Incidence and Risk Factors for Injuries to

the Anterior Cruciate Ligament in National

Collegiate Athletic Association Football
Data From the 2004-2005 Through 2008-2009
National Collegiate Athletic Association Injury
Surveillance System
Jason L. Dragoo,*y MD, Hillary J. Braun,y BA, Jennah L. Durham,y BA,
Michael R. Chen,y MD, and Alex H.S. Harris,y PhD
Investigation performed at the Department of Orthopaedic Surgery,
Stanford University, Redwood City, California

Background: Injuries to the anterior cruciate ligament (ACL) are common in athletic populations, particularly in athletes partici-
pating in football, soccer, and skiing.
Purpose: The purpose of this study was to analyze the National Collegiate Athletic Association (NCAA) Injury Surveillance System
(ISS) men’s football ACL injury database from the playing seasons of 2004-2005 through 2008-2009 to determine the incidence
and epidemiology of complete injury to the ACL in NCAA football athletes.
Study Design: Descriptive epidemiology study.
Methods: The NCAA ISS men’s football database was reviewed from the 2004-2005 through 2008-2009 seasons using the spe-
cific injury code, ‘‘Anterior cruciate ligament (ACL) complete tear.’’ The injury rate was computed for competition and practice
exposures. Ninety-five percent confidence intervals (CIs) for the incident rates were calculated using assumptions of a Poisson
distribution. Pairwise, 2-sample tests of equality of proportions with a continuity correction were used to estimate the associations
of risk factors such as event type, playing surface, season segment, and football subdivision. Descriptive data were also
described.
Results: The ACL injury rate during games (8.06 per 10,000 athlete-exposures [AEs] 95% CI, 6.80-9.42) was significantly greater
than the rate during practice (0.8 per 10,000 AEs 95% CI, 0.68-0.93). Players were 10.09 (95% CI, 8.08-12.59) times more likely to
sustain an ACL injury in competition when compared with practices. When practice exposures were analyzed separately, the
injury rate was significantly greater during scrimmages (3.99 per 10,000 AEs 95% CI, 2.29-5.94) compared with regular practices
(0.83 per 10,000 AEs 95% CI, 0.69-0.97) and walk-throughs (0 per 10,000 AEs 95% CI, 0-0.14). There was an incidence rate of
1.73 ACL injuries per 10,000 AEs (95% CI, 1.47-2.0) on artificial playing surfaces compared with a rate of 1.24 per 10,000 AEs
(95% CI, 1.05-1.45) on natural grass. The rate of ACL injury on artificial surfaces is 1.39 (95% CI, 1.11-1.73) times higher than
the injury rate on grass surfaces.
Conclusion: Between 2004 and 2009, NCAA football players experienced a greater number of ACL injuries in games compared
with practices, in scrimmages compared with regular practices, and when playing on artificial turf surfaces. This latter finding will
need to be confirmed by additional studies.
Keywords: anterior cruciate ligament; ACL; injury; football; NCAA; artificial turf

Football is one of the most popular sports in the United
States and has been played competitively at the collegiate
level for over 100 years. Football is a high-impact sport,
The American Journal of Sports Medicine, Vol. 40, No. 5
DOI: 10.1177/0363546512442336
Ó 2012 The Author(s)
with injuries occurring via both contact and noncontact
mechanisms, and a complex sport, requiring that athletes
perform position-specific skills and activities. It is also
the leading cause of sport-related injuries, with an injury
rate almost twice that of basketball.20,24 The demands of
the game are such that players’ physical characteristics
(eg, height and weight) vary widely, both within a team
and among National Collegiate Athletic Association

990
Vol. 40, No. 5, 2012
(NCAA) divisions. The large number of athletes involved in
NCAA football combined with the variability in their posi-
tions and individual characteristics reveals interesting
injury patterns.
