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
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
Reviewed by: Jeffrey

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