title: Prevention of Anterior Cruciate Ligament Injuries in Female Team Handball Players: A Prospective Intervention Study Over Three Seasons The Menstrual Cycle, Sex Hormones, and Anterior Cruciate Ligament Injury. Knee joint kinaesthesia and neuromuscular coordination during three phases of the menstrual cycle in moderately active women A prospective cohort study of anterior cruciate ligament injuries in elite Norwegian team handball. Hormonal therapy: ACL and ankle injury. The Association of the Menstrual Cycle with the Laxity of the Anterior Cruciate Ligament in Adolescent Female Athletes A Method to Help Reduce the Risk of Serious Knee Sprains Incurred in Alpine Skiing Biomechanical Measures of Neuromuscular Control and Valgus Loading of the Knee Predict Anterior Cruciate Ligament Injury Risk in Female Athletes: A Prospective Study Women's soccer injuries in relation to the menstrual cycle and oral contraceptive use.
abstract: Objective To assess the effect of a neuromuscular training program on the incidence of anterior cruciate ligament injuries in female team h and ball players . Design Prospect i ve intervention study . Setting Female team h and ball : Division I – III in Norway . Participants Players from the three top divisions : control season ( 1998–1999 ) , 60 teams ( 942 players ) ; first intervention season ( 1999–2000 ) , 58 teams ( 855 players ) ; second intervention season ( 2000–2001 ) , 52 teams ( 850 players ) . InterventionA five-phase program ( duration , 15 min ) with three different balance exercises focusing on neuromuscular control and planting/l and ing skills was developed and introduced to the players in the autumn of 1999 and revised before the start of the season in 2000 . The teams were instructed in the program and supplied with an instructional video , poster , six balance mats , and six wobble boards . Additionally , a physical therapist was attached to each team to follow up with the intervention program during the second intervention period . Main Outcome Measures The number of anterior cruciate ligament injuries during the three seasons and compliance with the program . Results There were  29 anterior cruciate ligament injuries  during the control season , 23 injuries during the first intervention season ( OR , 0.87 ; CI , 0.50–1.52 ; p = 0.62 ) , and 17 injuries during the second intervention season ( OR , 0.64 ; CI , 0.35–1.18 ; p = 0.15 ) . In the elite division , there were 13 injuries during the control season , six injuries during the first intervention season ( OR , 0.51 ; CI , 0.19–1.35 ; p = 0.17 ) , and five injuries in the second intervention season ( OR , 0.37 ; CI , 0.13–1.05 ; p = 0.06 ) . For the entire cohort , there was no difference in injury rates during the second intervention season between those who complied and those who did not comply ( OR , 0.52 ; CI , 0.15–1.82 ; p = 0.31 ) . In the elite division , the risk of injury was reduced among those who completed the anterior cruciate ligament injury prevention program ( OR , 0.06 ; CI , 0.01–0.54 ; p = 0.01 ) compared with those who did not . Conclusions This study shows that it is possible to prevent anterior cruciate ligament injuries with specific neuromuscular training OBJECTIVE : To determine if anterior cruciate ligament ( ACL ) injuries in female athletes occur r and omly or correlate with a specific phase of the menstrual cycle . DESIGN AND SETTING : Female athletes who sustained ACL injuries reported the days of their menstrual cycles and provided saliva sample s for sex-hormone determination . Salivary sex-hormone profiles were assessed to confirm the self-reported menstrual histories . SUBJECTS : A total of 38 female athletes ( 20 college , 15 high school , 1 middle school , 2 recreational ) with recent ACL injuries participated in the study over a 3-year period . MEASUREMENTS : Athletes with recent ACL injuries completed a question naire defining the injury , the last menstrual cycle , prior knee injury , school , and type of birth control used ( if any ) . Each subject provided a 30-cc saliva sample within 72 hours of injury . Saliva sample s were placed into sealed containers and frozen at -20 degrees C. We obtained 13 additional control sample s from uninjured females to test the correlation between saliva and serum sex-hormone levels . Progesterone and estrogen were assayed by radioimmunoassay . Physical examination , magnetic resonance imaging , or surgery confirmed the injury in all subjects . RESULTS : The correlations between saliva and serum estrogen and progesterone were 0.73 ( alpha = .01 ) and 0.72 ( alpha = .01 ) , respectively . Ten of 27 athletes who reported their cycle day at time of injury sustained an ACL injury immediately before or 1 to 2 days after the onset of menses . We rejected the null hypothesis that such high frequency was due to r and om chance . CONCLUSIONS : A significantly greater number of ACL injuries occurred on days 1 and 2 of the menstrual cycle . Salivary sex-hormone levels correlated with the reported cycle day An increased incidence of sports related injuries in the premenstrual phase as well as in the menstrual phase of the menstrual cycle has been described . This may be explained by alterations in proprioception and neuromuscular coordination due to hormonal variations . Prospect i ve , within women analysis of knee joint kinesthesia and neuromuscular coordination were performed by repeated measures analysis of variance in three hormonally verified phases of three consecutive menstrual cycles . Thirty-two healthy , moderately active female