulting, JRF Ortho, Moximed, Olympus America, Smith & Nephew, and Vericel; speaking fees from Arthrex, Smith & Nephew, and Vericel; and honoraria from Flexion Therapeutics and Vericel. M.R.S. has received research support from Smith & Nephew; consulting fees from Anika Therapeutics, Medacta, and Smith & Nephew; speaking fees from Medacta and Smith & Nephew; royalties from DJO, Saunders/Mosby-Elsevier, Smith & Nephew, Stryker, and Wolters Kluwer Health-Lippincott Williams & Wilkins; honoraria from Medacta; and stock/stock options from Biomimedica. G.D.A. has received education payments from Evolution Surgical; consulting fees from Cytonics, Fidia Pharma, RubiconMD, and Sideline Sports Doc; nonconsulting fees from Arthrex and Stryker; royalties from Orthofix; and stock/stock options from Cytonics. 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 diagram summarizing the literature search, screening, and review. ACL, anterior cruciate ligament.
Figure 2.
Figure 2.
Forest plot of pooled IRRs for ACL injury on AT versus NG in soccer players with subanalysis by exposure setting (game vs training). ACL, anterior cruciate ligament; AT, artificial turf; IRR, incidence rate ratio; NG, natural grass.
Figure 3.
Figure 3.
Forest plot of the subanalysis based on sex (male or female) of pooled IRRs for ACL injury in soccer games played on AT versus NG. ACL, anterior cruciate ligament; AT, artificial turf; IRR, incidence rate ratio; NG, natural grass.
See this image and copyright information in PMC

References

    1. Alentorn-Geli E, Myer GD, Silvers HJ, et al. Prevention of non-contact anterior cruciate ligament injuries in soccer players, part 1: mechanisms of injury and underlying risk factors. Knee Surg Sports Traumatol Arthrosc. 2009;17(7):705–729. - PubMed
    1. Ardern CL, Taylor NF, Feller JA, Webster KE. Return-to-sport outcomes at 2 to 7 years after anterior cruciate ligament reconstruction surgery. Am J Sports Med. 2012;40(1):41–48. - PubMed
    1. Ardern CL, Webster KE, Taylor NF, Feller JA. Return to sport following anterior cruciate ligament reconstruction surgery: a systematic review and meta-analysis of the state of play. Br J Sports Med. 2011;45(7):596–606. - 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. Am J Sports Med. 2015;43(7):1798–1804. - PubMed
    1. Bjørneboe J, Bahr R, Andersen TE. Risk of injury on third-generation artificial turf in Norwegian professional football. Br J Sports Med. 2010;44(11):794–798. - PubMed

LinkOut - more resources