Sports Med 2006; 36 (10): 847-862

REVIEW ARTICLE 0112-1642/06/0010-0847/$39.95/0

© 2006 Adis Data Information BV. All rights reserved.

The Effects of the Menstrual Cycle on

Anterior Knee Laxity
A Systematic Review
Bohdanna T. Zazulak,1,2 Mark Paterno,3,4 Gregory D. Myer,4 William A. Romani5 and
Timothy E. Hewett4,6
1 Departments of Orthopedics and Rehabilitation Services, Yale New-Haven Hospital, New
Haven, Connecticut, USA
2 Department of Physical Therapy, Quinnipiac University, New Haven, Connecticut, USA
3 Department of Occupational and Physical Therapy, Cincinnati Children’s Hospital Research
Foundation, Cincinnati, Ohio, USA
4 Sports Medicine Biodynamics Center and Human Performance Laboratory, Cincinnati
Children’s Hospital Research Foundation, Cincinnati, Ohio, USA
5 Department of Physical Therapy and Rehabilitation Science, University of Maryland School of
Medicine, Baltimore, Maryland, USA
6 Departments of Pediatrics and Orthopaedic Surgery, Rehabilitation Sciences and Biomedical
Engineering, University of Cincinnati College of Medicine, Cincinnati, Ohio, USA

Contents
Abstract . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 847
1. Methods . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 850
2. Results . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 850
2.1 Study 1: Heitz et al. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 852
2.2 Study 2: Karageanes et al. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 852
2.3 Study 3: Deie et al. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 853
2.4 Study 4: Arnold et al. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 854
2.5 Study 5: Van Lunen et al. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 855
2.6 Study 6: Belanger et al. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 855
2.7 Study 7: Romani et al. and Lovering and Romani . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 856
2.8 Study 8: Shultz et al. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 856
2.9 Study 9: Beynnon et al. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 857
3. Discussion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 858
4. Conclusions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 860

Abstract 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
848 Zazulak et al.

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 signifi-
cant 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 >1–9 days.
Future studies testing the relationship between the menstrual cycle and poten-
tially 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.

Female athletes have a higher risk of anterior
cruciate ligament (ACL) injury than their male
counterparts.[1,2] Many of these injuries require sur-
gical and rehabilitative intervention, with the finan-
cial burden in the US approaching $US650 million
annually at the combined secondary and collegiate
levels.[3] Although no definite aetiology for the dis-
crepancy of these injuries is established, structural,
neuromuscular and hormonal factors have been pro-
posed.[4] Moller-Nielsen and Hammar[5] were the
first to report an association between phases of the
menstrual cycle and soccer injuries in women. More
recent investigations suggest that sex hormones may
be directly involved in the ACL injury disparity,
with potential associations reported between phases
of the menstrual cycle and ACL injury rates (figure
1).[1,6-10] The reported relationships between ACL
injury and menstrual status may be related to associ-
ated changes in ligament mechanical properties
from cyclic fluctuations of female sex hormones.
The cyclic changes in the circadian blood serum
sex hormone levels are unique to the female endo-
crine system. The related sex hormones include
estrogen, progesterone, relaxin and testosterone.
The release of these hormones is orchestrated
through a complex interaction among the hypothala-
mus, pituitary gland, ovaries and uterus. During the
follicular or menstrual phase (days 1–9 of the men-
strual cycle), estrogen, in a normally cycling wo-
man, is secreted at a rate of approximately 60 μg/
day. By the ovulatory phase (days 10–14 of the
cycle), estrogen reaches a peak secretion rate of
400–900 μg/day, and decreases to approximately
300 μg/day during the luteal phase (day 15 to end of
cycle). It is during the luteal phase that progesterone
reaches its peak secretion rate of 25 mg/day making
it the ovarian hormone with the highest secretion
rate. These characterisations of the cycle are average
levels of hormones that often demonstrate high vari-
ability among women. Relaxin levels rise in the
follicular and luteal phases,[11] peaking approxi-

