The ACL...Period




So, an article came out about FIFA finally investigating the link between a woman's menstrual cycle and ACL tears.  Doctor Sarah Long and I talked about this on an Instagram live in October 2023.  
The menstrual cycle affects female athletes in various ways due to hormonal fluctuations, particularly involving estrogen and progesterone. These hormones can influence muscle, ligament, and tendon strength throughout the cycle. Here's how and why:



1. Hormonal Fluctuations Across the Menstrual Cycle

The menstrual cycle typically lasts around 28 days and can be divided into three main phases:

- Follicular phase (Day 1–14): Begins with menstruation; estrogen gradually increases.
- Ovulation (Around Day 14): Estrogen peaks; surge in luteinizing hormone (LH).
- Luteal phase (Day 15–28): Progesterone rises; estrogen drops slightly and then rises again.

These hormonal changes affect connective tissues and muscles in several ways.



2. Estrogen and Tissue Laxity

Estrogen has been shown to:

Increase collagen turnover, which can reduce the structural integrity of ligaments and tendons.
Increase joint laxity (looseness), especially around ovulation, when estrogen peaks.
This increased laxity can decrease stability around joints (like the knees or ankles), making ligaments more vulnerable to injury and reducing muscular control during high-intensity or high-skill movements.



3. Progesterone and Neuromuscular Coordination

In the luteal phase, higher progesterone levels can:

Interfere with neuromuscular coordination, leading to slower reaction times or decreased movement precision.
Contribute to fatigue and elevated body temperature, indirectly reducing muscular strength and performance.
This can impact muscle firing patterns and efficiency, increasing injury risk or reducing performance capacity.



4. Increased Risk of Injury

Due to the combination of greater ligament laxity, changes in coordination, and sometimes reduced strength:

ACL injuries are more common in female athletes, particularly during the ovulatory phase.
Tendons and muscles may not absorb and transmit force as effectively, increasing the strain on surrounding tissues.


5. Individual Variability Matters

Not all female athletes experience negative effects. Some feel stronger during certain phases, while others feel weaker. Monitoring the cycle and adapting training accordingly—often referred to as menstrual cycle-informed training—can help optimize performance and reduce injury risk.

Conclusion

An athlete's menstrual cycle can influence injury risk due to hormonal fluctuations, particularly in estrogen and progesterone levels. During the ovulatory phase, when estrogen peaks, ligament laxity may increase, potentially raising the risk of injuries like ACL tears. Additionally, changes in coordination, neuromuscular control, and joint stability throughout the cycle can affect movement quality. Understanding these patterns can help tailor training and recovery strategies to reduce injury risk and optimize performance.

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