SLR - February 2023 - Andrew Syndergaard, DPM
Title: Lower Extremity Injury Rates on Artificial Turf Versus Natural Grass Playing Surfaces- A Systematic ReviewReference: Gould HP, Lostetter SJ, Samuelson ER, Guyton GP. Lower Extremity Injury Rates on Artificial Turf Versus Natural Grass Playing Surfaces: A Systematic Review. Am J Sports Med. 2022 May 20:3635465211069562.
Level of Evidence: Level III
Reviewed By: Andrew Syndergaard, DPM
Residency Program: Ascension St. Vincent Hospital, Indianapolis IN
Podiatric Relevance: Since the early 1970s, studies have been done with reports of higher rates of injury on artificial turf versus playing on natural grass fields. Even studies of the difference of biomechanics between the two surfaces have shown to support the idea that artificial turf leads to increased stresses and foot-loading patterns. More friction, torque and rotational stiffness experienced by athletes lead to increased loads up the entire kinetic chain including central forefoot and lesser toes, exposing more athletes to greater foot inversion, and potentially resulting in lower extremity injuries. Newer varieties of artificial turf have attempted to mimic a more “natural grass-like” feel and experience but continue to prove to be more injury prone than actual grass fields. This study broadly analyzed all type of sports, levels of competition, and surfaces of play to show comparable rates of injury based on playing surface.
Methods: A systematic review of the English-language literature was performed according to PRISMA guidelines and searched keywords in PubMed, Embase, Web of Science Core Collection and SPORTDiscus across from early 1970s until August 2020. Studies were only included if they were of Level III or higher, and if they compared rate of overall injuries or any type of lower extremity injuries, such as the hip, thigh, knee, lower leg, ankle, or foot. Studies for both adults and pediatric athletes were included. Articles that met the eligibility criteria underwent data extraction for study design (prospective, retrospective, RCT, etc.), level of evidence, cohort selection process (ad hoc, systematic), sport (football, soccer, other), level of competition (professional, amateur), injury setting (practice, game), number of athletic seasons, and turf type (old generation, new generation, not reported).
Results: In total, 53 studies met inclusion criteria. Prospective studies made up 33 of the 53 studies and 20 were retrospective. 36 of the studies were cohort studies followed by 15 case control studies. Randomized controlled trials accounted for only 2 of the included studies. Injuries were separated into Hips, knees, foot and ankle, and overall rates.
Conclusions: Regardless of the level of evidence of the study (1-3), the sport being played (football, soccer, other), level of competition (professional, amateur), overall, 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. Newer generations of turf showed signs of having reduced rates when compared to older generations, however, the data was not overtly conclusive about this. Higher quality studies need to be done directly comparing the two. Many articles showed injury rates being equal when comparing the surface of play, but more studies seemed to show evidence leading to more injuries on artificial turf. Only 3 articles in the literature reported a higher overall injury rate on natural grass compared with artificial turf, and all these studies had received financial support from the artificial turf industry.