Sports Medicine

, Volume 36, Issue 10, pp 847–862

The Effects of the Menstrual Cycle on Anterior Knee Laxity

A Systematic Review
  • Bohdanna T. Zazulak
  • Mark Paterno
  • Gregory D. Myer
  • William A. Romani
  • Timothy E. Hewett
Review Article


Female athletes are at a 4- to 6-fold increased risk of anterior cruciate ligament (ACL) injury compared with male athletes. There are several medical, emotional and financial burdens associated with these injuries. Sex hormones may be involved in the ACL injury disparity, with potential associations reported between phases of the menstrual cycle and ACL injury rates. The reported relationships between ACL injury and menstrual status may be related to associated changes in ligament mechanical properties from cyclic fluctuations of female sex hormones. A PubMed electronic database literature search, including MEDLINE (1966‐2005) and CINAHL (1982‐2005), with the search terms ‘menstrual cycle’ and ‘knee laxity’ was used for this systematic review. Studies were included in this systematic review if they were prospective cohort studies and investigated the association between the menstrual cycle and anterior knee laxity in females.

Nine prospective cohort studies, published as 11 articles, were included in the systematic review. Six of nine studies reported no significant effect of the menstrual cycle on anterior knee laxity in women. Three studies observed significant associations between the menstrual cycle and anterior knee laxity. These studies all reported the finding that laxity increased during the ovulatory or post-ovulatory phases of the cycle. A meta-analysis, which included data from all nine reviewed studies, corroborated this significant effect of cycle phase on knee laxity (F-value = 56.59, p = 0.0001). In the analyses, the knee laxity data measured at 10‐14 days was > 15‐28 days which was >‐9 days.

Future studies testing the relationship between the menstrual cycle and potentially associated parameters should consider the limitations outlined in this article and control for potential biases and confounders. Power analyses should be utilised. Subjects should be randomly entered into the studies at alternate points in the cycle, and standard and consistent data acquisition and reporting methods should be utilised. Future studies should clearly define what constitutes a ‘normal’ cycle and appropriate control subjects should be utilised. Furthermore, there is a need to define cycle phase (and timing within cycle phase) with actual hormone levels rather than a day of the cycle. Although hormone confirmations were provided in many of the studies that selected specific days to depict a particular cycle for all women, it is unknown from these data if they truly captured times of peak hormone values in all women.

A combined systematic review and meta-analysis of the literature indicate that the menstrual cycle may have an effect on anterior-posterior laxity of the knee; however, further investigation is needed to confirm or reject this hypothesis.


