Quick answer
- Turf and cleats add load to the knee, but how an athlete lands and cuts decides more of the risk, and training changes that
- NFL players had 16% more lower-extremity injuries per play on synthetic turf, with a larger gap for non-contact injuries
- In soccer, artificial turf raised ACL risk in women's games by about 18%, with no significant effect for men
- Exercise-based prevention programs cut non-contact ACL injuries in women athletes by 67% in pooled analyses
Cleats and turf play a part in non-contact ACL tears, but they're a smaller part than most athletes and parents think. Synthetic turf and aggressive stud patterns grip harder, which can keep the foot fixed while the body turns over it, and NFL data show more non-contact lower-limb injuries on turf. The bigger driver is how an athlete lands, slows down and cuts, and that's the part training can change. Female athletes in cutting sports carry the most risk, so they gain the most from that work.
At True Sports we test landing and cutting mechanics in ACL rehab and in prevention work with soccer athletes. Here's what the turf research shows, how cleats change the load, who's most at risk, and what lowers it.
What the turf research actually shows
Turf raises the risk modestly, and only for some athletes. An analysis of five NFL seasons found 16% more lower-extremity injuries per play on synthetic turf, with a stronger effect for non-contact injuries. In soccer, a 2022 meta-analysis found turf raised ACL risk in women's games by about 18%, with no significant effect for men or for players overall.
The NFL study, published in the American Journal of Sports Medicine, covered every regular season game from 2012 to 2016. The incidence rate ratio for lower-extremity injury on synthetic turf was 1.16. For non-contact and surface-contact injuries, the ratios ranged from 1.20 to 2.03, all statistically significant.
The soccer meta-analysis pooled seven studies of professional, college and youth players. Female players had an incidence rate ratio of 1.18 for ACL injury in games on artificial turf. Male players showed the same ratio without statistical significance, and practices showed no difference. Most of this is adult game data on modern turf, and field age, infill and maintenance vary from one field to the next.
Why a planted foot loads the knee
Cleats decide how firmly the foot locks to the ground. More grip helps acceleration, but when the foot can't release during a cut, the turning force travels up the leg to the knee. Synthetic turf lets go of cleats less readily than grass, which is the mechanism researchers propose behind the NFL findings.
That fits how non-contact tears happen. NIH's StatPearls review describes most ACL tears in athletes as non-contact pivoting injuries, with the shin shifting forward while the knee is slightly bent and collapsing inward. A fixed foot makes that position harder to get out of.
Jack Rasmussen, founder of Caddx Cleats, made the footwear case on the True Sports Podcast:
You don't just get stuck on the ground when you're barefoot. The common denominator is the cleat. I don't care what you're playing on, turf or grass, you're always wearing cleats. That is the common variable you all often overlook.
His company makes cleats designed to reduce that grip, so his view comes from the shoe side, and published clinical evidence on specific cleat designs is still limited. The practical steps are simpler. Wear turf shoes or short studs on synthetic fields, and keep longer studs for soft natural grass.
Who carries the most risk
Female athletes in cutting and pivoting sports. AAOS reports that female athletes tear the ACL at 2 to 8 times the rate of males. Soccer, basketball and lacrosse pack in the pivoting and landing that produce non-contact tears, and a previous ACL injury adds to the risk.
The AAOS ACL page links the difference to knee shape, biomechanics, hormonal influences, and pelvis and leg alignment. Turf sits on top of those factors. For a female soccer or lacrosse player who lands with the knee caving inward, a surface that holds the foot adds load to a pattern that's already risky. The full list of ACL risk factors has its own guide.
What lowers the risk
Exercise-based prevention programs have the strongest evidence. The 2023 JOSPT guideline recommends them for athletes in cutting and pivoting sports, and a pooled analysis it cites found a 67% reduction in non-contact ACL injuries among women athletes. They work best run several times a week, for more than 20 minutes a session, from preseason through the season.
The JOSPT prevention guideline names programs such as the 11+, PEP and Sportsmetrics, and calls for programs in women athletes to combine several pieces:
- Strength: hamstrings, quadriceps and hips, loaded progressively
- Plyometrics: jumping and landing with the knee tracking over the foot
- Hip and trunk control during single-leg and cutting tasks
- Technique: deceleration and cutting drills at increasing speed
The same guideline says balance work alone isn't enough. Targeted training for female athletes goes into the details.
Back on turf after an ACL reconstruction
For an athlete returning from an ACL reconstruction, cutting is the last skill to come back and the one turf tests hardest. At True Sports' Hummelstown clinic, Dr. Tim Ervey introduced change-of-direction work for the first time with an athlete about seven months after surgery. It's one of the biggest checkpoints in ACL rehab, because the knee has to handle movement it can't fully predict. At the Timonium clinic, Dr. Jeremy Beyer opened one ACL session by mimicking the demands of the athlete's sport, then layered in change-of-direction drills and lower body loading.
The surface belongs in that final stage. Strength within 10% of the other side, hop tests that hold up and cutting at game speed should be shown on the surface the athlete will actually play on, because a clinic floor doesn't reproduce turf grip.
Fueling a prevention program
Prevention programs work through strength and power, and nutrition supports both. Creatine monohydrate at 5g daily is worth considering for athletes running a strength and plyometric program, because it adds energy for the short, hard efforts that jumping, landing and sprint work rely on. Vitamin D at 2,000 IU daily suits athletes who train indoors or through winter, since vitamin D supports normal muscle function and athletes who spend the off-season inside often run low. Protein at 1.6 to 2.2g per kilogram of body weight daily gives the hamstring and hip work the material it needs.
Questions athletes and parents ask about turf
Is turf worse than grass for ACL injuries? For some athletes. NFL data show more non-contact lower-extremity injuries on synthetic turf, and female soccer players show higher ACL risk in turf games. Male soccer players and overall soccer data show no significant difference.
What cleats should I wear on turf? Turf shoes or short studs. Longer, more aggressive studs grip synthetic surfaces harder and keep the foot planted during a cut. Save them for soft natural grass.
Should my daughter avoid playing on turf? Usually not. The risk difference is modest, and avoiding turf is rarely practical. A prevention program, footwear matched to the surface and a landing and cutting assessment do more to lower her risk.
Can ACL injuries be prevented? Many non-contact ones can. Programs combining strength, plyometrics, hip control and cutting technique cut non-contact ACL injuries in women athletes by 67% in pooled analyses, as long as they run through the whole season.
Before the season starts
The surface is one factor among several, and landing mechanics, cutting technique, strength and any prior injury matter more. We assess those on the athlete's own surface before calling a knee ready for game speed, whether the goal is prevention or a return from an ACL tear. To get a cutting and landing assessment before the season, book your evaluation.
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