subjects volunteered to participate in the study . Twenty-five of the subjects performed at least one hormonally verified menstrual cycle . A specially design ed device was used to investigate knee joint kinaesthesia and neuromuscular coordination was measured with the square hop test . These tests were carried out in the menstrual phase , ovulation phase and premenstrual phase determined by hormone analyses in three consecutive menstrual cycles . An impaired knee joint kinaesthesia was detected in the premenstrual phase and the performance of square hop test was significantly improved in the ovulation phase compared to the other two phases . The results of this study indicate that the variation of sex hormones in the menstrual cycle has an effect on performance of knee joint kinaesthesia and neuromuscular coordination The purpose of this study was to examine gender differences in the incidence of  anterior cruciate ligament ( ACL ) injuries in a population of high-level team h and ball players . We also wanted to examine injury mechanisms and possible risk factors for ACL injuries , including menstrual status . The study was done prospect ively during the 1993 - 94 , 1994 - 95 , and 1995 - 96 seasons . We found 28 ACL injuries , 23 among women ( incidence : 0.31 + /- 0.06 injuries per 1000 player hours ) and 5 among men ( 0.06 + /- 0.03 inj./1000 h ; P < 0.001 vs women ; risk ratio : 5.0 ) . Of the 28 injuries , 24 occurred during competition ( 0.91 + /- 0.19 inj./1000 h ; women : 1.60 + /- 0.35 inj./1000 h ; men : 0.23 + /- 0.13 inj./1000 h ; P < 0.001 vs. women ; risk ratio : 7.0 ) and 4 during training ( 0.03 + /- 0.02 inj./1000 h ; P < 0.001 vs. competition ; risk ratio : 29.9 ) . Nearly all the injuries ( n = 25 ) occurred in non-contact situations when the players performed high-speed plant- and -cut movements which they were well accustomed to . A reliable menstrual history could be obtained in 17 of the 23 cases among females . Five of the injuries occurred in the menstrual phase , 2 in the follicular phase , 1 in the early luteal phase and 9 in the late luteal phase ( chi-square3 d.f . = 13.2 ; P < 0.01 ) . The results suggest that there may be an increased risk of ACL injury during the week prior to or after the start of the menstrual period BACKGROUND No definitive explanation for the difference in rate of male and female noncontact ACL injury has been found . The hormonal environment , known to be different in men and women has been hypothesized as a possible source for this difference in injury rate . PURPOSE To confirm earlier work looking at periodicity of noncontact ACL injury . To increase sample size by adding ankle sprains . To determine the rate of  noncontact ACL injury and ankle sprains in collegiate basketball and soccer . To determine if the use of oral contraceptives affects the rate of noncontact ACL injury and ankle sprains . METHODS Data was collected from a sample of NCAA schools over the 2000 - 2001 basketball and the 2001 - 2002 basketball and soccer seasons . RESULTS Recall and prospect i ve data collection of length of menstrual cycle did not produce equivalent results . Periodicity was present only in the recall group of " off pill " users . The rate of noncontact ACL injury and noncontact ankle sprains was twice as high in basketball as in soccer . There was no difference in rate of injuries between those athletes using  hormonal therapy and those athletes not using hormonal therapy . CONCLUSIONS Noncontact ACL injuries and ankle sprains occurred at significantly higher rates in basketball than in soccer but this rate difference was not linked to hormonal therapy usage . The overall rate of noncontact ACL injury and ankle sprain to women 's collegiate basketball and soccer players is very low Objective To identify a significant change in the laxity of the anterior cruciate ligament ( ACL ) in the competitive adolescent female athlete throughout the different phases of the menstrual cycle . Design Prospect i ve , single-blinded 8-week study set during a winter sports season . Setting Suburban Ohio Division I high school . Participants 26 members of gymnastics , soccer , track , tennis , and basketball teams . All participants were screened for normal menstrual cycles ( 26–30 days , menses 4–7 days long ) . Main Outcome Measures  KT-1000 arthrometer  was used to measure laxity by performing repeated measures throughout an 8-week period . Measurements were taken before the athletes ' workouts . The athlete charted the menstrual periods on a monthly calendar . The measurements were then grouped into the three phases of the menstrual cycle ( follicular , ovulatory , and luteal ) and averaged . Results Right knee laxity measured 4.98 mm follicular phase , 5.24 mm ovulatory , and 5.09 mm luteal . Left knee laxity measured 4.51 mm follicular , 4.43 mm ovulatory , and 4.62 mm luteal . There was no statistical difference among the three phases in the left ( p = 0.9 ) and right ( p = 0.7977 ) . Additionally , left ACL laxity was significantly less in all three phases . We found no statistically significant variability in laxity among the five sports sample d ( p > 0.63 to 0.10 ) and different ages ( p = 0.404 ) Conclusions We found an insignificant change in ACL laxity from follicular to luteal phases of the menstrual cycle . This indicates that no single phase of the menstrual cycle clinical ly affects the ACL more than the next . Although the presence of sex hormones — particularly estrogen — may indeed predispose females to higher ACL injury rates , we did not find any evidence