Knee Surgery, Sports Traumatology, Arthroscopy

, Volume 20, Issue 8, pp 1647–1652 | Cite as

Menstrual cycle and knee joint position sense in healthy female athletes

  • Rose Fouladi
  • Reza Rajabi
  • Nasrin NaseriEmail author
  • Fereshteh Pourkazemi
  • Mehrnaz Geranmayeh
Sports Medicine



The aim of this study was to investigate the effect of menstrual cycle on knee joint position sense (JPS) in healthy female athletes.


Sixteen healthy female athletes participated in this study. Serum estrogen and progesterone levels were collected during the three phases of menstrual cycle. The knee JPS was also measured during the same phases using a system comprise of skin markers, digital photography, and AutoCAD software. Absolute angular errors were calculated as well as changes in hormone levels between the three phases.


Serum estrogen concentration was significantly higher during the mid-luteal (179.5 Pg/ml) and mid-follicular (125.6 Pg/ml) phases as compared with the early-follicular (menses) (22.8 Pg/ml) phase (P = 0.0001). Also serum progesterone concentration was significantly higher during the mid-luteal phase (7.35 Ng/ml) as compared with the menses (0.58 Ng/ml) and mid-follicular (0.5 Ng/ml) phases (P = 0.0001). The greatest amount of mean (SD) value of absolute error was at menses (4.2°), and the least amount of it was at mid-luteal (2.5°) phase. Also, a significant difference was observed within three phases of menstrual cycle (P = 0.025).


The result of this study suggests that healthy female athletes have different levels of knee JPS across a menstrual cycle. JPS accuracy decreases in menses, when circulating sex-hormones levels are low. Therefore, female athletes are at higher risk of injury at menses and improving their awareness regarding the knee injury risk factors can be a fundamental step toward preventing injuries.

Level of evidence

Case series, Level IV.


Knee joint Joint position sense Menstrual cycle 



The study was funded by Faculty of Rehabilitation, Tehran University of Medical Sciences (Grant No: 89043211693) and Faculty of Sport Sciences and Physical Education.

Conflict of interest

None of the authors have any potential conflict of interest to declare.


