Preliminary Evaluation of Knee Kinetics in Female Athletes on Hormonal Contraceptives

Abstract

Recently, an emphasis has been placed on understanding how ovarian sex hormones and hormonal contraceptives affect risk for anterior cruciate ligament (ACL) injury. The literature presents large discrepancies in whether or not hormonal contraceptives affect ACL injury risk; therefore, the purpose of this study was to evaluate whether vertical ground reaction force (GRF) and knee valgus force are different between athletes who do and do not use hormonal contraceptives. Twenty-two female athletes volunteered to participate and were divided into two groups based on their answers to a health history questionnaire: those who use hormonal contraceptives and those who do not. Participants performed a drop vertical jump (DVJ) and single leg crossover dropdown (SCD) at two different time points in their menstrual cycle (pre-ovulatory phase and mid-luteal phase). Kinetic data were collected at 1000 Hz. Independent samples t-tests revealed no significant differences between groups in vertical GRF and knee valgus force at both time points. Findings from this study suggest that hormonal contraceptives do not elicit detectable changes in vertical GRF and knee valgus force. Ultimately, this calls for further studies on the relationship between hormones and ACL injury risk and physicians to consider hormonal screening in addition to neuromuscular and biomechanical screening.

Key words

anterior cruciate ligament - hormonal screening - injury prevention

• References

• 1 Samuelson K, Balk EM, Sevetson EL. et al. Limited evidence suggests a protective association between oral contraceptive pill use and anterior cruciate ligament injuries in females: A systematic review. Sports Health 2017; 9: 498-510 doi:10.1177/1941738117734164
• 2 Gornitzky AL, Lott A, Yellin JL. et al. Sport-specific yearly risk and incidence of anterior cruciate ligament tears in high school athletes: A systematic review and meta-analysis. Am J Sports Med 2016; 44: 2716-2723 doi:10.1177/0363546515617742
• 3 Renstrom PA. Eight clinical conundrums relating to anterior cruciate ligament (ACL) injury in sport: Recent evidence and a personal reflection. Br J Sports Med 2013; 47: 367-372 doi:10.1136/bjsports-2012-091623
• 4 Hart DA, Archambault JM, Kydd A. et al. Gender and neurogenic variables in tendon biology and repetitive motion disorders. Clin Orthop Relat Res 1998; 44-56
• 5 Liu SH, al-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: 526-533 doi:10.1002/jor.1100140405
• 6 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: 1298-1304 doi:10.1177/0363546505275149
• 7 Beynnon BD, Shultz SJ. Anatomic alignment, menstrual cycle phase, and the risk of anterior cruciate ligament injury. J Athl Train 2008; 43: 541-542 doi:10.4085/1062-6050-43.5.541
• 8 Brynhildsen J, Lennartsson H, Klemetz M. et al. Oral contraceptive use among female elite athletes and age-matched controls and its relation to low back pain. Acta Obstet Gynecol Scand 1997; 76: 873-878
• 9 Torstveit MK, Sundgot-Borgen J. Participation in leanness sports but not training volume is associated with menstrual dysfunction: A national survey of 1276 elite athletes and controls. Br J Sports Med 2005; 39: 141-147 doi:10.1136/bjsm.2003.011338
• 10 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: 126-129
• 11 Arendt EA, Bershadsky B, Agel J. Periodicity of noncontact anterior cruciate ligament injuries during the menstrual cycle. J Gend Specif Med 2002; 5: 19-26
• 12 Granan LP, Bahr R, Steindal K. et al. Development of a national cruciate ligament surgery registry: The Norwegian National Knee Ligament Registry. Am J Sports Med 2008; 36: 308-315 doi:10.1177/0363546507308939
• 13 Ulmer HE, Saggau WW. [Pulmonary microembolism: Pulmonary hemodynamics following trauma and hemorrhage (author's transl]. Basic Res Cardiol 1975; 70: 406-419
• 14 Rahr-Wagner L, Thillemann TM, Mehnert F. et al. Is the use of oral contraceptives associated with operatively treated anterior cruciate ligament injury? A case-control study from the Danish Knee Ligament Reconstruction Registry. Am J Sports Med 2014; 42: 2897-2905 doi:10.1177/0363546514557240
