Sports Medicine Research: In the Lab & In the Field: Phase of Menstrual Cycle may be a Risk Factor for ACL Tears in Female Athletes (Sports Med Res)


Wednesday, July 31, 2013

Phase of Menstrual Cycle may be a Risk Factor for ACL Tears in Female Athletes

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


Jeffrey Driban said...

Letter to the editor:

Conversation on twitter:
@TenanATC: @sportsmedres @ATC_NCAA13 Conflicts with many other studies. Lig lax across menstrual cycle also very debatable. Spurious chunking of data?

ATC_NCAA13: @TenanATC @sportsmedres another excellent example of why nothing is better than a thorough lit review and appraisal of works cited
9:13am, Jul 31 from Twitter for iPhone

TenanATC: @ATC_NCAA13 @sportsmedres Just finished menstrual study, removed >50% women before testing bc cycle irregularity. See
11:20am, Jul 31 from Web

sportsmedres: @tenanatc @ATC_NCAA13 The discrepancies point to key aspect noted in the post: female hormones levels is only be one risk factor of many

sportsmedres: @TenanATC @ATC_NCAA13 Swanik noted in NATA talk that we freq ignore the role of testosterone levels. We need to look @ all poss risk factors

Kyle Harris said...


Great comments, thank you for the discussion. Hormonal levels may be 1 specific risk factor but it is certainly a risk factor which has not gained much clinical clout. I believe that the clinical applicability will be more determined by the level of competitiveness that the athlete participates in. As we all know, the expectations of an athlete at the Division I level than that of a high school. The level of individualized attention is greater in the higher level and rehabilitation and conditioning programs can be more tailored to that athlete. My major question to clinicians in, how applicable do you see this information being with regards to implementation to conditioning programs?

Gabriella Basile said...

I find this interesting because I did not know that during the first fourteen days of my menstrual cycle I am more prone to ACL injuries. I was a year round soccer player from a young age up until college and fortunately did not experience an ACL tear, but many of my teammates did. I wonder if they were in the pre-ovulatory phase.

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