© 2006 Adis Data Information BV. All rights reserved. Sports Med 2006; 36 (10)
Menstrual Cycle Effects on Anterior Knee Laxity 849

mately 6–9 days after the luteinising hormone
surge.[12] Testosterone levels also fluctuate across
menstrual cycle phases[13] and contribute to the cir-
culating concentration of estradiol by conversion via
the process of aromatisation.[14]
Sex hormones may affect the mechanical proper-
ties of the ACL, specifically collagen structure and
metabolism.[15-21] Estrogen, progesterone, relaxin
and testosterone receptors are present in human
ACL tissue.[16,22-24] There is evidence to suggest
effects of these hormones on the tensile properties of
ligaments. Effects of ACL exposure to increased
estrogen (specifically estradiol) levels include de-
creased fibroblast proliferation and reduced procol-
lagen synthesis in cell cultures,[16,20] and a reduced
load to failure rate in animal models.[15,18] Converse-
ly, ACL exposure to increased progesterone is asso-
ciated with increased fibroblast proliferation and
collagen formation in cell cultures.[21] Although es-
tradiol and progesterone are the primary focus of
previous research on hormonal influences on liga-
ment properties, fluctuating levels of other hor-
mones may also play a role in ligament behaviour.
These potentially interrelated hormones include re-
laxin, which decreases soft tissue tension,[17] endog-
enous testosterone,[23,25] estrone and estrial (two oth-
er circulating estrogens) and sex-hormone-binding
globulin.[26]

±
Myklebust et al.
2003

Laxity
Slauterbeck et al.*
Menses
2002
28 begins 1
27 2
Injury
26 3
25 4
nstrual cy
me cle
24 he 5 ±
T

Arendt et al.
23 1999
6

22
7
Shultz et al.* 21
2004–5 8
±
Arendt et al.
20 2002
9

19 Ovulation 10
18 11
Deie et al.*
2002 17 12
16 13
15 14 ±
Wojtys et al.
1999
Heitz et al.* ± Heitz et al.*
Wojtys et al.
1999 1999
2002

Deie et al.*
2002
Shultz et al.*
2004–5

Fig. 1. Schematic diagram illustrating time and menstrual cycle stage versus anterior knee laxity and anterior cruciate ligament (ACL) injury
risk. Each designated study reported anterior knee laxity (outer circle) or ACL injury rate (inner circle). * indicates significant difference; ±
indicates trend.

