Epidemiological Comparison of ACL Injuries on Different Playing Surfaces in High School Football and Soccer

BACKGROUND: Anterior cruciate ligament (ACL) injuries are among the most common serious injuries to athletes in the United States. Among high school sports, the highest rates of ACL injury occur in soccer and football. PURPOSE: To compare ACL injuries on artificial turf and natural grass using a nationally representative sample of high school athletes participating in football and boys’ and girls’ soccer. STUDY DESIGN: Descriptive epidemiology study. METHODS: ACL injuries among high school athletes participating in football and soccer were obtained from the High School Reporting Information Online surveillance system during the 2007-08 through 2018-19 school years. National estimates and injury proportion ratios (IPRs) with 95% CIs were calculated for ACL injuries that occurred on artificial turf versus natural grass. RESULTS: A total of 1039 ACL injuries were reported, which represented an estimated 389,320 (95% CI, 358,010-420,630) injuries nationally. There were 74,620 estimated football-related ACL injuries on artificial turf and 122,654 on natural grass. Likewise, 71,877 of the estimated soccer-related ACL injuries occurred on artificial turf and 104,028 on natural grass. A contact-injury mechanism accounted for 50.2% of football-related ACL injuries on artificial turf and 60.8% on natural grass. For soccer-related ACL injuries, a noncontact mechanism predominated on artificial turf (61.5%) and natural grass (66.4%). Among all injuries, ACL injuries were more likely to occur on artificial turf than natural grass in both football (IPR, 1.23 [95% CI, 1.03-1.47]) and girls’ soccer (IPR, 1.53 [95% CI, 1.08-2.16]); however, no significant association was found in boys’ soccer (IPR, 1.65 [95% CI, 0.99-2.75]). Among lower extremity injuries, ACL injuries were more likely to occur on artificial turf than natural grass in both boys’ soccer (IPR, 1.72 [95% CI, 1.03-2.85]) and girls’ soccer (IPR, 1.61 [95% CI, 1.14-2.26]); however, the association was not significant in football (IPR, 1.17 [95% CI, 0.98-1.39]). CONCLUSION: ACL injuries were more likely to occur (ie, had larger IPRs) on artificial turf than natural grass; however, this relationship was not statistically significant for all sports.