Anterior cruciate ligament tear during the menstrual
cycle in female recreational skiers.
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].
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.
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.
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.
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?
considered when designing and implementing ACL injury prevention protocols?
Written by: Kyle
Harris
Harris
Reviewed by: Jeffrey
Driban
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
Letter to the editor:
https://ajs.sagepub.com/content/36/11/e4.long
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 https://t.co/hWuAmzeXa8
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
Everyone,
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?
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.