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Introduction A subject of ongoing debate within the National Football League (NFL) community revolves around the comparative risk of anterior cruciate ligament (ACL) injuries on natural versus artificial turf field surfaces. There have been mixed results as to whether there is a difference in injury rates depending on the playing surface and what factors might play a role in affecting these rates. Methods This study aims to compare the incidence of in-game knee ligament tears in the NFL during the 2020-2023 seasons. Data was collected from publicly available resources to determine and classify specific injury characteristics such as ligament, injury date, location, and field surface type. Only in-game knee ligament tears, including those occurring in pre-season games, were included. Significance was determined using two-sample T-tests. Results Over the 2020, 2021, 2022, and 2023 seasons, there were 149 ligament tears, with 58 occurring on natural turf (38.9%) and 91 occurring on artificial turf (61.1%). Over the course of the same four years, 1213 games were played, with 524 (43.2%) games on natural turf and 689 games on artificial turf (56.8%). Accounting for the number of games played on each surface, natural turf saw a rate of 0.111 knee ligament tears per game, while artificial turf saw 0.132 ligament tears per game. Conclusion Over the course of the study period, we determined that there was no significant difference between the rates of in-game knee ligament tears on natural and artificial turf playing surfaces. Our study shows that regardless of differences in composition and other playing surface features, there is ultimately no difference in the incidence of knee ligament tears. Playing surfaces should still be monitored and regulated, and the incidence of other injuries, such as concussions, as well as player preference, should be considered when considering the ideal surface., Competing Interests: Human subjects: All authors have confirmed that this study did not involve human participants or tissue. Animal subjects: All authors have confirmed that this study did not involve animal subjects or tissue. Conflicts of interest: In compliance with the ICMJE uniform disclosure form, all authors declare the following: Payment/services info: All authors have declared that no financial support was received from any organization for the submitted work. Financial relationships: All authors have declared that they have no financial relationships at present or within the previous three years with any organizations that might have an interest in the submitted work. Other relationships: All authors have declared that there are no other relationships or activities that could appear to have influenced the submitted work., (Copyright © 2024, McCormick et al.)

There is growing concern over the safety of artificial turf when it comes to the incidence of player injuries. The artificial surfaces can withstand more play, are cheaper to maintain, and are more predictable. However, there is concern that this beneficial durability comes at the expense of the forgiveness of the surface, leading to more injuries. In this study, we aim to compare the incidence of in-game season-ending lower extremity injuries on natural and artificial playing surfaces in the National Football League (NFL) during the 2020, 2021, and 2022 seasons. For this study, we used publicly available data to determine and classify the specific injury, where the injury occurred, field surface type, and duration of recovery. All data were collected, and significance was determined using two-sample T -tests. Only in-game injuries were included in this study. Over the course of 2020, 2021, and 2022, there were 199 season-ending lower-extremity injuries. Of these, 79 occurred on natural turf (39.7%) and 120 on artificial turf (60.3%). Of the 891 games played in this three-year period, 396 were played on natural turf (44.4%) and 495 were played on artificial turf (55.6%). Natural turf saw an injury rate of 0.199 per game, and artificial turf saw 0.242 injuries per game. We determined that there is no significant difference in rates of season-ending lower-extremity injury between artificial and natural turf. Any perceived difference in injury rates could possibly be attributed to the increased amount of play on artificial surfaces and anecdotal evidence related to high profile cases. While there is no significant difference in incidence, surfaces should continue to be monitored and regulated for traits such as hardness, and player preferences should be considered for qualities that are not quantifiable., Competing Interests: The authors declare no conflicts of interest., (Copyright © 2024 William F. McCormick et al.)