  1. 1.
    Arendt EA, Agel J, Dick R. Anterior cruciate ligament injury patterns among collegiate men and women. J Athl Train 1999; 34: 86–92PubMedGoogle Scholar
  2. 2.
    Arendt E, Dick R. Knee injury patterns among men and women in collegiate basketball and soccer: NCAA data and review of literature. Am J Sports Med 1995; 23 (6): 694–701PubMedCrossRefGoogle Scholar
  3. 3.
    Myer GD, Ford KR, Hewett TE. Rationale and clinical techniques for anterior cruciate ligament injury prevention among female athletes. J Athl Train 2004; 39 (4): 352–64PubMedGoogle Scholar
  4. 4.
    Hewett TE. Neuromuscular and hormonal factors associated with knee injuries in female athletes: strategies for intervention. Sports Med 2000; 29 (5): 313–27PubMedCrossRefGoogle Scholar
  5. 5.
    Moller-Nielsen J, Hammar M. Women’s soccer injuries in relation to the menstrual cycle and oral contraceptive use. Med Sci Sports Exerc 1989; 21 (2): 126–9PubMedGoogle Scholar
  6. 6.
    Arendt EA, Bershadsky B, Agel J. Periodicity of noncontact anterior cruciate ligament injuries during the menstrual cycle. J Gend Specif Med 2002; 5 (2): 19–26PubMedGoogle Scholar
  7. 7.
    Myklebust G, Maehlum S, Holm I, et al. A prospective cohort study of anterior cruciate ligament injuries in elite Norwegian team handball. Scand J Med Sci Sports 1998; 8 (3): 149–53PubMedCrossRefGoogle Scholar
  8. 8.
    Slauterbeck JL, Fuzie SF, Smith MP, et al. The menstrual cycle, sex hormones, and anterior cruciate ligament injury. J Athl Train 2002; 37 (3): 275–8PubMedGoogle Scholar
  9. 9.
    Wojtys EM, Huston LJ, Lindenfeld TN, et al. Association between the menstrual cycle and anterior cruciate ligament injuries in female athletes. Am J Sport Med 1998; 26 (5): 614–9Google Scholar
  10. 10.
    Wojtys EM, Huston LJ, Boynton MD, et al. The effect of the menstrual cycle on anterior cruciate ligament injuries in women as determined by hormone levels. Am J Sports Med 2002; 30 (2): 182–8PubMedGoogle Scholar
  11. 11.
    Wreje U, Kristiansson P, Aberg H, et al. Serum levels of relaxin during the menstrual cycle and oral contraceptive use. Gynecol Obstet Invest 1995; 39 (3): 197–200PubMedCrossRefGoogle Scholar
  12. 12.
    Bani D. Relaxin: a pleiotropic hormone. Gen Pharmacol 1997; 28 (1): 13–22PubMedCrossRefGoogle Scholar
  13. 13.
    Mathor MB, Achado SS, Wajchenberg BL, et al. Free plasma testosterone levels during th normal menstrual cycle. J Endocrinol Invest 1985; 8 (5): 437–41PubMedGoogle Scholar
  14. 14.
    Longcope C, Kato T, Horton R. Conversion of blood androgens to estrogens in normal adult men and women. J Clin Invest 1969; 48 (12): 2191–201PubMedCrossRefGoogle Scholar
  15. 15.
    Booth FW, Tipton CM.Ligamentous strength measurements in pre-pubescent and pubescent rats. Growth 1970; 34 (2): 177–85PubMedGoogle Scholar
  16. 16.
    Liu SH, Ali-Shaikh R, Panossian V, et al. Primary immunolocalization of estrogen and progesterone target cells in the human anterior cruciate ligament. J Orthop Res 1996; 14 (4): 526–33PubMedCrossRefGoogle Scholar
  17. 17.
    Samuel CS, Butkus A, Coghlan JP, et al. The effect of relaxin on collagen metabolism in the nonpregnant rat pubic symphysis: the influence of estrogen and progesterone in regulating relaxin activity. Endocrinology 1996; 137 (9): 3884–90PubMedCrossRefGoogle Scholar
  18. 18.
    Slauterbeck J, Clevenger C, Lundberg W, et al. Estrogen level alters the failure load of the rabbit anterior cruciate ligament. J Orthop Res 1999; 17 (3): 405–8PubMedCrossRefGoogle Scholar
  19. 19.
