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The Knee 20 (2013) 191–195

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The Knee

The effect of playing surface on the incidence of ACL injuries in National Collegiate
Athletic Association American Football
Jason L. Dragoo ⁎, Hillary J. Braun, Alex H.S. Harris
Department of Orthopaedic Surgery, Stanford University, Palo Alto, CA, USA

a r t i c l e i n f o a b s t r a c t

Article history: Background: Artificial playing surfaces are widely used for American football practice and competition and
Received 4 April 2012 anterior cruciate ligament (ACL) injuries are common. This study analyzed the National Collegiate Athletic
Received in revised form 14 June 2012 Association (NCAA) Injury Surveillance System (ISS) men's football ACL injury database from 2004–2005
Accepted 8 July 2012 through 2008–2009 to determine the effect of playing surface on ACL injury in NCAA footballathletes.
Methods: This database was reviewed from the 2004–2005 through 2008–2009 seasons using the specific
Keywords:
injury code, “Anterior cruciate ligament (ACL) complete tear.” The injury rate was computed for competition
Playing surface
Artificial turf
and practice exposures. Ninety-five percent confidence intervals were calculated using assumptions of a
Anterior cruciate ligament Poisson distribution. Pair-wise, two-sample tests of equality of proportions with a continuity correction
Injury were used to estimate the associations of risk factors.
American football Results: There was an incidence rate of 1.73 ACL injuries per 10,000 athlete-exposures (A-Es) (95% CI 1.47–2.0)
ACL on artificial playing surfaces compared with a rate of 1.24 per 10,000 A-Es (1.05–1.45, p b 0.001) on natural
Grass grass. The rate of ACL injury on artificial surfaces is 1.39 times higher than the injury rate on grass surfaces.
Non-contact injuries occurred more frequently on artificial turf surfaces (44.29%) than on natural grass
(36.12%).
Conclusions: NCAA football players experience a greater number of ACL injuries when playing on artificial
surfaces.
© 2012 Elsevier B.V. All rights reserved.

1. Introduction increase overall injury incidences, patterns in specific injury types


are not widely discussed in current literature. Certain injuries, such
Artificial playing surfaces provide cost-effective, all-weather alter- as those to the anterior cruciate ligament (ACL), are of particular in-
natives to natural grass surfaces and are used for a wide range of terest because they frequently occur via non-contact mechanisms
sports and activities. In the United States, more than 3500 synthetic that may be related to surface type. Current literature investigating
fields are currently in use for a variety of sports, including American the effect of playing surface on ACL injury is divided; two reports doc-
football [1]. Players at the high school, intercollegiate, and profession- umented no difference in ACL injury rates on artificial turf and grass
al levels practice and compete on artificial playing surfaces with in- surfaces [13,14], while a different study found increased rates of
creasing frequency [2–4]. non-contact ACL injuries on grass compared with artificial turf [15].
Recent literature reviews have categorized the various types of ar- Others have reported an increased overall risk of ACL injury on turf
tificial playing surfaces, investigated their biomechanical properties, when compared with grass [8,9,15]. Collectively, these studies fail to
and documented distinct injury patterns [1,5–7]. The overall rate of reach a consensus about the effect of artificial playing surfaces on
football injuries has been reported to be significantly higher on artifi- ACL injury rates. These conflicting results highlight the variable na-
cial surfaces compared with natural grass [8–12]. It is increasingly ture of surface-related injuries and reinforce the need for more com-
clear that playing surface is an important factor in injury incidences prehensive studies.
and mechanisms. While it is evident that artificial playing surfaces The NCAA Injury Surveillance System (ISS) was developed in 1982
to provide current and reliable data on injury trends in intercollegiate
athletics. The purpose of this study was to analyze the NCAA ISS men's
⁎ Corresponding author at: Department of Orthopaedic Surgery, Stanford University,
450 Broadway Street, Pavilion C, 4th floor, Redwood City, CA 94063-6342, USA. Tel.:
football ACL injury database from the playing seasons of 2004-2005
+1 650 721 7800; fax: +1 650 721 3470. through 2008-2009 to 1) compare the incidence of ACL injury on
E-mail address: jdragoo@stanford.edu (J.L. Dragoo). natural grass and artificial turf playing surfaces and 2) determine if