Over 100,000 injuries to the anterior cruciate ligament
(ACL) occur annually in the United States,8 frequently
during activities involving cutting, jumping, and pivot-
ing.13 Sports such as soccer, football, and skiing have
been characterized as high-risk activities, with several
authors reporting the risk of ACL injury in these sports
to be as much as 10 times higher than in other activi-
ties.3,9,28 In football players, ACL injuries are relatively
common and can often have devastating career consequen-
ces. Data from the National Football League (NFL) Com-
bine show that approximately 8% of participants have
a history of ACL injury,7 ACL injuries represent 35% of
all knee injuries previously sustained by participants,4
and ACL injury is the number one reason for receiving
a medical failure grade.6 Brophy et al6 reported that a pre-
vious ACL injury was associated with a decreased probabil-
ity of playing in the NFL, as only 45.9% of patients
reporting an ACL injury at the NFL Combine went on to
play at least 1 game. Furthermore, injury to the ACL
also places patients at an increased risk for development
of posttraumatic osteoarthritis, regardless of concomitant
meniscal injury18,19 or whether they undergo surgical
reconstruction of the ruptured ligament.16 It is important
to understand the incidence and causes of ACL injuries
in this vulnerable population.
The NCAA Injury Surveillance System (ISS) was devel-
oped in 1982 to provide current and reliable data on injury
trends in intercollegiate athletics. The purpose of this
study was to analyze the NCAA ISS men’s football ACL
injury database from the playing seasons of 2004-2005
through 2008-2009 to determine the incidence and epide-
miology of complete injury to the ACL in NCAA football
athletes. Our goal was to determine the injury rate and
risk factors associated with ACL injuries (eg, position,
playing surface, activity at time of injury, injury mecha-
nism, game vs practice, and season segment). No formal
hypothesis testing was proposed at the time this survey
was initiated, so all findings represent post hoc analysis
for specific comparisons.
MATERIALS AND METHODS
Sampling and Methods
Collegiate institutions sponsoring varsity football pro-
grams voluntarily participated in the fall NCAA ISS by
collecting data annually during the 5-year period from
2004-2005 through 2008-2009. The ISS is a surveillance
system that collects a sample of data from a larger popula-
tion as opposed to a registry that records every event’s
*Address correspondence to Jason L. Dragoo, MD, Department of Orthopaedic Surgery, Stanford University, 450 Broadway Street, Pavilion C, 4th
Floor, Redwood City, CA 94063-6342 (e-mail: jdragoo@stanford.edu).
y
Department of Orthopaedic Surgery, Stanford University, Redwood City, California.
The authors declared that they have no conflicts of interest in the authorship and publication of this contribution.
ACL Injuries in NCAA Football 991
occurrence. The ISS uses a convenience sample—the
online database permits any institution from any of the 3
NCAA divisions to submit data. This creates a determinis-
tic rather than a random sample but has been deemed an
acceptable manner of data collection for monitoring injury
trends and patterns because it maintains a representative
cross-section of NCAA participants while being courteous
to the needs of the volunteering institutions. Since 1982,
the ISS has employed stable, basic system definitions and
recording methods, served as the basis for NCAA policy,
and emerged as a powerful resource for monitoring injuries
in NCAA sports.
During the 2004-2005 through 2008-2009 seasons, the
ISS collected data on injuries and exposures in NCAA
football players that occurred during organized practices
and competitions from the first day of preseason to the
final postseason competition. Injury data collection was
achieved via an online submission form that asked ques-
tions pertaining to the basic mechanism of injury, time
and place of injury, body part injured, type of injury,
severity of injury (time loss and surgical interventions
required), and sport-specific questions such as player
position and equipment involved. Exposures were col-
lected through a web-based system as they were entered
by participating institutions through a 1-page exposure
form summarizing the number of practices and competi-
tions, the average number of participants per activity,
season (preseason, regular season, or postseason), type
of playing surface, and location of competition (home or
away).
The Men’s Football Injury Data Set for this 5-year
period (2004-2005 to 2008-2009 seasons) was examined
using the specific injury code ‘‘Anterior cruciate ligament
(ACL) complete tear.’’ The number of participating institu-
tions varies each year, but during the time period of this
investigation, the overall number of participating institu-
tions ranged from 8.9% to 10.1% of schools sponsoring
NCAA intercollegiate football teams. Injuries were
reported to the ISS by the team athletic trainers when
the injury satisfied 3 criteria: (1) occurred as a result of
participation in an organized NCAA intercollegiate prac-
tice or competition, (2) subsequently required medical
attention, and (3) resulted in restriction of the student-
athlete’s participation in practice or competition for at
least 1 calendar day beyond the initial day of injury. We
also looked at the Men’s Football Exposure Data Set
2004-2005 to 2008-2009 to determine the number of
athlete-exposures (AEs) to be used as the denominator
when calculating injury rates. A reportable AE was defined
as 1 student-athlete participating in 1 practice or competi-
tion in which there was the possibility for athletic injury,
regardless of the duration of that participation. Of note,
preseason intrasquad scrimmages were classified as prac-
tices rather than games. Athletic trainers submitted data
starting on the first official day of preseason practice,
992 Dragoo et al
and data collection extended to and included the final day
postseason competition.