© 2006 Adis Data Information BV. All rights reserved. Sports Med 2006; 36 (10)
850
The potential influence of these sex hormones on
the physical properties, specifically tensile strength
and laxity, of the ACL in women is not delineated.
However, it has been demonstrated that women
generally have greater knee laxity than men.[27-29]
Knee laxity (measured by knee hyperextension and
generalised joint laxity) has been identified as a risk
factor for ACL injury.[30-32] Several studies have
examined the possibility that acute transient changes
in knee laxity across the menstrual cycle may be a
function of changing sex hormone levels.[23,25,26,33-40]
The purpose of this article is to systematically re-
view the literature regarding the association be-
tween menstrual cycle and anterior tibiofemoral mo-
tion of the knee as an indicator of ACL laxity.
1. Methods
A PubMed electronic database literature search,
including MEDLINE (1966–2005) and CINAHL
(1982–2005), with the search terms ‘menstrual cy-
cle’ and ‘knee laxity’, was used for the current
systematic review.[41] The results were further limit-
ed to the terms ‘anterior cruciate ligament’ and
‘hormones’. Papers were included in the systematic
review if they were prospective cohort studies and
investigated the association between the menstrual
cycle and anterior knee laxity in women. Abstracts
and unpublished studies were excluded. The search
was supplemented by review of the bibliographies
of the retrieved articles, personal correspondence
with the authors of the retrieved articles, as well as
hand searching of pertinent journals to identify any
and all potentially published or unpublished studies
addressing this topic of investigation. Nine prospec-
tive cohort studies, published as 11 articles, met
inclusionary criteria and were included in the sys-
tematic review. These relatively liberal inclusionary
criteria were utilised in order to review all those
relevant studies published in the literature and to
maximise the generalisability of this systematic re-
view. A database was developed in order to system-
atically determine if each of the studies had the
relevant information required for a systematic com-
parison of data sets between studies. A brief summa-
ry of the collated data is presented in table I.
1 The use of trade names is for product identification purposes only and does not imply endorsement.
© 2006 Adis Data Information BV. All rights reserved.
Zazulak et al.
There is controversy regarding menstrual phase
terminology, specifically how cycle phases should
be designated. For example, we have utilised the
term ‘ovulatory phase’ to match the terminology
used by all nine studies included in the systematic
review.[23,25,26,33-40] However, ovulation is a point in
time, not necessarily a ‘phase’ of the menstrual
cycle. It may be more appropriate to simply break
the cycle into two phases: pre-ovulatory and post-
ovulatory. It is important to note that all nine studies
reported their female subjects were either eumenor-
rheic or had a ‘normal’ cycle phase, which was
defined.[23,25,26,33-40] The ‘normal’ phase ranged from
24 to 35 days and the methods used to determine
cycle phase varied from subject recall,[34] day of
cycle with hormone confirmation,[25,26,35,37-39] or
hormone data alone.[33] There is also a discrepancy
in the terminology used by Heitz et al.[38] compared
with the other studies. Heitz et al.[38] referred to the
day 1 measurement as ‘menstrual’ phase, not follic-
ular and they referred to their day 11–13 measure-
ments as captured during the follicular, not ovulato-
ry phase.[38] For purposes of consistency, we com-
pare their ‘menstrual’ phase measure with the
follicular phase of the other eight authors and we
compared their ‘follicular’ phase measure with the
ovulatory phase designated in the other studies (ta-
ble I).
2. Results
The nine studies (11 articles) retrieved varied in
the population of subjects and the method of deter-
mining the phase of menstrual cycle/hormone
levels. Subjects consisted of collegiate athletes,[33,34]
high-school athletes,[36] athletes participating in va-
rious levels of sports and recreational activities,[26,38]
non-athletes[37,40] and unspecified sports participa-
tion status.[35,39] The cohort sizes ranged from 7[38] to
41,[33] with a median of 18. The anterior tibi-
ofemoral motion was measured in all of the included
studies with an anterior-directed force on the tibia
(with a KT1000™ or KT2000™ arthrometer)1 with
the subjects supine and the knee positioned at 25° of
knee flexion. In addition, the reported data had large
standard deviations for most studies. This variability
may have masked potential positive effects. Worth
Sports Med 2006; 36 (10)
© 2006 Adis Data Information BV. All rights reserved.

Menstrual Cycle Effects on Anterior Knee Laxity

Table I. Menstrual cycle effects on anterior knee laxity

Study Subjects Sports Age (mean ± Testing method Randomisation Laxity (mm)
SD or range) and force applied follicular ovulatory luteal
[y] (day 1–9) (day 10–14) (day 15 to menses)
Heitz et al.[38] 7F Recreational 21–32 KT2000™: 133N Not randomised 5.6 ± 1.3 6.4 ± 1.6a 7.0 ± 1.7b
athletes (day 1) (days 10–13) (days 20–23)

Karageanes et 26 F Division I 15.65 ± 0.98 KT1000™: 89N Randomly Right: 5.0 Right: 5.2 Right: 5.1
al.[36] high-school entered Left: 4.5 Left: 4.4 Left: 4.6
athletes Not tested

Deie et al.[39] 16 F ND 21–23 KT2000™: 89N Randomly 4.7 ± 0.8 5.3 ± 0.7a > follicular 5.2 ± 0.7a > follicular
entered