0968-0160/$ – see front matter © 2012 Elsevier B.V. All rights reserved.
doi:10.1016/j.knee.2012.07.006
192 J.L. Dragoo et al. / The Knee 20 (2013) 191–195

subsets such as football subdivision, season segment, event type, The incidence of injury, i.e. the injury rate (number of injuries divided
practice type, practice segment, player activity at time of injury, athlete's by number of A-Es) was computed per 10,000 A-Es for competition
position, and basic injury mechanism are factors in ACL injury on natural and practice exposures. A-Es for the period of interest were established
grass versus artificial turf playing surfaces. by looking at the A-Es contained in the Men's Football Exposure Data Set
2004–2005 to 2008–2009. Ninety-five percent confidence intervals for
2. Methods the incidence rates were calculated based on assumptions of a Poisson
distribution using the standard large sample formula as implemented
2.1. Sampling and methods in the ci:poisson() function in the epicalc package of the R statistical
program (Epidemiological Calculator, R package version 2.9.2.0).
Collegiate institutions sponsoring varsity football programs volun- Rate ratios were also calculated, to determine whether there is an in-
tarily participated in the fall NCAA Injury Surveillance System (ISS) by creased rate of injury associated with one particular participation type
collecting data annually during the five-year period from 2004–2005 over another. For instance, if the competition injury rate was 6.0 times
through 2008–2009. The ISS collects data using an online database higher than the practice injury rate, then the competition-to-practice
that permits any institution from any of the three NCAA divisions to rate ratio would be 6.0. Ninety-five percent confidence intervals (95%
submit data. This convenience sample creates a deterministic rather CIs) were computed for all rates and rate ratios using standard large-
than a random sample but has been deemed an acceptable manner of sample formulas.
data collection for monitoring injury trends and patterns because it
maintains a representative cross-section of the NCAA. 2.2.2. Descriptive data on injuries
During 2004–2005 through 2008–2009 seasons, the ISS collected Descriptive data was also analyzed, such as player's activity at time
data on injuries and exposures in NCAA football players that occurred of injury, athlete's position, and injury mechanism. These variables
during organized practices and competitions from the first day of could not be considered risk factors because no data on the relevant
preseason to the final postseason competition. The online submission denominators were available (e.g., how many players at the same field
form asked questions pertaining to the basic mechanism of injury, location were not injured).
time and place of injury, body part injured, type of injury, severity of in-
jury (time loss and surgical interventions required), and sport-specific 3. Results
questions such as player position and equipment involved. Exposures
were entered by participating institutions through a one-page exposure During the 5-year period between 2004–2005 and 2008–2009, a total of 318
form summarizing the number of practices and competitions, the aver- injuries to the ACL occurred in NCAA collegiate football players during 2,222,155
A-Es, accounting for 0.23% of all injuries sustained during this five-year surveillance
age number of participants per activity, season (preseason, regular sea-
period. Thus, the overall incidence rate of ACL injuries in NCAA football players was