Once the injury and exposure variables contained in
the Men’s Football Injury Data Set 2004-2005 to 2008-
2009 and the Men’s Football Exposure Data Set 2004-
2005 to 2008-2009 were identified, we included them in
the statistical analysis described below to establish the
incidence and epidemiology of ACL injuries and the risk
factors associated with ACL injury in NCAA football
players.
Statistical Methods
Incidence. To be able to make inferences regarding all
NCAA football exposures from the convenience sample
reflected in these data, the NCAA has created sampling
weights, which were used in all analyses. The incidence
of injury, that is, the injury rate (the number of injuries
divided by the number of AEs), was computed per 10,000
AEs for competition and practice exposures. The AEs for
the period of interest were established by looking at the
AEs contained in the Men’s Football Exposure Data Set
2004-2005 to 2008-2009. Ninety-five percent confidence
intervals (CIs) for the incidence rates were calculated
based on assumptions of a Poisson distribution using the
standard large-sample formula as implemented in the
ci:poisson() function in the epicalc package of the R statis-
tical program.27
Rate ratios were also calculated, as they are useful for
determining whether there is an increased rate of injury
associated with 1 particular participation type over
another. For instance, if the competition injury rate were
14.0 times higher than the practice injury rate, then the
competition-to-practice rate ratio would be 14.0. Ninety-
five percent CIs were computed for all rates and rate ratios
using standard large-sample formulas.
Descriptive Data on Injuries. Descriptive data were also
described, such as player’s activity at time of injury, ath-
lete’s position, side of body, and injury mechanism. These
variables cannot be considered risk factors because no
data on the relevant denominators were available (eg,
how many players at the same field location were not
injured).
RESULTS
During the 5-year period between 2004-2005 and 2008-
2009, a total of 318 injuries to the ACL occurred in
NCAA football players during 2,222,155 AEs, accounting
for 0.23% of all injuries sustained during this 5-year sur-
veillance period. Thus, the overall incidence rate of ACL
injuries in NCAA football players was 1.42 per 10,000
AEs (95% CI, 1.27-1.59). The injury rate was highest dur-
ing the postseason at 1.55 injuries per 10,000 AEs (95%
CI, 0.76-2.57), but this rate was not significantly different
from the rates of ACL injury in season (1.45 per 10,000 AEs
95% CI, 1.25-1.66) or preseason (1.34 per 10,000 AEs 95%
CI, 1.08-1.63). When divided based on competition type,
The American Journal of Sports Medicine
the injury rate during games (8.06 per 10,000 AEs 95%
CI, 6.80-9.42) was greater than the rate during practice
(0.8 per 10,000 AEs 95% CI, 0.68-0.93). Players were
10.09 (95% CI, 8.08-12.59) times more likely to sustain
an ACL injury in competition when compared with practi-
ces. When practice exposures were analyzed separately,
the injury rate was significantly greater during scrim-
mages (3.99 per 10,000 AEs 95% CI, 2.29-5.94) compared
with regular practices (0.83 per 10,000 AEs 95% CI, 0.69-
0.97) and walk-throughs (0 per 10,000 AEs 95% CI, 0-
0.14). Players were 4.8 (95% CI, 3.01-7.68) times more
likely to sustain an ACL injury in a scrimmage when com-
pared with a regular practice. The ACL injury rate was
highest in Division III football players at 1.56 per 10,000
AEs (95% CI, 1.28-1.87), but this was not statistically dif-
ferent from the rates in Division I (1.45 per 10,000 AEs
95% CI, 1.22-1.71) or Division II (1.17 per 10,000 AEs
95% CI, 0.88-1.48).
