Turf sports (e.g., football, soccer, field hockey) may be played on either artificial turf or natural grass.

First-generation artificial turf, AstroTurf, was introduced in the late 1960s and consisted of short pile carpet monofilament fibers on top of padding over concrete. Second-generation artificial turf incorporated longer fibers, sand filing, and a rubber base.

Early studies comparing these surfaces with natural grass found a higher incidence of injuries when playing on these artificial surfaces (11,21).

Third-generation artificial turf (e.g., FieldTurf), which is composed of longer synthetic fibers and infill made of rubber pellets or sand, more closely mimics the physical properties of natural turf.

Multiple studies have demonstrated no significant difference in overall injury incidence for soccer players when third-generation artificial turf is compared with natural grass (2,8,9,10,25).

Evidence is sparse and less conclusive when comparing injury rates on third-generation artificial turf versus natural grass in American football. A 5-year study comparing injury rates in high school football players found a higher rate of injuries occurring during games played on third-generation turf (17). By contrast, Meyers’ most recent study involving National Collegiate Athletic Association (NCAA) Division I-A football players found a significantly lower overall incidence of injury on artificial turf (16).

Although overall injury incidence may be comparable between third-generation turf and natural grass, injury patterns differ.

Ankle ligament injuries in soccer players tend to be more prevalent and have been shown to be the most common season-ending injury on artificial turf. By contrast, ligamentous knee injuries are the most common season-ending injury for soccer players on grass (8,9,10).

Grass surfaces have been associated with a higher incidence of both ligamentous knee injuries and concussion in high school football players (17).

Certain types of minor injuries are exclusive to artificial turf. These include turf burns, the common abrasions associated with the surface. In one study, college football players were seven times more likely to have a methicillin-resistant Staphylococcus aureus infection after acquiring turf burn (5).

Tennis is another sport with playing surface options, including hard court, clay, composition, grass, and carpet.

Hard courts are associated with greater stress on the lower extremities as a result of the reduced shock-absorbing ability and increased traction between shoe and court.

With its energy-absorbing properties, clay is more forgiving to the upper extremities due to reduced ball speed (20).

During rehabilitation from injury, carpet, composition, and clay offer more cushion and are more forgiving to the lower extremities.

The NCAA mandates the use of a helmet, face mask, four-point or six-point chin strap, mouthguard, shoulder pads, and hip, coccyx, thigh, and knee pads during football competition.

There are two types of helmets currently in use: (a) padded, and (b) air and fluid filled, with combinations of both types.

All football helmets in use at the high school or college level must be certified by the National Operating Committee on Standards for Athletic Equipment (NOCSAE). This ensures that each helmet has been tested to withstand repeated blows of high mass and low velocity. A study by Cantu and Mueller (7

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