son, or postseason), type of playing surface, and location of competition 1.42 per 10,000 A-Es (95% CI 1.27–1.59). Of 318 reported ACL injuries, 147 occurred
(home or away). on an artificial turf surface, while 161 occurred on natural grass, however per 10,000
The Men's Football Injury Data Set for this 5-year period (2004– A–Es, there was a greater rate of ACL injuries on artificial turf (1.73, CI 1.47–2.00) ver-
2005 to 2008–2009 seasons) was examined using the specific injury sus natural grass (1.24, CI 1.05–1.45). The rate ratio of ACL injury on artificial surfaces
to grass surfaces is 1.39 (95% CI, 1.11–1.73), signifying a 39% difference in the expected
code “Anterior cruciate ligament (ACL) complete tear.” During the injury rate on artificial turf when compared with natural grass. Of the ACL injuries
time period of this investigation, the overall annual number of partici- occurring on artificial playing surfaces, 89.79% occurred on third generation surfaces,
pating institutions ranged from 8.9% to 10.1% of schools sponsoring documented as “artificial surfaces with fill” while the remaining 10.21% occurred on
NCAA intercollegiate football teams. Injuries were reported to the ISS first- or second-generation surfaces (“artificial surfaces without fill”). When artificial
playing surfaces were further subdivided, the rate of injury on artificial surfaces with
by the team athletic trainers when the injury satisfied three criteria:
fill (1.77 per 10,000 A-Es, 95% CI 1.47–2.08) was greater than the injury rate on artifi-
(1) occurred as a result of participation in an organized NCAA intercol- cial surfaces without fill, (1.43 per 10,000 A-Es, 95% CI 0.78–2.30) and natural grass
legiate practice or competition, (2) subsequently required medical (1.24 per 10,000 A-Es, 95% CI 1.05–1.45) (Fig. 1).
attention, and (3) resulted in restriction of the student- athlete's partic- When controlling for surface type, both the pre-season incidence of ACL injuries
ipation in practice or competition for at least one calendar day beyond (1.38 per 10,000 A-Es, 95% CI 0.97–1.86) and in season incidence (1.9 per 10,000 A-Es,
95% CI 1.6–2.3) on artificial turf were significantly greater than on natural grass (1.31
the initial day of injury. We also looked at the Men's Football Exposure per 10,000 A-Es, CI: 0.96–1.65 and 1.19 per 10,000 A-Es, CI: 0.97–1.43, respectively). In
Data Set 2004-2005 to 2008-2009 to determine the number of the post-season, the incidence of ACL injuries was greater on natural grass at 1.8 injuries
athlete-exposures (A-Es) to be used as the denominator when calculat- per 10,000 A-Es (95% CI 0.6–3.6) compared with artificial surfaces (1.5 per 10,000 A-Es,
ing injury rates. A reportable athlete-exposure (A-E) was defined as one 95% CI 0.5–2.7) (Fig. 2).
In games only, the incidence of ACL injuries on artificial turf was greater than
student-athlete participating in one practice or competition in which
on natural grass for games played at home (8.76 per 10,000 A-Es, CI: 6.28–11.46 vs.
there was the possibility for athletic injury, regardless of the duration 5.57 per 10,000 A-Es, CI: 3.72–7.87) and games played away (9.34 per 10,000 A-Es,
of that participation. Of note, preseason intra-squad scrimmages were CI: 6.69–12.38 vs. 9.2 per 10,000 A-Es, CI: 6.69–11.97). The injury rate was lowest in
classified as practices rather than games. Athletic trainers submitted home games played on grass at approximately 5.5 injuries per 10,000 A-Es. The other
data starting on the first official day of preseason practice and data combinations had approximately the same higher rate of 9 injuries per 10,000 A-Es.