134N Not tested 6.4 ± 1.0 6.8 ± 0.9a > follicular 6.9 ± 1.1a > follicular

Arnold et al.[33] 41 F athletes Athletes and 19.3 ± 1.5 KT1000™: 67N, Not randomised 6.3 ± 1.6 to 6.3 ± 1.6 to 6.3 ± 1.6 to
8 F non- non-athletes 89N and manual 7.1 ± 2.7 7.1 ± 2.7 7.1 ± 2.7
athletes maximum

Van Lunen et 12 F Mild-mod 24.3 ± 4.9 KT2000™:134N Not randomised 6.0 ± 0.5 6.4 ± 0.4 6.1 ± 0.4
al.[37] active

Belanger et al.[34] 18 F Collegiate ND KT2000™: 134N Randomly 4.6 4.8 4.7

athletes entered
Not tested

Romani et al.[26] 20 F Recreational 25 ± 5.1 KT2000™: 156N Randomised 5.8 ± 1.6 5.7 ± 1.8 6.1 ± 1.7
and Lovering and athletes
Romani[23]

Shultz et al.[25,40] 25 (22)c F Non-athletes 23 ± 3.5 KT2000™: 89N Not randomised 3.8 ± 1.5 to 4.3 ± 1.5 to 3.3 ± 1.4 to
but balanced 4.3 ± 1.5 4.7 ± 1.5a 4.3 ± 1.7a

133N 4.8 ± 1.6 to 5.2 ± 1.6 to 4.2 ± 1.8 to

5.3 ± 1.6 5.8 ± 1.6a 5.4 ± 1.9a

Beynnon et al.[35] 17 F ND 21.7 (17–29) KT1000™: 90N Randomly 9.1 8.9 Early: 8.7
entered Late: 8.5
Not tested
Sports Med 2006; 36 (10)

a Significant increase in anterior tibiofemoral laxity (p < 0.05).

b Reported significant increase in anterior tibiofemoral laxity (p = 0.06).

c n = 22 in the 2005 study.[40]

F = females; mild-mod = mildly to moderately; ND = not defined.