    Hewett TE, Zazulak BT, Myer GD. The effects of the menstrual cycle on ACL injury risk: a systematic review and meta analysis. Am J Sports Med. In pressGoogle Scholar
  20. 20.
    Yu B, Liu SH, Hatch J. Effects of estrogen on cellular metabolism of the human anterior cruciate ligament. Clin Orthop 1999; 366: 229–38PubMedCrossRefGoogle Scholar
  21. 21.
    Yu B, Panossian V, Hatch J. Combined effects of estrogen and progesterone on the anterior cruciate ligament. Clin Orthop 2001; 383: 268–81PubMedCrossRefGoogle Scholar
  22. 22.
    Dragoo JL, Lee RS, Benhaim P, et al. Relaxin receptors in the human female anterior cruciate ligament. Am J Sports Med 2003; 31 (4): 577–84PubMedGoogle Scholar
  23. 23.
    Lovering RM, Romani WA. Effect of testosterone on the female anterior cruciate ligament. Am J Physiol Regul Integr Comp Physiol 2005; 289 (1): R15–22PubMedCrossRefGoogle Scholar
  24. 24.
    Sciore P, Frank CB, Hart DA. Identification of sex hormone receptors in human and rabbit ligaments of the knee by reverse transcription-polymerase chain reaction: evidence that receptors are present in tissue from both male and female subjects. J Orthop Res 1998; 16 (5): 604–10PubMedCrossRefGoogle Scholar
  25. 25.
    Shultz SJ, Kirk SE, Johnson ML, et al. Relationship between sex hormones and anterior knee laxity across the menstrual cycle. Med Sci Sports Exerc 2004; 36 (7): 1165–74PubMedCrossRefGoogle Scholar
  26. 26.
    Romani W, Patrie J, Curl LA, et al. The correlations between estradiol, estrone, estriol, progesterone, and sex hormone-binding globulin and anterior cruciate ligament stiffness in healthy, active females. J Womens Health (Larchmt) 2003; 12 (3): 287–98CrossRefGoogle Scholar
  27. 27.
    Huston LJ, Wojtys EM. Neuromuscular performance characteristics in elite female athletes. Am J Sports Med 1996; 24 (4): 427–36PubMedCrossRefGoogle Scholar
  28. 28.
    Rosene JM, Fogarty TD. Anterior tibial translation in collegiate athletes with normal anterior cruciate ligament intergrity. J Athl Train 1999; 34: 93–8PubMedGoogle Scholar
  29. 29.
    Rozzi SL, Lephart SM, Gear WS, et al. Knee joint laxity and neuromuscular characteristics of male and female soccer and basketball players. Am J Sports Med 1999; 27 (3): 312–9PubMedGoogle Scholar
  30. 30.
    Ramesh R, Von Arx O, Azzopardi T, et al. The risk of anterior cruciate ligament rupture with generalised joint laxity. J Bone Joint Surg Br 2005; 87 (6): 800–3PubMedCrossRefGoogle Scholar
  31. 31.
    Uhorchak JM, Scoville CR, Williams GN, et al. Risk factors associated with noncontact injury of the anterior cruciate ligament: a prospective four-year evaluation of 859 West Point cadets. Am J Sports Med 2003; 31 (6): 831–42PubMedGoogle Scholar
  32. 32.
    Medrano D, Smith D. A comparison of knee joint laxity among male and female collegiate soccer players and non-athletes. Sports Biomech 2003; 2 (2): 203–12PubMedCrossRefGoogle Scholar
  33. 33.
    Arnold C, Van Bell C, Rogers V, et al. The relationship between serum relaxin and knee joint laxity in female athletes. Orthopedics 2002; 25 (6): 669–73PubMedGoogle Scholar
  34. 34.
    Belanger MJ, Moore DC, Crisco JJ, et al. Knee laxity does not vary with the menstrual cycle, before or after exercise. Am J Sports Med 2004; 32 (5): 1150–7PubMedCrossRefGoogle Scholar
  35. 35.
    Beynnon BD, Bernstein IM, Belisle A, et al. The effect of estradiol and progesterone on knee and ankle joint laxity. Am J Sports Med 2005; 33 (9): 1298–304PubMedCrossRefGoogle Scholar
  36. 36.
    Karageanes SJ, Blackburn K, Vangelos ZA. The association of the menstrual cycle with the laxity of the anterior cruciate ligament in adolescent female athletes. Clin J Sport Med 2000; 10 (3): 162–8PubMedCrossRefGoogle Scholar