Playing surface had a significant effect on injury rates,
as there was an incidence rate of 1.73 ACL injuries per
10,000 AEs (95% CI, 1.47-2.0) on artificial surfaces com-
pared with a rate of 1.24 per 10,000 AEs (95% CI, 1.05-
1.45) on natural grass. The rate of ACL injury on artificial
surfaces is 1.39 (95% CI, 1.11-1.73) times higher than the
injury rate on grass surfaces. When artificial playing sur-
faces were further subdivided, the rate of injury on third-
generation surfaces, documented as ‘‘artificial surfaces
with fill’’ (1.77 per 10,000 AEs 95% CI, 1.47-2.08), was
significantly greater than the injury rate on first- and
second-generation artificial surfaces, ‘‘artificial surfaces
without fill’’ (1.43 per 10,000 AEs 95% CI, 0.78-2.30) and
natural grass (1.24 per 10,000 AEs 95% CI, 1.05-1.45).
Athlete positions were only recorded for game expo-
sures. As a result, athlete positions were missing or not
applicable in 186.79 (51.69%) of weighted exposures and
were therefore excluded from analysis. Of the remaining
injuries for which a position was known, linebackers
(7.73%), running backs (7.32%), special teams players
(6.32%), wide receivers (5.35%), cornerbacks (3.51%), and
quarterbacks (3.2%) were most frequently injured (Figure
1). Injuries to safeties (2.8%), defensive tackles (2.68%),
defensive ends (2.55%), offensive guards (2.26%), offensive
tackles (2.23%), centers (1.17%), tight ends (0.28%), kick-
ers/punters (0.28%), long snappers (0.28%), and holders
(0%) composed the remaining ACL injuries during this 5-
year surveillance period. In evaluating these numbers, it
is important to remember that exposure varies by the num-
ber of players at each position during a play.
The basic injury mechanism was reported as contact
with another player in 53.03% of injuries, while acute non-
contact (40.13%) and contact with the playing surface
(4.38%) accounted for the majority of the remaining inju-
ries (Figure 2). The specific mechanism of injury was unde-
fined, or other, in 45.78% of injuries. Being tackled
(20.05%), blocking (11.31%), being blocked (9.66%), tack-
ling (6.6%), being stepped on/fallen on/kicked (5.64%), or
contact with a blocking sled/dummy (0.96%) accounted
for the remaining injuries. Athletes were most likely to
be participating in offensive passing (19.79%), offensive
Vol. 40, No. 5, 2012
0.28% 3.20%
6.32% 0.28%
2.23%
0.28% 2.26%
1.17%
2.80%
3.51%
7.32%
7.73%
5.35%
2.68% 2.55%
Figure 1. Distribution of anterior cruciate ligament injuries
based on player position.
running (18.78%), defensive passing (13.65%), or defensive
running (12.75%) plays at the time of injury. General play
(10.11%), kick-off coverage (6.42%), blocking drills (4.02%),
punt return (3.74%), kick-off return (3.62%), punt coverage
(2.93%), tackling drills (1.82%), point after touchdown
(PAT)/field goal attempt (0.81%), and PAT/field goal
defense (0.40%) account for the remainder of the injuries.
There was no difference with regard to laterality, with
48.76% of injuries occurring on the left and 51.24% occur-
ring on the right.
DISCUSSION
Our analysis of the NCAA ISS Men’s Football Injury Data
Set from 2004-2005 to 2008-2009 revealed several impor-
tant findings: (1) players are over 10 times more likely to
sustain an ACL injury in games versus practices, (2) play-
ers are significantly more likely to sustain an ACL injury
in scrimmages compared with regular or walk-through
practices, and (3) the rate of ACL injury sustained on arti-
ficial turf is significantly greater than on natural grass. We
also observed that the vast majority (93.16%) of ACL inju-
ries are caused by player contact or acute noncontact
mechanisms and that player position may influence the
likelihood of sustaining an ACL injury.