851
852
noting, the Karageanes et al.[36] and Belanger et
al.[34] studies did not numerically report the standard
deviations of their data. Only one study randomised
testing order by phase,[26] one used a balance design
for testing in the follicular and luteal phases,[25] four
studies randomly entered subjects but did not
randomise testing by phase,[34-36,39] and three did not
randomise subjects at all (started testing all subjects
in the same phase [table I]).[1,7,33,38] The nine studies,
published in 11 articles, are reviewed in sections
2.1–2.9 by order of publication date.
2.1 Study 1: Heitz et al.
This study[38] was a prospective cohort study
designed to determine if female recreational athletes
experienced significant differences in knee laxity
concomitant with the estrogen and progesterone
surges during a normal menstrual cycle. The small
cohort of female patients (n = 7) had a mean age of
26.9 years, no history of taking oral contraception
medication and had a self-reported ‘normal’ (28–30
days) menstrual cycle. There was no control group
(oral contraceptive female, pre-pubertal female,
menopausal or matched male comparative group)
for this study.
Baseline levels of estrogen and progesterone,
measured on day 1 (onset of menses) of the cycle,
were utilised as a baseline measurement of hormo-
nal concentrations (phase I). Peak estrogen levels
occur between days 10 and 13, which was cat-
egorised as the follicular phase (phase II). Progester-
one level peaks at days 20–23, which was labelled
the luteal phase (phase III). A venous blood draw
was administered to each subject to assess circulat-
ing levels of estrogen and progesterone on days 1,
10, 11, 12, 13, 21, 22, 23 and 24. Immediately
following each blood draw, each subject was as-
sessed for knee laxity with the KT2000™ knee
arthrometer at 67N, 89N and 133N of force. Knee
laxity at 133N of force was analysed and reported.
The authors reported a significant increase (p =
0.048) in knee laxity between phase I and phase II
(peak estrogen surge), and a significant increase (p =
0.006) in knee laxity between phase I and phase III
(peak progesterone surge).
The most notable limitations of this study were
the size of the study group (n = 7) and the lack of a
matched control group. In addition, the authors did
© 2006 Adis Data Information BV. All rights reserved.
Zazulak et al.
not stipulate whether an experienced examiner was
utilised, random assignment or counterbalance of
subjects prior to data collection were utilised. Every
subject was tested at menses and then sequentially
during the later stages. Wroble et al.[42] reported that
subjects who were tested over several trials on dif-
ferent days with the KT arthrometer had the least
translation on the first trial and then increased and
plateaued translation during subsequent trials. They
suggested that the KT arthrometer can be uncom-
fortable, which may cause protective muscular
guarding tension that resists anterior tibial transla-
tion. Wroble et al.[42] attributed their findings to a
learning or ‘comfort’ effect of being exposed to the
KT arthrometer. Since the single initial value of KT
laxity at the onset of menses was the lowest in the
subjects tested by Heitz et al.,[38] it is possible that
without a counterbalanced subject testing, the
demonstrated effects between the first and the sub-
sequent measures could have been due to the de-
scribed ‘comfort effect’ rather than sex hormones or
cycle phase.
The authors attempted to target multiple points in
time around the onset of menses and near the pro-
jected peak of estrogen and progesterone. However,
as Shultz et al.[25] have shown, changes in laxity may
occur several days after fluctuations in hormonal
concentrations occur. The authors did attempt to
account for this variability by sampling multiple
days during the target points to offer a better oppor-
tunity to capture laxity changes at critical points in
the cycle than would be accomplished on a single
test day; however, the data collection points targeted
the peaks in hormones as opposed to days following
peaks. A further limitation is that the authors did not
state how they defined the term ‘normal’ menses.
Ultimately, these study limitations may have de-
creased the potential to elucidate a conclusive rela-
tionship between cycle phase and laxity.
2.2 Study 2: Karageanes et al.
This prospective, single-blind cohort study[36]
monitored 26 female high-school athletes (mean age
15.7 ± 1.0 years) during a 5- to 8-week period in
order to collect data from each phase of one com-
plete menstrual cycle. The stated objective of this
study was to determine if a significant change in
laxity of the ACL occurs in the competitive adoles-
Sports Med 2006; 36 (10)
Menstrual Cycle Effects on Anterior Knee Laxity
cent female athlete throughout different phases of
the menstrual cycle. The cohort included high-
school females who participated in gymnastics, soc-
cer, track, tennis and basketball with no comparative
control group. The population of females had nor-
