Anterior cruciate ligament tear during the menstrual cycle in female recreational skiers.
Lefevre N, Bohu Y, Klouche S, Lecocq J and Herman S. Orthop Traumatol Surg Res. 2013; [Epub Ahead of print].
Take Home Message: A recreational female skier may be more likely to suffer an ACL injury in the pre-ovulatory phase than during the luteal phase of her menstrual cycle. This may provide more evidence that female hormone fluctuations should be considered when we try to reduce the risk of ACL tears among females.
Anterior cruciate ligament (ACL) tears occur more frequently in women compared with men who are equally active. While many mechanical and hormonal factors may be the reason for this, little data exists concerning female recreational skiers and their risk of ACL tears during different phases of menstrual cycle. A better understanding of this mechanism may aid clinicians in optimizing injury prevention programs. Therefore, Lefevre and colleagues conducted a prospective cohort study to "describe the distribution of ACL tear over the menstrual cycle in a large population of female recreational skiers." The authors studied 172 recreational skiers who were admitted to 1 of 12 medical units of alpine ski resorts. A physician evaluated the skiers within 24 hours of the injury and diagnosed them with an ACL tear. All patients completed a questionnaire designed by the research team, which assessed the details of the accident, patient's level of activity, and patient's menstrual cycle (date of last menstrual period and use of contraceptives). Patients were classified into 1 of 3 groups: 1) follicular phase: 1 to 9 day follicular phase, 2) ovulation: at 10 to 14 days, and 3) luteal phase of 15 to 30 days. Patients were also classified as either pre-ovulatory (follicular and ovulatory) or post-ovulatory (luteal). Overall, 58 (34%) of the 172 injured patients were in follicular phase, while 63 (37%) and 51 (30%) were in ovulatory and luteal phases, respectively. Women in the pre-ovulatory phase (follicular and ovulatory) suffered the majority of ACL tears (71%) regardless of whether they used contraceptives.
The study is interesting because it suggests that a recreational female skier may be more likely to rupture her ACL in the first 14 days of a menstrual cycle. This is not surprising since a woman experiences greater knee ligament laxity and lower knee stiffness during ovulation compared with her follicular phase. This study supports Hewett and colleagues’ systematic review that found that women in the pre-ovulatory phase suffered more ACL injuries than women in the luteal phase. Unfortunately, the authors did not measure hormone levels and other factors that may account for the injuries. While hormonal fluctuations of the menstrual cycle may be risk factors for ACL tears, it is important to note that these are not the only risk factors. A man can still suffer an ACL injury despite him lacking the same fluctuations of hormones as a woman. Regardless, the study adds evidence to the notion that hormonal fluctuation in the female body may contribute to risk of ACL injury.
Question for Discussion: Should menstrual cycle be considered when designing and implementing ACL injury prevention protocols?
Written by: Kyle Harris
Reviewed by: Jeffrey Driban
Related Posts:Lefevre N, Bohu Y, Klouche S, Lecocq J, & Herman S (2013). Anterior cruciate ligament tear during the menstrual cycle in female recreational skiers. Orthopaedics & Traumatology, Surgery & Research : OTSR PMID: 23764504