Executive Summary
Individual studies on turf and injury risk can pull in different directions depending on sport, competition level, and turf generation studied. This 2023 systematic review from MedStar Union Memorial Hospital and Georgetown University set out to step back from any single study and synthesize the full available body of literature — 53 peer-reviewed articles published between 1972 and 2020 — into the most comprehensive picture assembled to date of how artificial turf and natural grass compare across overall injury, knee injury, hip injury, and foot/ankle injury.
The result is a nuanced, sport- and body-region-specific picture rather than a single verdict — which is exactly the kind of finding that resists being reduced to a marketing claim in either direction.
Key Findings
- Overall injury rates were broadly similar between surfaces. Of 31 articles comparing overall injury rates, just over half (51.6%) found no significant difference; 35.5% found a higher rate on artificial turf; 12.9% found a higher rate on natural grass.
- Knee injury rates were also broadly similar overall — of 26 articles, 53.8% found no difference, 30.8% found a higher rate on artificial turf, and 15.4% found a higher rate on natural grass. However, football players at higher levels of competition were more likely to sustain a knee injury on artificial turf than on natural grass — a sport- and level-specific exception to the broader pattern.
- Foot and ankle injuries were the clearest area of elevated risk on artificial turf. A majority of articles (58.3%) reported a higher foot/ankle injury rate on turf — and this pattern held for both old-generation and new-generation turf, not just older systems.
- For soccer specifically on new-generation turf, knee and hip injury rates were similar between surfaces.
- Most studies evaluating new-generation turf specifically (13 of 18) found similar overall injury rates compared to natural grass — suggesting the picture has generally improved as turf technology has evolved, with foot/ankle injury as the persistent exception.
Important Limitations
- No quantitative meta-analysis was performed. The authors explicitly note that the studies included were too heterogeneous in design, sport, and methodology to statistically pool — this review synthesizes patterns across studies rather than calculating a single combined risk ratio.
- Study quality varied widely. Of the 53 included articles, only 2 were randomized controlled trials; most were cohort or case-control studies, and 20 were retrospective — a lower tier of evidence than a controlled trial.
- The dataset spans nearly 50 years (1972–2020), meaning “artificial turf” as a category includes vastly different technologies, and the authors themselves point out that specific surface design characteristics and maintenance quality — factors most individual studies don’t capture — likely moderate these results significantly.
- As with most turf-vs-grass research, individual field condition and construction quality are not standardized or measured across the underlying studies.
Why This Matters
This is one of the most useful single sources in the turf safety conversation precisely because it doesn’t collapse into a simple “safer” or “riskier” conclusion. For architects and athletic directors, the practical takeaway is body-region and sport specific: overall and knee injury risk looks broadly comparable between well-built modern turf and natural grass, with football at high competition levels as a notable exception worth discussing directly with medical and coaching staff. Foot and ankle injury risk is the area where the literature most consistently points toward turf as a distinguishing factor — and that’s worth taking seriously in surface and cleat selection, rather than downplaying because it’s a less dramatic-sounding injury category than knee ligament tears.
Act Global Perspective
This review’s honesty about foot and ankle injury risk is a good example of exactly the kind of finding we think field owners deserve to see clearly, not buried. Foot and ankle injuries are strongly linked to traction and release characteristics — how much a shoe grips and then releases from the surface during cutting and pivoting movements — which is precisely what rotational resistance testing is designed to measure and manage at the system level.
We also think the review’s finding on new-generation turf is worth highlighting fairly: most current-generation systems studied showed overall injury rates comparable to natural grass, which is a meaningfully different picture than turf technology from decades past. That’s consistent with why Act Global treats traction engineering as a core testing category for every system, not an afterthought — and why we’d encourage any field owner concerned about foot and ankle injury risk specifically to ask for a system’s rotational resistance data before installation, rather than relying on turf-versus-grass generalizations.
Related Resources
- Rotational Resistance Explained — Traction and Lower-Extremity Injury Risk
- Knee Injury Incidence in NCAA Football — Review of Loughran et al. 2019
- ACL Injury Risk on Synthetic Turf vs. Natural Grass — Review of Howard et al. 2020
Access the Original Study
This review is Act Global’s independent summary of publicly available peer-reviewed research, prepared for educational purposes. Act Global does not host or reproduce the original article. Read the full study directly from the publisher:
- Gould HP, Lostetter SJ, Samuelson ER, Guyton GP. “Lower Extremity Injury Rates on Artificial Turf Versus Natural Grass Playing Surfaces: A Systematic Review.” American Journal of Sports Medicine, 51(6):1615–1621, 2023. DOI: 10.1177/03635465211069562
This is an Act Global Research Review — an independent interpretation of publicly available peer-reviewed research prepared for educational purposes only. It does not constitute medical, legal, or engineering advice.