mal menstrual cycles.
A KT1000™ arthrometer was used to measure
anterior tibiofemoral laxity (89N) during repeated
measures over an 8-week period. Each subject was
tested prior to workouts or competition at discontin-
uous intervals. The mean number of measurements
taken per knee was 12.8, with a range between 6 and
21. The range of time between measurements was
1–7 days. The athletes charted menstrual periods on
a monthly calendar that was submitted after testing
in order to minimise bias in laxity readings.
The three phases of the menstrual cycle were
calculated from the questionnaires. The authors
counted 14 days prior to the first day of menses to
estimate ovulation, and counted 3 days back to
represent the ovulatory phase. The days from the
beginning of menses to the beginning of ovulation
represented the follicular phase, and the time from
the estimated ovulation day to the first day of men-
ses was designated as the luteal phase. The mean
laxity measures for each phase were statistically
compared (table I). The authors reported no signifi-
cant difference in knee laxity throughout the three
phases of the menstrual cycle (p > 0.05).
One limitation of this study was using a question-
naire to estimate the estrogen surge that occurs
during ovulation. This is more accurately done
through daily serum assay to account for the individ-
ual variability in fluctuating sex hormone levels.
Moreover, the authors relied on self-report measures
to describe the previous menstrual cycles, even
though the correlation between blood hormone
levels, cycle phase and self-report of phase is
poor.[10] The authors’ definition of ‘normal’ was the
subject’s report of a cycle of 26–30 days with men-
ses 4–7 days over the past 6 months. This may not be
an adequate method for high data reliability and
reproducibility especially given the inherent cycle
variability in adolescent populations such as those
tested. Furthermore, the population in this study was
notably younger than the subjects included in the
other studies.
© 2006 Adis Data Information BV. All rights reserved.
853
It is not clear which laxity measurements were
selected and extracted for the final data for analysis.
In the measures that were selected, there was high
variability in the number of measurements taken
(range 6–21 measurements), as well as the range of
time between measurements (1–7 days). The varia-
bility of the data measures was not reported, there-
fore it was difficult to interpret the relative coeffi-
cient of variation and whether there was potential
beta error in the findings. The data were sampled
randomly within each phase, which would make the
presumption that each day within the phase is repre-
sentative of a particular hormone milieu. Another
potential limitation is that two examiners made the
laxity measures and only measured at 89N (seven of
the remaining eight studies measured laxity at
133–134N of force). There tends to be relatively
high inter-rater variability in KT arthrometer mea-
surements.[42]
2.3 Study 3: Deie et al.
This prospective cohort study[39] evaluated ante-
rior-posterior tibiofemoral laxity changes in women
during their menstrual cycle. The authors studied a
cohort of 16 young women (mean age 21.6 years)
regular menstrual cycles (28 ± 4 days) and no histo-
ry of oral contraceptive use, and a control group of
eight young men (mean age 21.5 years). Data collec-
tion in the study group occurred over a 4-week span.
The data collected included a self-assessment of
daily basal body temperature, weekly assessments
of estradiol and progesterone levels via blood serum
and two to three assessments of knee laxity per week
using a KT2000™ arthrometer, administered by a
single tester.
The control group was assessed three times per
week with the KT2000™ for three consecutive
weeks. No assessments of hormonal levels were
assessed in the control group. For the study group,
each knee laxity assessment was grouped into the
follicular phase, the ovulatory phase or the luteal
phase, based on the basal body temperature and the
levels of estradiol and progesterone in the subject’s
blood. The control group’s data were grouped by
week. The authors reported significant differences
in knee laxity between the follicular phase and the
luteal phase at 134N and differences between the
follicular and both the ovulatory and luteal phase at
Sports Med 2006; 36 (10)
854
89N (p < 0.05). The authors reported no significant
difference in anterior knee laxity between the test
periods for the control group.
The description of the methods used in this study
was not sufficient to make accurate comparisons to
other cited methodological approaches for phase
categorisation of knee laxity data. The authors did
state that each subject was measured for basal body
temperature and levels of estradiol and progester-
one, but there is no description of how these mea-
sures were used to classify each female subject into
an appropriate menstrual stage. Secondly, the inter-
pretation of the findings is limited, as the authors do