  37. 37.
    Van Lunen BL, Roberts J, Branch JD, et al. Association of menstrual-cycle hormone changes with anterior cruciate ligament laxity measurements. J Athl Train 2003; 38 (4): 298–303PubMedGoogle Scholar
  38. 38.
    Heitz NA, Eisenman PA, Beck CL, et al. Hormonal changes throughout the menstrual cycle and increased anterior cruciate ligament laxity in females. J Athl Train 1999; 34 (2): 144–9PubMedGoogle Scholar
  39. 39.
    Deie M, Sakamaki Y, Sumen Y, et al. Anterior knee laxity in young women varies with their menstrual cycle.Int Orthop 2002; 26 (3): 154–6PubMedCrossRefGoogle Scholar
  40. 40.
    Shultz SJ, Sander TC, Kirk SE, et al. Sex differences in knee joint laxity change across the female menstrual cycle. J Sports Med Phys Fitness 2005; 45 (4): 594–603PubMedGoogle Scholar
  41. 41.
    Thacker SB, Stroup DF, Branche CM, et al. Prevention of knee injuries in sports: a systematic review of the literature. J Sports Med Phys Fitness 2003; 43 (2): 165–79PubMedGoogle Scholar
  42. 42.
    Wroble RR, VanGinkel LA, Grood ES, et al. Repeatability of the KT-1000 arthrometer in a normal population. Am J Sport Med 1990; 18: 396–9CrossRefGoogle Scholar
  43. 43.
    Alliende ME, Cabezon C, Figueroa H, et al. Cervicovaginal fluid changes to detect ovulation accurately. Am J Obstet Gynecol 2005; 193 (1): 71–5PubMedCrossRefGoogle Scholar
  44. 44.
    Berry J, Kramer K, Binkley J, et al. Error estimates in novice and expert raters for the KT-1000 arthrometer. J Orthop Sports Phys Ther 1999; 29 (1): 49–55PubMedGoogle Scholar
  45. 45.
    Myrer JW, Schulthies SS, Fellingham GW. Relative and absolute reliability of the KT-2000 arthrometer for uninjured knees: testing at 67, 89, 134, and 178 N and manual maximum forces. Am J Sports Med 1996; 24 (1): 104–8PubMedCrossRefGoogle Scholar
  46. 46.
    Shultz SJ, Shimokochi Y, Nguyen AD, et al. Nonweight-bearing anterior knee laxity is related to anterior tibial translation during transition from nonweight bearing to weight bearing. J Orthop Res 2006; 24 (3): 516–23PubMedCrossRefGoogle Scholar
  47. 47.
    Nattiv A, Agostini R, Drinkwater B, et al. The female athlete triad: the inter-relatedness of disordered eating, amenorrhea, and osteoporosis. Clin Sports Med 1994; 13 (2): 405–18PubMedGoogle Scholar
  48. 48.
    Griffin LE, Albohm MJ, Arendt EA, et al. Understanding and preventing noncontact anterior cruciate ligament injuries: a review of the Hunt Valley II meeting, January 2005. Am J Sports Med 2006; 34: 1512–32PubMedCrossRefGoogle Scholar

Copyright information

© Adis Data Information BV 2006

Authors and Affiliations

  • Bohdanna T. Zazulak
    • 1
    • 2
  • Mark Paterno
    • 3
    • 4
  • Gregory D. Myer
    • 4
  • William A. Romani
    • 5
  • Timothy E. Hewett
    • 4
    • 6
  1. 1.Departments of Orthopedics and Rehabilitation ServicesYale New-Haven HospitalNew HavenUSA
  2. 2.Department of Physical TherapyQuinnipiac UniversityNew HavenUSA
  3. 3.Department of Occupational and Physical TherapyCincinnati Children’s Hospital Research FoundationCincinnatiUSA
  4. 4.Sports Medicine Biodynamics Center and Human Performance LaboratoryCincinnati Children’s Hospital Research Foundation, MLC 10001CincinnatiUSA
  5. 5.Department of Physical Therapy and Rehabilitation ScienceUniversity of Maryland School of MedicineBaltimoreUSA
  6. 6.Departments of Pediatrics and Orthopaedic Surgery, Rehabilitation Sciences and Biomedical EngineeringUniversity of Cincinnati College of MedicineCincinnatiUSA

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