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The Female Athlete Menstrual Cycle: Effect on Performance and Injury/ACL Risk

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This is a common question that we get from Ladyballers in terms of the effect of the menstrual cycle on injury risk. We wanted to share more information on the matter so we teamed up with Certified Strength & Conditioning Specialist, Erica Suter, to share her findings.

As we all know, female athletes may deal with obstacles as she grows from a young lady baller into a woman. Not only are there an incredible amount of emotional and physical changes occurring – from oscillating moods, to fitting in with friend groups, to experiencing awkward motor patterns, to dealing with changes in height and weight – there are also many natural hormonal fluctuations as well.


These hormone fluctuations happen all throughout the female athlete's menstrual cycle EACH MONTH (Read our blog about it here) However, when the athlete is not aware of how to support her hormones and cycle it can leave her feeling confused on how to navigate/stay healthy to perform at a high level.

On top of that, the fear of injury comes into play. You may have heard, “You’re at a higher risk for ACL because you’re female and you have your period.” 

Whether it's TRUE or NOT, this is when the conversation surrounding the menstrual cycle gets complex, and it is crucial that coaches share the right information with their players.

It's also important to note that female athletes are not powerless when it comes to ACL risk just because of their period/menstrual cycle. In fact, there is much we can proactively do to feel supported and confident on the feel! 

When it comes to MENSTRUAL CYCLE and ACL RISK, there appears to be NO definitive research yet on increased joint laxity during a female athlete’s period.

There are SO MANY that we will list at the bottom of this blog. However, right now let's just show you three findings...

One recent study in 2021 said that knee laxity and stiffness DID NOT CHANGE significantly among the phases of the menstrual cycle (Maruyama et al. 2021).

on the contrary...

Another study in 2021, said the opposite. They said that anterior joint laxity was SIGNIFICANTLY HIGHER in the ovulation and luteal phases compared with the early follicular phase (Yamazaki et al 2021).

And some earlier studies also said that during ovulation and luteal phases, female athletes are at higher risk of ACL (Yu et al 2001).

After reviewing over 6 studies, we've concluded that there is no definitive/NOT enough thorough research on the connection between your menstrual cycle and injury risk! 

 

It's clear that there is no DEFINITIVE answer on whether you are more prone to injury during a certain time of your menstrual cycle.

 

While research is conflicted, here’s what is known:

  1. Symptoms during menstrual cycle are highly individual, so be sure to journal.
  2. The knee joint may become more lax, so strength train anyway.
  3. Symptoms can impact performance (cognition) and recovery (sleep patterns), so be sure to get quality rest and manage stress.
  4. Symptoms can be alleviated through simple and controllable lifestyle changes as mentioned above (sleep, neuromuscular training, and nutrition)

Instead of saying “you’re a higher risk of injury and decreased performance because of your period!” - we need to approach this topic differently.

Coaches and parents need to share that young female-athletes can be PROACTIVE as far as training and recovery to reduce their risk of injury. We need to reiterate that we can control what we can control for peace of mind on injury. 

Here is what we can proactively do to reduce our injury risk overall:
  1. Training the lower extremity mechanics year-round: fine motor skill reinforcement becomes even more paramount, from reinforcing landing mechanics to deceleration work, to change of direction techniques.
  2. Strengthening the youth female athletes: when it comes to strength training, this can be an optimal time to reap the benefits of muscle building and help girls feel empowered and confident
  3. Focusing on recovering hard: coaches can be repetitive in their messaging to young girls and help them to dial in on nutrition, sleep and recovery lifestyle changes


One more thing a female athlete should be paying attention to in order to stay injury-free is whether her cycle is regular or not.

A missed period is a red flag and something that needs to be addressed immediately.

It is urgent for girls to get in tune with their bodies and understand when something feels off. Whether it is from fatigue, chronic muscle soreness, disrupted sleep, loss of love for training, brain fog, these are all warning signs that something is not right. Worse yet, the missed period is the alarm bell.

A missed period means a female athlete’s hormones are out of equilibrium leaving her at a higher risk for:

  • Low bone mineral density
  • Musculoskeletal injuries
  • Decreased immunity
  • Decreased protein synthesis
  • Decreased cardiovascular health
  • Increased GI distress 

    If not taken care of over time, she may suffer stress fractures, soft tissue injuries, or a wane in motivation, energy and focus. It becomes a vicious cycle that permeates into all facets of her life and wellbeing.

    While we are not here to give medical advice, before female athletes jump to contraceptives for hormonal balance, check in with lifestyle factors as well.

    There is always more to the story with missed periods, so girls have other options than relying on a pill to save them.

    They could change something as simple as taking more rest days, fueling with more calories, or managing stress better.

    The best part? Instead of masking her symptoms, she is directly improving them. Mind you, improving all pieces of her life will also help her bolster her performance – speed, sharpness, quickness – on the pitch. It’s a win-win to be healthy and look through the holistic lens, rather than relying on a quick fix.


    TO SUMMARIZE:

    It is inconclusive whether the structural integrity of the knee joint changes in every female athlete during her luteal and bleed phase.

    Given there are still so many question marks in this space and more research needs to be conducted on the female athlete population, it is best to do what you can control.