  1. 1.
    Adachi N, Ochi M, Uchio Y et al (2002) Mechanoreceptors in the anterior cruciate ligament contribute to the joint position sense. Acta Orthop Scand 73:330–334PubMedCrossRefGoogle Scholar
  2. 2.
    Alentorn-Geli E, Myer GD, Silvers HJ et al (2009) Prevention of non-contact anterior cruciate ligament injuries in soccer players. Knee Surg Sports Traumatol Arthrosc 17:705–729PubMedCrossRefGoogle Scholar
  3. 3.
    Arendt E, Dick R (1999) Knee injury patterns among men and women in collegiate basketball and soccer. NCAA data and review of literature. Am J Sports Med 23:694–701CrossRefGoogle Scholar
  4. 4.
    Aydog ST, Hascelik Z, Demirel HA et al (2005) The effects of menstrual cycle on the knee joint position sense:preliminary study. Knee Surg Sports Troumatol Arthrosc 13:649–653CrossRefGoogle Scholar
  5. 5.
    Baker V, Bannel K, Stillman B et al (2002) Abnormal knee joint position sense in individuals with patello femoral pain syndrome. J Orthop Res 20:208–214PubMedCrossRefGoogle Scholar
  6. 6.
    Berek JS (2002) Berek and Novak’s gynecology. Lippincott Williams & Wilkins, Philadelphia, pp 159–161Google Scholar
  7. 7.
    Boden B, Dean G, Feagin J et al (2000) Mechanisms of anterior cruciate ligament injury. Orthopedics 23:573–578PubMedGoogle Scholar
  8. 8.
    Bowerman SJ, Smith DR, Carlson M et al (2006) Comparison of factors influencing ACL injury in male and female athletes and non-athletes. Phys Ther Sport 7:144–152CrossRefGoogle Scholar
  9. 9.
    Cesar GM, Pereira VS, Santiago PR et al (2011) Variations in dynamic knee valgus and glotus medius onset timing in non- athletic females related to hormonal changes during the menstrual cycle. Knee 18:224–230PubMedCrossRefGoogle Scholar
  10. 10.
    Deie M, Sakamaki Y, Sumen Y et al (2002) Anterior knee laxity in young women varies with their menstrual cycle. Int Orthop 26:154–156PubMedCrossRefGoogle Scholar
  11. 11.
    Ekenros L, Hirschberg AL, Backstrom T, Friden C (2011) Postural control in women with premenstrual symptoms during oral contraceptive treatment. Acta Obstet Gynecol Scand 90:97–102PubMedCrossRefGoogle Scholar
  12. 12.
    Hamlet WP, Liu SH, Panossian V et al (1997) Primary immuno-localization of androgen target cells in the human ACL ligament. Orthop Res 15:657–663CrossRefGoogle Scholar
  13. 13.
    Heitz NA (1999) Hormonal changes throughout the menstrual cycle and increased anterior cruciate ligament laxity in females. J Athl Train 343:144–149Google Scholar
  14. 14.
    Herrington L (2005) Knee joint position sense: The relationship between open and closed kinetic chain tests. J Sport Rehabil 14:356–362Google Scholar
  15. 15.
    Hertel J, Williams NI, Olmsted-Kramer LC, Leidy HJ, Putukian M (2006) Neuromuscular performance and knee laxity do not change across the menstrual cycle in female athletes. Knee Surge Sports Traumatol Arthrosc 14:817–822CrossRefGoogle Scholar
  16. 16.
    Hopper DM, Creagh MJ, Formby PA et al (2003) Functional measurement of knee joint position sense after anterior cruciate ligament reconstruction. Arch Phys Med Rehabil 84:868–872PubMedCrossRefGoogle Scholar
  17. 17.
    Lebrun CM (1994) The effect of the phase of the menstrual cycle and the birth control pill in athletic performance. Clin Sports Med 13:419–441PubMedGoogle Scholar
  18. 18.
    Lephart SM, Pincivero DM, Giraldo Jl et al (1997) The role of proprioception in the management and rehabilitation of athletic injuries. Am J Sports Med 25:130–137PubMedCrossRefGoogle Scholar
  19. 19.
    Liu SH, Al-Shaikh RA, Panossian V et al (1996) Primary immunolocalization of estrogen and progesterone target cells in the human anterior cruciate ligament. Orthop Res Soc 14:526–533CrossRefGoogle Scholar
  20. 20.
    Marks R (1994) The reliability of knee position sense measurements in healthy women. Physiother Can 46:37–41Google Scholar
  21. 21.
    Marks R, Quinney HA, Wessel J (1993) Proprioceptive sensibility in women with normal and osteoarthritic knee joints. Clin Rheumatol 12:170–175PubMedCrossRefGoogle Scholar
  22. 22.
    Moller-Neilsen J, Hammar M (1989) Women’s soccer injury in relation to the menstrual cycle and oral contraceptive use. Med Sci Sports Exerc 21:126–129Google Scholar
  23. 23.
