Higher Rates of Lower Extremity Injury on Synthetic Turf Compared With Natural Turf Among National Football League Athletes: Epidemiologic Confirmation of a Biomechanical Hypothesis

Am J Sports Med. 2019 Jan;47(1):189-196. doi: 10.1177/0363546518808499. Epub 2018 Nov 19.


Background: Biomechanical studies have shown that synthetic turf surfaces do not release cleats as readily as natural turf, and it has been hypothesized that concomitant increased loading on the foot contributes to the incidence of lower body injuries. This study evaluates this hypothesis from an epidemiologic perspective, examining whether the lower extremity injury rate in National Football League (NFL) games is greater on contemporary synthetic turfs as compared with natural surfaces.

Hypothesis: Incidence of lower body injury is higher on synthetic turf than on natural turf among elite NFL athletes playing on modern-generation surfaces.

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

Methods: Lower extremity injuries reported during 2012-2016 regular season games were included, with all 32 NFL teams reporting injuries under mandated, consistent data collection guidelines. Poisson models were used to construct crude and adjusted incidence rate ratios (IRRs) to estimate the influence of surface type on lower body injury groupings (all lower extremity, knee, ankle/foot) for any injury reported as causing a player to miss football participation as well as injuries resulting in ≥8 days missed. A secondary analysis was performed on noncontact/surface contact injuries.

Results: Play on synthetic turf resulted in a 16% increase in lower extremity injuries per play than that on natural turf (IRR, 1.16; 95% CI, 1.10-1.23). This association between synthetic turf and injury remained when injuries were restricted to those that resulted in ≥8 days missed, as well as when categorizations were narrowed to focus on distal injuries anatomically closer to the playing surface (knee, ankle/foot). The higher rate of injury on synthetic turf was notably stronger when injuries were restricted to noncontact/surface contact injuries (IRRs, 1.20-2.03; all statistically significant).

Conclusion: These results support the biomechanical mechanism hypothesized and add confidence to the conclusion that synthetic turf surfaces have a causal impact on lower extremity injury.

Keywords: football injury; lower extremity; natural turf; stadium surface; synthetic turf.

Publication types

  • Research Support, Non-U.S. Gov't

MeSH terms

  • Athletic Injuries / epidemiology
  • Athletic Injuries / physiopathology
  • Biomechanical Phenomena
  • Floors and Floorcoverings*
  • Football / injuries*
  • Football / physiology
  • Humans
  • Incidence
  • Lower Extremity / injuries*
  • Lower Extremity / physiopathology
  • Male
  • Poaceae
  • Retrospective Studies