ACL Injury Rates & The Menstrual Cycle: A Cause For Concern?
Dr. Patti Darland, PT, DPT – February, 2022
All right, let’s get right into it! As if it wasn’t hard enough being a female athlete, let’s go ahead and add in the possibility of our menstrual cycle affecting our risk for significant injury.
Studies have found that female soccer players miss participation due to injury approximately 20% more than their male counterparts. And the question is why? One obvious answer is the greater incidence of severe injury to the lower extremity. As we know, female athletes are upwards of six time more likely to tear their ACL. There are many ideas as to why female athletes tend to tear their ACL more regularly than male athletes, let’s be real, that could be an entire other article, but, one of those ideas centers around the concept of the menstrual cycle.
So what exactly does the menstrual cycle have to do with injury rates? Hormones! To get really specific, the main hormone we are hitting on is estrogen, though I’ll keep the in-depth science to a minimum. As I’m sure all female athletes are aware, when our hormones fluctuate, we get a lot of fun symptoms such as mood swings, bloating, cramps, headaches, etc. But the same changes in hormones are also impactful on muscle, tendon, and ligament laxity.
The menstrual cycle has very specific phases and determining which portions are problematic is key to reducing the risk of injury amidst the cycle. So let’s keep it simple, these hormones are highest around ovulation and lowest around your actual period. What does that mean in simpler terms? Your greatest risk for injury would be in the ovulation phase because as these hormones increase so does the presence of laxity within your knee joint.
So what can we do about it?
- Use an app to track your menstrual cycle
Tracking your menstrual cycle has never been easier than it is today. There are a number of free apps that you can use to track your cycle simply by putting when your period comes and the days that you are actively bleeding. These apps are then able, overtime, to determine your cycle length and when you are at peak ovulation. These are predominantly used for women who are trying to conceive however it’s the same information regardless of purpose.
So while this information won’t change your injury rates, it will allow you to be more aware of the laxity within your joints at that given time. By knowing this information, you might make different decisions regarding participation in specific games, trainings, etc.
- Oral Contraceptives
As we are often talking about youth female athletes, this can be viewed as a somewhat taboo topic. However, recent research indicates that there is a possible reduction in the risk of ACL injury with the utilization of oral contraceptives. Though the research is somewhat limited, there is belief that the use of contraceptives could potentially reduce the risk of ACL injury by 20%.
The other consideration here is that estrogen plays a key role in promoting repair of muscle tissue as well as muscle growth. Through the use of oral contraceptives, you reduce the presence of estrogen, which in theory would reduce the increase laxity; however, you would also then reduce recovery. Ultimately, what you need to determine is which is more imperative, recovery or reduce laxity? That is a very difficult question to answer, and one the research is still working to understand.
- Injury Reduction Programming
If you have read my bio, you will notice that this is my bread and butter so to speak. Knowledge of your body and ligamentous changes is very important information. That said, there are things that can be done to improve your body awareness and movement in space that can reduce the risk of injury regardless of menstrual phase.
Long story short, this is a relatively new space that researchers are investigating as women become more prevalent in the athletic community. As the information evolves, so too will the approach. As always, no strategies can prevent all injuries but knowledge is power. The main takeaway here is, the more you know about your body, the better.
- Herzberg SD, Motu’apuaka ML, Lambert W, Fu R, Brady J, Guise JM. The Effect of Menstrual Cycle and Contraceptives on ACL Injuries and Laxity: A Systematic Review and Meta-analysis. Orthop J Sports Med. 2017;5(7):2325967117718781. Published 2017 Jul 21. doi:10.1177/2325967117718781
- Martin D, Timmins K, Cowie C, Alty J, Mehta R, Tang A and Varley I. Injury Incidence Across the Menstrual Cycle in International Footballers. Sports Act. Living. 2021 Mar 1;3:616999. doi: 10.3389/fspor.2021.616999. eCollection 2021.
About the Author:
Dr. Patti Darland is a former Division I soccer player as well as Mayo Clinic trained Injury Prevention Specialist. She is the Founder of Stay Well Sports LLC. Her goal is reduce the risk of injury for as many athletes as possible and keep athletes participating in the sports they love.