not report the timepoint at which each participant
began testing (such as at the onset of menses).
Another limitation was the timing between the rela-
tionship of knee laxity testing and the estradiol and
progesterone assessment. The authors reported that
knee laxity was tested two to three times per week,
but no routine cycle of testing was reported. Similar-
ly, the concentrations of estradiol and progesterone
were only assessed weekly. Considering that fluctu-
ations in hormone concentrations are variable, and
can dramatically change in 2–4 days, their weekly
assessment may not have accurately classified the
stages of the menstrual cycle for each subject. The
testing was not randomised nor counterbalanced by
phase and the knee laxity testing in the control group
did not temporally match the testing frame of the
female subjects. Lastly, the subjects’ sports status
was not defined, which may limit the generalisabili-
ty to the high-risk sports population.
2.4 Study 4: Arnold et al.
This study[33] represents a prospective cohort
study examining the relationship between serum
relaxin levels and joint laxity in female athletes. The
cohort of college-aged female athletes (n = 57) was
subdivided into 41 uninjured athletes, eight non-
athletes and eight ACL-injured athletes with a mean
age of 19.3 + 1.5 years. A control group of five
males was included. The authors may not have
adequately controlled for use of oral contraceptives,
menstrual history or the onset of menses in their
methods. Relaxin levels were measured weekly for
4 weeks through venous blood assessment. Knee
laxity was assessed at the time of the weekly blood
draw, via a KT1000™ knee arthometer, adminis-
© 2006 Adis Data Information BV. All rights reserved.
Zazulak et al.
tered by a single examiner. Anterior tibiofemoral
translation was assessed at 67N (15lb), 89N (20lb)
and manual maximum force; however, only maxi-
mum force was utilised for data analysis.
The authors reported no sex differences in mean
levels of relaxin, but noted significant fluctuations
in relaxin levels in women, week to week. They
reported a trend towards increased knee laxity in
women compared to men (especially in the injured
female athlete group), no change in knee laxity
measures through the course of a menstrual cycle
and no significant correlation between laxity and
relaxin levels (table I). The authors concluded that
there was not a significant relationship between
relaxin level and knee laxity.
Determining a relationship between a specific
point in the menstrual cycle and knee laxity was
difficult because of the lack of association of the
days of testing to any stage of the menstrual cycle.
Several authors have reported changes in hormonal
levels during specific stages of the menstrual cycle.
However, this study failed to link testing points to a
significant cyclical event (i.e. onset of menses).
Secondly, the testing was only executed weekly.
Data from other authors[25] suggest changes in knee
laxity several days after changes in hormonal levels.
Testing only once per week as opposed to daily is a
concern as this would not be frequent enough to
detect subtle changes in knee laxity after onset of
menses. As previously noted, the testing of 1 day
may be problematic as it is difficult to discern
whether this 1 day in each phase is testing the same
hormone environment.
The authors attempted to control for the use of
oral contraceptives. However, as they noted, only
82% of the participants completed a questionnaire
that determined the use of oral contraceptive use
among the female participants. This is a potentially
confounding variable, especially given that there is
an uncertainty regarding the use of oral contracep-
tives in the remaining 18% and thus, the classifica-
tion of these subjects. Interpretation of the hormonal
effects on the ACL is confounded with the use of
maximum force KT testing as the secondary re-
straints may contribute increased resistance at in-
creased amounts of anterior force. Finally, the varia-
bility of the data was relatively high, which may
have lead to potential beta error.
Sports Med 2006; 36 (10)
Menstrual Cycle Effects on Anterior Knee Laxity
2.5 Study 5: Van Lunen et al.
This controlled laboratory cohort study[37] moni-
tored 12 mildly to moderately active females during
three points of one menstrual cycle. The stated ob-
jective of this study was to determine whether ACL
laxity was associated with concentrations of repro-
ductive hormones during the menstrual cycle. The
cohort of 12 ‘mildly to moderately active’ females
was included in the study with no control group. The
population of 12 females (mean age 24.3 ± 4.9
years) had ‘normal’ menstrual cycles of 28–35 days
over the 12 months prior to the study. Subjects were
tested at onset of menses, near ovulation and day 23
(mid-luteal phase). At each session, blood was
drawn for radioimmunoassay and anterior tibi-
ofemoral laxity was measured with KT2000™
(133N). One-day measures within each phase of the