• 15 Ruedl G, Ploner P, Linortner I. et al. Are oral contraceptive use and menstrual cycle phase related to anterior cruciate ligament injury risk in female recreational skiers?. Knee Surg Sports Traumatol Arthrosc 2009; 17: 1065-1069 doi:10.1007/s00167-009-0786-0
• 16 Lefevre N, Bohu Y, Klouche S. et al. Anterior cruciate ligament tear during the menstrual cycle in female recreational skiers. Orthop Traumatol Surg Res 2013; 99: 571-575 doi:10.1016/j.otsr.2013.02.005
• 17 Zeller BL, McCrory JL, Kibler WB. et al. Differences in kinematics and electromyographic activity between men and women during the single-legged squat. Am J Sports Med 2003; 31: 449-456 doi:10.1177/03635465030310032101
• 18 Hewett TE, Ford KR, Xu YY. et al. Utilization of ACL Injury biomechanical and neuromuscular risk profile analysis to determine the effectiveness of neuromuscular training. Am J Sports Med 2016; 44: 3146-3151 doi:10.1177/0363546516656373
• 19 Hewett TE, Myer GD, Ford KR. et al. Biomechanical measures of neuromuscular control and valgus loading of the knee predict anterior cruciate ligament injury risk in female athletes: A prospective study. Am J Sports Med 2005; 33: 492-501 doi:10.1177/0363546504269591
• 20 Myer GD, Ford KR, Brent JL. et al. Differential neuromuscular training effects on ACL injury risk factors in “high-risk” versus “low-risk” athletes. BMC Musculoskelet Disord 2007; 8: 39 doi:10.1186/1471-2474-8-39
• 21 Powers CM. The influence of abnormal hip mechanics on knee injury: A biomechanical perspective. J Orthop Sports Phys Ther 2010; 40: 42-51 doi:10.2519/jospt.2010.3337
• 22 Chang A, Hayes K, Dunlop D. et al. Hip abduction moment and protection against medial tibiofemoral osteoarthritis progression. Arthritis Rheum 2005; 52: 3515-3519 doi:10.1002/art.21406
• 23 Dragoo JL, Castillo TN, Braun HJ. et al. Prospective correlation between serum relaxin concentration and anterior cruciate ligament tears among elite collegiate female athletes. Am J Sports Med 2011; 39: 2175-2180 doi:10.1177/0363546511413378
• 24 Harriss DJ, Macsween A, Atkinson G. Standards for ethics in sport and exercise science research: 2020 update. Int J Sports Med 2019; 40: 813-817
• 25 Dehghan F, Muniandy S, Yusof A. et al. Sex-steroid regulation of relaxin receptor isoforms (RXFP1 & RXFP2) expression in the patellar tendon and lateral collateral ligament of female WKY rats. Int J Med Sci 2014; 11: 180-191 doi:10.7150/ijms.6283
• 26 Maegawa M, Kamada M, Takayanagi M. et al. Difference of the hormonal profile at the periovulatory phase in pregnant and nonpregnant cycles of infertile women with unexplained etiology. Gynecol Obstet Invest 1993; 35: 228-231 doi:10.1159/000292705
• 27 Wu G, Siegler S, Allard P. et al. ISB recommendation on definitions of joint coordinate system of various joints for the reporting of human joint motion--part I: Ankle, hip, and spine. International Society of Biomechanics. J Biomech 2002; 35: 543-548
• 28 Meskers CG, Fraterman H, van der Helm FC. et al. Calibration of the “Flock of Birds” electromagnetic tracking device and its application in shoulder motion studies. J Biomech 1999; 32: 629-633
• 29 Perie D, Tate AJ, Cheng PL. et al. Evaluation and calibration of an electromagnetic tracking device for biomechanical analysis of lifting tasks. J Biomech 2002; 35: 293-297
• 30 Fleisig GS, Barrentine SW, Zheng N. et al. Kinematic and kinetic comparison of baseball pitching among various levels of development. J Biomech 1999; 32: 1371-1375
• 31 Hinrichs RN. Adjustments to the segment center of mass proportions of Clauser et al. (1969). J Biomech 1990; 23: 949-951
• 32 Hewett TE, Myer GD, Ford KR. et al. Mechanisms, prediction, and prevention of ACL injuries: Cut risk with three sharpened and validated tools. J Orthop Res 2016; 34: 1843-1855 doi:10.1002/jor.23414
• 33 Lange T, Freiberg A, Droge P. et al. The reliability of physical examination tests for the diagnosis of anterior cruciate ligament rupture-a systematic review. Man Ther 2015; 20: 402-411 doi:10.1016/j.math.2014.11.003
• 34 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: 182-188 doi:10.1177/03635465020300020601