    Nasseri N, Hadian MR, Bagheri H et al (2007) Reliability and accuracy of joint position sense measurement in the laboratory and clinic; utilizes a new system. Acta Med Ir 45:395–404Google Scholar
  24. 24.
    Naylor JM, Ko V, Adie S et al (2011) Validity and reliability of using photography for measuring knee range of motion:a methodological study. BMC Musculoskelet Disord 12:77–87PubMedCrossRefGoogle Scholar
  25. 25.
    Park SK, Stefanyshyn DJ, Loitz-Ramage B et al (2009) Changing hormone levels during the menstrual cycle affect knee laxity and stiffness in healthy female subjects. Am J Sports Med 37:588–598PubMedCrossRefGoogle Scholar
  26. 26.
    Park SK, Stefanyshyn DJ, Ramage B (2009) Relationship between knee joint laxity and knee joint mechanics during the menstrual cycle. Br J Sports Med 43:174–179PubMedCrossRefGoogle Scholar
  27. 27.
    Park SK, Stefanyshyn DJ, Ramage B et al (2009) Alterations in knee joint laxity during the menstrual cycle in healthy women leads to increases in joint loads during selected athletic movements. Am J Sports Med 37:1169–1177PubMedCrossRefGoogle Scholar
  28. 28.
    Posthuma BW, Bass MJ, Bull SB et al (1987) Detecting changes in functional ability in women with premenstrual syndrome. Am J Obstet Gynecol 159:275–278Google Scholar
  29. 29.
    Riemann BL, Lephart SM (2002) The sensory system. Part II: the role of proprioception in motor control and functional joint stability. J Athl Train 37:80–84PubMedGoogle Scholar
  30. 30.
    Rozzi SL, Lephart SM, Gear WS (1999) Knee joint laxity and neuromuscular characteristics of male and female soccer and basketball players. Am J Sports Med 27:312–319PubMedGoogle Scholar
  31. 31.
    Sarwer R, Beltran NB, Rutherford OM (1996) Changes in muscle strength, relaxation rate and fatiguability during the human menstrual cycle. J Physiol 493:267–272Google Scholar
  32. 32.
    Sciore P, Smith S, Frank CB (1997) Detection of receptors for estrogen and progesterone in human ligaments and rabbit ligaments and tendons by RT-PCR. Trans Orthop Res Soc 22:51–56Google Scholar
  33. 33.
    Slauterbeck JR, Fuzie SF, Smith MP et al (2002) The menstrual cycle, sex hormones and anterior cruciate ligament injury. J Athl Train 37:275–280PubMedGoogle Scholar
  34. 34.
    Shultz SJ, Carcia CR, Perrin DH (2004) Knee joint laxity affects muscle activation patterns in the healthy knee. J Electromyogr Kines 14:475–483CrossRefGoogle Scholar
  35. 35.
    Shultz SJ, Sander TC, Kirk SE et al (2005) Sex differences in knee joint laxity change across the female menstrual cycle. J Sports Med Phys Fitness 45:594–603PubMedGoogle Scholar
  36. 36.
    Shultz SJ, Sander TC, Johnson KM et al (2004) Relationship between sex hormones and anterior knee laxity across the menstrual cycle. Med Sci Sports Exerc 36:1165–1174PubMedCrossRefGoogle Scholar
  37. 37.
    Speroff L, Fritz MA (2005) Clinical gynecologic endocrinology and infertility. Lippincott Williams E Wilkins. 7th ed., A Wolters Kluwer company, pp 187–225Google Scholar
  38. 38.
    Stillman BC, McMeeken JM (2001) The role of weight bearing in the clinical assessment of knee joint position sense. Aust J Physiother 47:247–253PubMedGoogle Scholar
  39. 39.
    Wojtys EM, Huston LJ, Lindenfeld TN et al (1998) Association between the menstrual cycle and anterior cruciate ligament injuries in female athletes. Am J Sports Med 26:614–619PubMedGoogle Scholar
  40. 40.
    Yu WD, Hatch JD, Panossian V et al (1999) Effect of estrogen on cellular growth and collagen synthesis of human ACL. Clin Orthop Relat Res 366:229–238PubMedCrossRefGoogle Scholar

Copyright information

© Springer-Verlag 2011

Authors and Affiliations

  • Rose Fouladi
    • 1
  • Reza Rajabi
    • 1
  • Nasrin Naseri
    • 2
    Email author
  • Fereshteh Pourkazemi
    • 3
  • Mehrnaz Geranmayeh
    • 4
  1. 1.Sports Science and Physical Education DepartmentTehran UniversityTehranIran
  2. 2.Physiotherapy Department, Rehabilitation FacultyTehran University of Medical ScienceTehranIran
  3. 3.Physiotherapy Department, Faculty of Health SciencesUniversity of SydneyNSWAustralia
  4. 4.Midwifery DepartmentTehran University of Medical ScienceTehranIran

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