collection extended to and included the final day of postseason


competition.
Once the injury and exposure variables contained in the Men's
Football Injury Data Set 2004–2005 to 2008–2009 and the Men's
Football Exposure Dataset 2004–2005 to 2008–2009 were identified,
we analyzed them to establish the incidence and epidemiology of
ACL injuries and the risk factors associated with ACL injury in NCAA
football players on artificial turf and natural grass playing surfaces.

2.2. Statistical methods

2.2.1. Incidence
In order to be able to make inferences regarding all NCAA Football
exposures from the convenience sample reflected in these data, the Fig. 1. ACL injuries by playing surface. Rates of injuries per 10,000 exposures on artifi-
NCAA has created sampling weights, which were used in all analyses. cial surfaces with fill, artificial surfaces without fill, and natural grass.
J.L. Dragoo et al. / The Knee 20 (2013) 191–195 193

The results of the present investigation clearly demonstrate an in-


creased risk and occurrence of ACL injuries on artificial surfaces com-
pared with natural grass. Not only was the overall ACL injury rate
higher on artificial surfaces, it was also elevated when controlling for
almost all other parameters: during pre-season and regular season
games (Fig. 2), during both home and away games, during scrimmage
and regular practices, and across Divisions I, II, and III (Fig. 3). The
only circumstance in which the incidence of ACL injury was significantly
greater on natural grass was during post-season games (Fig. 2). These
findings overwhelmingly demonstrate that participation on artificial
surfaces places NCAA football players at an increased risk for ACL injury.
Structural characteristics, response to physical wear, and environ-
mental exposures [7] are identified in current literature as variables
influencing the performance of playing surfaces. First-generation artifi-
cial surfaces are characterized by short grass fibers over minimal pad-
ding and concrete [6], while second-generation surfaces consist of
longer fibers, sand filling, and a rubber base [16]. Third-generation sur-
Fig. 2. ACL injuries by season. Rates of injuries on artificial turf and natural grass
faces, characterized in this investigation as “artificial surfaces with fill,”
pre-season, in season, and post-season.
were developed to mimic the properties of natural grass and consist of
long fibers and sand or rubber infill [17]. Despite this attempt at repli-
cating natural surfaces, we observed an increased risk of ACL injury on
In practice scrimmages, the incidence of ACL injuries on artificial turf (6.20 per
10,000 A-Es, CI 3.30–10.16) was greater than on natural grass (2.65 per 10,000 A-Es,
third-generation artificial surfaces compared with natural grass. A pre-
95% CI 1.06–4.86). For regular practices, the increased rate of injuries on artificial turf vious investigation of National Football League (NFL) players found an
(0.91 per 10,000 A-Es, 95% CI 0.70–1.15) versus natural grass (0.78 per 10,000 A-Es, increased incidence of ACL injury on AstroTurf, which is generally char-
95% CI 0.63–0.96) was also observed. acterized as a first- or second-generation surface [18]. However, more
In Divisions I, II, and III, the incidence of ACL injury was greater on artificial sur-
recent comparisons of natural grass and third-generation turf revealed
faces compared with natural grass. In Division I, the incidence of ACL injuries on artifi-
cial turf was 1.5 per 10,000 A-Es (95% CI 1.15-1.9) compared with 1.41 per 10,000 A-Es similar rates of overall injury in NCAA [19,20] and European [16,21]
(95% CI 1.12-1.73) on natural grass. The rate of ACL injuries was also greater on artifi- soccer players and collegiate football players [22]. Furthermore, an
cial surfaces compared with grass in Division II (1.72 vs. 0.87 per 10,000 A-Es,) and evaluation of high school football athletes identified a non-significant
Division III (2.03 vs. 1.32 per 10,000 A-Es) (Fig. 3).
trend of increased ACL injury on natural grass when compared with
Athlete positions were only recorded for game exposures. As a result, athlete positions
were not recorded in 185.9 (51%) of weighted exposures and were therefore excluded from
third-generation surfaces [4]. These previous results were encouraging
analysis. Of those injuries with documented positions occurring on artificial turf, special and supported the use of third-generation surfaces as a safe and appro-
teams players (9.19%), linebackers (9.08%), wide receivers (5.43%), running backs (4.96%) priate alternative to natural grass playing surfaces. However, our results
and quarterbacks (4.91%) were most frequently injured. On natural grass, injuries to run- demonstrated the opposite trend, which may be due to different athletic
ning backs (10.03%), linebackers (6.83%), wide receivers (4.44%), special teams players
populations, nebulous characterization of third-generation surfaces, or
(3.86%) and cornerbacks (3.49%) were most frequent.
The basic injury mechanism on artificial turf was reported as contact with another varying natural grass surfaces. This final variable is particularly impor-
player in 48.61% of injuries, while acute non-contact (44.29%) and contact with the tant; though they are regarded as the standard for comparison, natural
playing surface (6.25%) accounted for the majority of remaining injuries. On natural grass surfaces are inherently variable due to factors such as soil type,
grass, 56.92% of injuries resulted from player contact, while 36.12% were due to
soil density, grass root density, and soil moisture content [6].
non-contact mechanisms and 2.8% resulted from contact with the playing surface
(Fig. 4). The specific mechanism of injury on artificial turf was undefined or other in
Our results also demonstrated an increased incidence of non-contact
50.32% of injuries. Being tackled (15.53%), being blocked (10.82%), blocking (10.3%), ACL injuries on artificial surfaces versus natural grass, a finding that
tackling (7.31%), and being stepped on/fallen on/kicked (5.71%) accounted for the
remaining injuries. On natural grass, the specific mechanism was undefined or other
in 41.70% of injuries. Being tackled (23.86%), blocking (12.91%), being blocked
(8.54%), tackling (5.71%), being stepped on/fallen on/kicked (5.31%), and contact
with a blocking sled/dummy (1.95%) accounted for the remaining injuries. On artificial
turf, athletes were most likely to be participating in offensive passing (18.09%), offen-
sive running (16.42%), defensive passing (15.45%), and defensive running (14.18%)
plays. Players were also frequently injured in kick-off coverage (8.4%), punt coverage
(4.9%), kick-off return (3.78%), and punt return (2.66%). On natural grass, athletes
were most likely to be participating in offensive running (21.0%), offensive passing
(20.83%), defensive running (11.5%), and defensive passing (11.05%) plays. Blocking
drills (6.34%), punt return (5.0%), kick-off coverage (4.84%), and kick-off return
(3.66%) were additional activities resulting in frequent injuries.