Injuries to the knee are widely recognized as the most
common form of musculoskeletal injury sustained by
American football players.4,10 Dick et al10 evaluated the
NCAA ISS from the 1988-1989 through 2003-2004 seasons
and found that knee internal derangement injuries were
the most commonly sustained injury in both games and
practices. A recent investigation by Bradley et al4 exam-
ined the incidence of knee injury in collegiate football play-
ers at the NFL Combine and determined that 53% of the
population had sustained a knee injury and an average
of 1.3 knee injuries were sustained per player. In this par-
ticipant population, ACL injuries were the third most com-
mon type of knee injury, behind medial collateral ligament
ACL Injuries in NCAA Football 993
Quarterback 0.4%
Tight End
Offensive Tackle 40.13%
Offensive Guard
Center
Player Contact
Running Back
Wide Receiver Playing Surface
Defensive End Contact
Defensive Tackle Apparatus Contact
53.03%
Linebacker Acute noncontact
Cornerback
Overuse/gradual
Safety
Kicker/Punter
Special Teams
0.96%
Long Snapper
4%
Figure 2. Basic mechanism of anterior cruciate ligament
injuries.
and meniscal injuries, and surgical reconstruction of the
ACL was the second most common type of surgery, behind
arthroscopic meniscectomy.4
Our results indicate that ACL injuries occur over 10
times more frequently in competition than in practice,
a finding that is consistent with the current literature.
Dick et al10 reported that the rate of knee internal derange-
ment injuries in NCAA football players was 13 times greater
in games when compared with practices. Shankar et al24
reported injuries were over 6 times more prevalent in both
high school and collegiate football games compared with
practices, while Bradley et al5 found that twice as many
ACL injuries occurred during competition compared with
routine practices. A plausible explanation for this signifi-
cant trend observed in our analysis and in previous studies
is that game conditions involve a less predictable playing
environment and greater speeds and intensity. The increase
in magnitude and frequency of collisions may increase the
risk of injury, particularly given our finding that player con-
tact mechanisms account for over half of all ACL injuries.
This theory may likely also account for the increased risk
of injury in practice scrimmages compared with regular or
walk-through practices; we observed an almost 5-fold
increase in ACL injuries in scrimmages compared with reg-
ular practices, which was consistent with a previous litera-
ture report of increased injury in football scrimmage
practices in the Big Ten Conference.1 Given that the objec-
tive of a practice scrimmage is to simulate game-like playing
conditions, this similarity in injury rates is expected.
Recent literature reviews have categorized the varying
types of artificial playing surfaces, investigated their bio-
mechanical properties, and documented distinct injury
patterns.11,25,29,30 Although it is becoming increasingly
clear that playing surface is an important factor in injury
incidences and mechanisms, the exact role and ideal sur-
face have yet to be determined. Significantly higher overall
injury rates in football have been reported on artificial sur-
faces compared with natural grass.12,14,15,21,22 However,
current literature examining the rates of ACL injury
994 Dragoo et al
specifically on artificial surfaces and natural grass has
revealed mixed results. Two reports documented no differ-
ence in ACL injury rates on artificial turf and grass surfa-
ces,5,17 while a different study found increased rates of
noncontact ACL injuries on grass compared with artificial
turf.23 Others still have reported an increased overall risk
of ACL injury on turf when compared with grass.12,14,23
This lack of consensus may be because of the shortage of
studies specifically designed to test this hypothesis, an
issue further complicated by the widely variable nature
of artificial surfaces. First- and second-generation surfaces
consist of short nylon fibers, with variable padding, while
third-generation surfaces are characterized by longer fiber
lengths, rubber synthetic infill, and increased shock absor-
bency. Our analysis of the data in this survey indicates
a greater incidence of ACL injuries in NCAA football play-
ers on artificial playing surfaces when compared with
grass. Furthermore, the rate of injury on artificial surfaces
with fill (third-generation) is significantly greater than
both artificial surfaces without fill (first- and second-gener-
ation) and natural grass surfaces. A potential cause of this
difference might be the unique shoe-surface interaction
associated with artificial surfaces. Extensive research has
been conducted to evaluate the mechanical properties of
artificial turf. Previous studies have indicated that playing
surface plays a significant role in peak torque, rotational
stiffness, and foot loading.30 Compared with grass, artifi-
cial turf surfaces showed higher peak torques and rota-
tional stiffness, potentially explaining the mechanism by
which artificial turf might contribute to knee injuries.26
A large percentage of injury reports omitted specific
data such as player position or injury mechanism. How-
ever, our analysis of the available data revealed that line-
backers, running backs, special teams players, wide
receivers, cornerbacks, and quarterbacks most frequently
sustained an ACL injury (Figure 1). Shankar et al24
reported similar findings for overall injury rates, noting
that linebackers and running backs had the highest rates
of injury at both the high school and intercollegiate levels.