that hormonal level changes equate with significant ACL laxity changes . We conclude that the menstrual cycle does not significantly affect ACL laxity in the competitive adolescent female athlete The incidence of severe anterior cruciate ligament sprains was once only a third the current rate . This fact led the authors to believe a means to help reduce the risk of anterior cruciate ligament injury among skiers might be found . Using videotapes of the occurrences of anterior cruciate ligament sprains in alpine skiers and the data associated with more than 1400 anterior cru ciate ligament injuries observed in a 22-year study , the authors identified two common mechanisms of anterior cruciate ligament injury . From this information , a study was design ed to determine if training could help reduce the risk of anterior cruciate ligament sprains . During the 1993 to 1994 season , the on-slope staff from 20 ski areas participated in a training program involving view ing videotaped scenes where knee injuries occurred . Data from 22 ski areas , where staff were not exposed to the training , were assembled to form a control group . Data concerning anterior cruciate ligament injuries were collected from both groups for the three seasons 1991 to 1994 . A total of 179 serious knee sprains were evalu ated .  Serious knee sprains declined by 62 % among trained patrollers and instructors compared with the two previous seasons , but no decline occurred in the control group Background Female athletes participating in high-risk sports suffer anterior cruciate ligament injury at a 4- to 6-fold greater rate than do male athletes . Hypothesis Prescreened female athletes with subsequent anterior cruciate ligament injury will demonstrate decreased neuromuscular control and increased valgus joint loading , predicting anterior cruciate ligament injury risk . Study Design Cohort study ; Level of evidence , 2 . Methods There were 205 female athletes in the high-risk sports of soccer , basketball , and volleyball prospect ively measured for neuromuscular control using 3-dimensional kinematics ( joint angles ) and joint loads using kinetics ( joint moments ) during a jump-l and ing task . Analysis of variance as well as linear and logistic regression were used to isolate predictors of risk in athletes who subsequently ruptured the anterior cruciate ligament . Results Nine athletes had a confirmed anterior cruciate ligament rupture ; these 9 had significantly different knee posture and loading compared to the 196 who did not have anterior cruciate ligament rupture . Knee abduction angle ( P < . 05 ) at l and ing was 8 ° greater in anterior cruciate ligament-injured than in uninjured athletes . Anterior cruciate ligament-injured athletes had a 2.5 times greater knee abduction moment ( P < . 001 ) and 20 % higher ground reaction force ( P < . 05 ) , whereas stance time was 16 % shorter ; hence , increased motion , force , and moments occurred more quickly . Knee abduction moment predicted anterior cruciate ligament injury status with 73 % specificity and 78 % sensitivity ; dynamic valgus measures showed a predictive r2 of 0.88 . Conclusion Knee motion and knee loading during a l and ing task are predictors of anterior cruciate ligament injury risk in female athletes . Clinical Relevance Female athletes with increased dynamic valgus and high abduction loads are at increased risk of anterior cruciate ligament injury . The methods developed may be used to monitor neuromuscular control of the knee joint and may help develop simpler measures of neuromuscular control that can be used to direct female athletes to more effective , targeted interventions During 1984 , 86 women soccer players answered detailed question naires concerning contraceptive use , menstruation data , premenstrual and menstrual symptoms , and data concerning soccer activities including injuries . This prospect i ve study showed that women soccer players were more susceptible to traumatic injuries during the premenstrual and menstrual period compared to the rest of the menstrual cycle ( P less than 0.05 ) , especially among players with premenstrual symptoms such as irritability/irascibility , swelling/discomfort in the breasts , and swelling/congestion in the abdomen . It was also found that women using contraceptive pills had a lower rate of traumatic injuries ( P less than 0.05 ) compared to women who were not on the Pill . The results can be explained by the fact that oral contraceptives ameliorate some symptoms of the premenstrual and menstrual period which might also affect coordination and hence the risk of injury
target: The clinical relevance of this finding is that female athletes may be more predisposed to anterior cruciate ligament injuries during the preovulatory phase of the menstrual cycle .
  These findings may lead to potential interventions targeted toward this phase of the menstrual cycle to reduce the incidence of anterior cruciate ligament injury
background: Several theories have been proposed to explain the 3- to 6-fold gender difference in the incidence of anterior cruciate ligament injuries .
  One potential theory for the increased incidence is based on gender-related hormonal differences between men and women , especially after puberty and the onset of menses in the female athlete .
  The purpose of this systematic review was to compile and systematic ally analyze the published literature to determine if the menstrual cycle is associated with anterior cruciate ligament injury risk and to provide an objective comparison of the published results .