4. Discussion

Our analysis of the NCAA ISS Men's Football Injury Data Set from
2004–2005 to 2008–2009 revealed several important findings: 1) ath-
letes are more likely to sustain an ACL injury on artificial turf compared
with natural grass playing surfaces, 2) the rate of ACL injury on artificial
surfaces with fill is greater than on artificial surfaces without fill or nat-
ural grass, both of which have comparable injury rates, 3) compared
with natural grass, a greater percentage of injuries sustained on artificial
surfaces are due to non-contact mechanisms.
Artificial playing surfaces have been correlated with an increased
risk of overall injury in football players [8–12]. However, previous find- Fig. 3. ACL injuries by NCAA division. Rates of injuries on artificial turf and natural grass
ings with regard to ACL injury specifically are sparse and inconsistent. in Divisions I, II, and III.
194 J.L. Dragoo et al. / The Knee 20 (2013) 191–195

Fig. 4. ACL injury basic mechanism. The basic mechanism of ACL injury on artificial turf (A) and natural grass (B). The incidence of non-contact injuries is higher on artificial surfaces.

echoes a 2004 study that documented that the overall non-contact foot- 5. Conclusion
ball injury rates were greater on FieldTurf compared with grass surfaces
[4]. Non-contact ligamentous knee injuries, such as acute injury of NCAA football players experience a greater number of ACL injuries
the ACL, often involve a foot planted on the playing surface with exces- when playing on artificial turf surfaces, particularly on artificial sur-
sive rotation of the upper body [23]. The shoe-surface interface has faces with fill. A greater percentage of injuries sustained on artificial
been postulated as a variable that may help explain the difference in turf are due to non-contact mechanisms. The incidence of ACL injury
non-contact injury rates between artificial and natural playing surfaces. varies with position type and playing surface, however it is most
Peak torque between the shoe and the playing surface presents a risk for prevalent in linebackers, running backs, and special teams players.
lower extremity injury [24–27], and artificial surfaces have repeatedly
demonstrated higher frictional forces [28], peak torques [24–27,29],
and rotational stiffness [29] when compared with natural surfaces. Conflict of interest statement
Foot loading patterns also differ by playing surface; a recent investiga-
tion revealed that higher loads on the medial and lateral forefoot were None.
observed on natural grass, while loading of the central forefoot and
lateral lesser toe was observed on artificial turf [30]. Though the exact
Acknowledgements
relationship of these variables to ACL injury remains to be identified,
these factors may help explain the increased incidence of non-contact
Each of the authors has read and concurs with the content in the
ACL injuries observed on artificial surfaces in the present investigation.
final manuscript.
The findings of this study highlight the need for further investiga-
This publication contains materials created, compiled or produced
tion of ACL injury patterns and mechanisms on artificial playing sur-
by the Datalys Center on behalf of the National Collegiate Athletic Asso-
faces. While it is discouraging that the injury rates observed here
ciation. Copyright [date of First Publication] National Collegiate Athletic
are elevated on artificial turf, the fact that a substantial percentage
Association. All rights reserved.
of injuries are due to non-contact mechanisms may suggest an oppor-
tunity for implementing prevention programs aimed at improving
athlete biomechanics to help reduce the rates of injury overall and References
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