Similarly, Dick et al10 found that NCAA running backs,
quarterbacks, and linebackers most frequently sustained
injuries in games. With regard to the ACL specifically,
a review of these injuries in the NFL also reported run-
ning backs and linebackers to be among the positions
most frequently injured.5 Additionally, our study revealed
that ACL injuries occurred most frequently during offen-
sive running and passing plays. When combining offense
and defense, running plays accounted for 31.53% of all
injuries, while passing plays accounted for 33.44% and
special teams play for 17.92%. These results were similar
to those reported by Bradley et al5; in the NFL, ACL
injury most frequently occurred during passing plays
(32.4%), special teams plays (31.7%), and running plays
(28.2%).
Analysis of the data set revealed that the majority of
ACL injuries occurred via player contact (53.03%) and non-
contact (40.13%) mechanisms (Figure 2). Given the high-
impact nature of football, it is unsurprising that the major-
ity of injuries were caused by player contact mechanisms.
The American Journal of Sports Medicine
Interestingly, though, a large proportion of injuries were
caused by noncontact mechanisms. Previous reports have
identified a plethora of variables that may contribute to
noncontact ACL injuries, including biological, biomechani-
cal, and environmental risk factors.2 Environmental risk
factors include weather, footwear, and shoe-surface inter-
action. Of the injuries sustained on natural grass, 36.12%
were noncontact, while 44.29% of injuries sustained on
artificial turf were caused by noncontact mechanisms.
This difference, combined with the structural and mechan-
ical differences of natural grass and artificial playing sur-
faces, suggests the possibility of a playing surface–
associated environmental risk factor at play in noncontact
ACL injuries.
We did not observe a difference in ACL injury rates
between preseason, regular season, and postseason. This
observation was in contrast to previous literature reports,
which found the rate of preseason ACL injury to be greater
than regular season injury rates5 and the overall rate of
NCAA football injuries to be greater during preseason
than regular season.10 We also did not observe a significant
difference in ACL injury rates between Divisions I, II, or
III, which was in contrast to a previous study that reported
a significantly greater rate of overall injury in Division I
compared with Division II.10
The results of this study suggest 3 areas for future
investigations and possible interventions aimed at reduc-
ing the number of ACL injuries in NCAA football players.
The increased injury incidence on third-generation artifi-
cial turf may suggest that this surface is not an adequate
substitute for natural grass surfaces and should be further
investigated. Additionally, both the increased incidence of
injury in games versus practices and the large percentage
of injuries due to noncontact mechanisms suggest it may be
necessary to alter training programs to improve factors
such as strength, proprioception, and decision making in
response to unexpected stimuli in order to improve overall
and game-time biomechanics.
The NCAA ISS is a well-established and sophisticated
injury reporting system. Nonetheless, the current findings
are subject to several limitations. First, as with any study
relying on reported information, it is possible that ACL
injuries at participating institutions were unreported or
underreported and are therefore missing from analysis.
Second, the NCAA ISS pools data from NCAA institutions
sponsoring intercollegiate football teams and uses sam-
pling weights to determine overall injury and exposure val-
ues. Because a large percentage of schools are not included
in this system, actual rates and incidences of ACL injuries
may vary from those that are ultimately reported. Finally,
nearly 50% of reported injuries were missing data for some
categories such as player position or specific injury mecha-
nism. The trends reported here were based off the remain-
ing subset of available information; however, it is still
worth noting the large percentage of missing data, which
may have ultimately skewed the results. Despite these lim-
itations, we believe the information presented here is the
best means of classifying and evaluating incidence and
risk factors for ACL injury in NCAA football players.
Vol. 40, No. 5, 2012
CONCLUSION
Between 2004 and 2009, NCAA football players experi-
enced a greater number of ACL injuries in games com-
pared with practices, in scrimmages compared with
regular practices, and when playing on artificial turf surfa-
ces. The majority of injuries were caused by contact with
another player or acute noncontact mechanisms. The dis-
tribution of ACL injury varied with position type and
was most often reported in linebackers, running backs,
and special teams players.
ACKNOWLEDGMENT
This publication contains materials created, compiled, or
produced by the Datalys Center on behalf of the NCAA.
Copyright National Collegiate Athletic Association. All
rights reserved.
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