    You can be PROACTIVE on a daily basis to reduce your risk of injury. Here is the winning line-up for ACL risk reduction:

    • Year-round resistance training
    • Quality sleep
    • Proper nutrition
    • Load monitoring

    A missing period during the reproductive years could be a sign of a hormonal imbalance or underlying condition that could cause problems like low bone mineral density, musculoskeletal injuries, decreased immunity, and more (leading to higher risk of injuries.) It is important to see your doctor and get your hormones tested!

      ^^Nail these down and female athletes have nothing to worry about when it comes to their menstrual cycle. Rather, they are empowered that a good chunk of their performance and injury prevention is in their control.

      __________________________________________________

      CO-WRITTEN BY SOCCERGRLPROBS AND ERICA SUTER, CERTIFIED STRENGTH & CONDITIONING COACH

      More about Erica:
      Erica Suter is a certified strength and conditioning coach in Tampa, Florida, as well as online coach to thousands of youth soccer players. She has worked with kids, starting at the elementary level and going all the way up to the college level, for the past nine years. She believes in long-term athletic development and the gradual progression of physical training for safe and effective results. She helps youth master the basic skills of balance, coordination, and stability, and ensures they blossom into powerful, fast and strong athletes when they’re older. Beyond working with kids, she mentors coaches of youth athletes in her Total Youth Female Athlete Fitness Video Course and Community. Erica is driven and excited to provide youth coaches with simple, actionable drills to build their athletes into strong, fast and healthy humans.  Follow Erica on Twitter and Instagram and book a discovery call to become an online client HERE.

      __________________________________________________

      STUDIES

      In a study done in 2013, a systematic review found 13 clinical trials investigating the effect of the menstrual cycle on ACL laxity (Belanger et al. 2013).This review suggested that ACL does become more lax during the luteal phase, but overall, these reviews found statistically significant differences for variation in ACL laxity and injury throughout the menstrual cycle.

      One recent study in 2021, concluded that knee laxity and stiffness did not change significantly among the phases of the menstrual cycle (Maruyama et al. 2021).

      Another study in 2021, said the opposite: anterior joint laxity was significantly higher in the ovulation and luteal phases compared with the early follicular phase (Yamazaki et al 2021).

      And... earlier studies also said that during ovulation and luteal phases, female athletes are at higher risk of ACL (Yu et al 2001).

      Several studies have suggested that the menstrual cycle does significantly impact female athletic performance, while others are not so clear.

      In a study done by Pallavi et al a difference during the follicular and luteal phases was reported when examining muscle function. They found that muscle contractions were significantly higher, more forceful, and less fatigable during the follicular phase than during the luteal phase (Pallavi).

      Julian et al studied soccer players’ performance in both an endurance test and a sprint test. Athletes’ scores on the endurance test were significantly lower during the luteal phase than during the follicular phase (Julian).

      Sprint performance and high intensity running remains unclear in the literature, as there is no found difference in performance measures between the follicular and luteal phases (Tremback-Ball). Overall, we can deduce that there might be some hindrances in performance and higher injury risks during the luteal phase, but this will still vary amongst athletes. 

      REFERENCES

      Belanger, L., Burt, D., Callaghan, J., Clifton, S., & Gleberzon, B. J. (2013). Anterior cruciate ligament laxity related to the menstrual cycle: an updated systematic review of the literature. The Journal of the Canadian Chiropractic Association, 57(1), 76–86. 

      Maruyama, S., Yamazaki, T., Sato, Y., Suzuki, Y., Shimizu, S., Ikezu, M., Kaneko, F., Matsuzawa, K., Hirabayashi, R., & Edama, M. (2021). Relationship Between Anterior Knee Laxity and General Joint Laxity During the Menstrual Cycle. Orthopaedic Journal of Sports Medicine. https://doi.org/10.1177/2325967121993045

      Yamazaki, T., Maruyama, S., Sato, Y. et al. A preliminary study exploring the change in ankle joint laxity and general joint laxity during the menstrual cycle in cis women. J Foot Ankle Res 14, 21 (2021). https://doi.org/10.1186/s13047-021-00459-7


      Yu, WD, Panossian, V, Hatch, JD, Liu, SH, Finerman, GA. Combined effects of estrogen and progesterone on the anterior cruciate ligament. Clin Orthop Relat Res. 2001;383:268–281.

      Pallavi LC, D Souza UJ, Shivaprakash G. Assessment of Musculoskeletal Strength and Levels of Fatigue during Different Phases of Menstrual Cycle in Young Adults. J Clin Diagn Res. 2017 Feb;11(2):CC11-CC13. doi: 10.7860/JCDR/2017/24316.9408. Epub 2017 Feb 1. PMID: 28384857; PMCID: PMC5376807.

      Julian R, Hecksteden A, Fullagar HH, Meyer T. The effects of menstrual cycle phase on physical performance in female soccer players. PLoS One. 2017 Mar 13;12(3):e0173951. doi: 10.1371/journal.pone.0173951. PMID: 28288203; PMCID: PMC5348024.

      Tremback-Ball, Amy PT, PhD; Fulton, Kaitlin DPT; Giampietro, Nicole DPT; Gibbons, Megan DPT; Kneller, Arielle DPT; Zelinka, Hayley DPT Effect of the Menstrual Cycle on Athletic Performance in NCAA Division III Collegiate Athletes, Journal of Women's Health Physical Therapy: January/March 2021 - Volume 45 - Issue 1 - p 20-26 doi: 10.1097/JWH.0000000000000188

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