menstrual cycle were examined and statistically
compared (table I). The authors reported no associa-
tions between follicular, ovulatory and luteal phase
hormonal concentrations and anterior tibiofemoral
laxity (p < 0.05).
This study attempted to test laxity and sex hor-
mone levels near significant landmarks throughout
the menstrual cycle. As the authors acknowledged,
there was a variable time delay between initiation of
menses (between 16 and 35.5 hours) or ovulation
(9.75 and 35 hours) and the laxity measurements or
blood draws that may have influenced the accurate
timing between cycle phase, hormonal levels and
these measurements. They attempted to account for
this time delay by characterising mid-cycle mea-
surements as ‘near ovulation’. One examiner made
most, but not all, of the laxity measures (11 of 12),
which permits increased potential inter-rater error.
However, the reported data demonstrated low varia-
bility.
All of the subjects in this study began testing at
the reported onset of menses. However, unlike Heitz
et al.,[38] their consistent order of testing did not
result in significant differences in knee laxity be-
tween cycle stages. This may be due to the formal-
ised training session that the examiner underwent
prior to testing. Consistency of menstrual cycle
length prior to the study was self-reported rather
than documented by the investigators. However, this
issue may be mitigated by the fact that ovulation kits
© 2006 Adis Data Information BV. All rights reserved.
855
and actual hormone assays were used to determine
ovulation. Lastly, the current description of the pop-
ulation ‘mildly to moderately active’ females may
limit the comparison with female athletes who are at
increased risk of ACL injury.
2.6 Study 6: Belanger et al.
This controlled laboratory cohort study[34] moni-
tored 18 female high-level collegiate athletes (age
not defined) 2 times/week for 10 weeks. The stated
objective of this study was to determine whether
anterior tibiofemoral laxity was associated with con-
centrations of reproductive hormones during the
menstrual cycle. The authors hypothesised that ante-
rior tibiofemoral laxity would be significantly dif-
ferent in the follicular, ovulatory and luteal phases
of the menstrual cycle. Knee laxity was measured by
a single examiner using a KT2000™ (134N). Men-
strual cycle phases were determined by charts of
waking temperature and menstruation.
The initial cohort of 27 females had normal men-
strual cycles and no history of amenorrhoea. How-
ever, the authors did not provide a definition of
‘normal’. Data from seven subjects were dropped
due to inadequate compliance, whereas two subjects
were dropped due to a failure to menstruate over the
10-week testing period. Individual cycle lengths
were normalised to a 28-day cycle and divided into
three phases: follicular, ovulatory and luteal. Knee
laxity data were grouped according to these three
phases and statistically compared (table I). The au-
thors reported no significant differences in anterior
tibiofemoral laxity in any of the three menstrual
phases, before or after exercise (p < 0.05).
The authors acknowledged several limitations to
this study. One was the high drop-out rate (data from
nine of the initial 27 subject cohort were excluded,
seven for non-compliance with the protocol and two
because of oligomenorrhoea). Although these meth-
ods are commonly used to track ovulation, there is
potential error and inconsistency in the methods of
self-reported time of menstruation[10] as well as the
method of using waking temperature to detect ovu-
lation.[43] Another notable limitation of the study is
normalisation of the menstrual cycle to 28 days via
proportional scaling (although the authors did per-
form sensitivity analyses to determine if this
normalisation affected the results). Furthermore, al-
Sports Med 2006; 36 (10)
856
though the authors sampled multiple days, they did
not attempt to sample around critical events. Even
within each of the described phases, there are fluctu-
ations in hormones from day to day. Thus treating
all measurement days within a general phase (and
not necessarily time around a particular event) as
representative of the same may compromise the
ability to capture peaks and valleys in the laxity
data. The variability of the data measures was not
reported, therefore it was difficult to interpret the
relative coefficient of variation and whether there
was potential beta error in the findings.
2.7 Study 7: Romani et al. and Lovering
and Romani
This prospective cohort study was published in
two separate reports.[23,26] The first identified the
relationship between hormone levels and ACL stiff-
ness.[26] The second included free and total testoster-
one into the original statistical model.[23] The cohort
included 20 active, healthy female subjects (mean
age = 25.9 ± 5.1 years) with menstrual cycles report-
ed to be between 28 and 32 days long for the 3
months prior to the study. All subjects participated
in an introductory session with the KT2000™ knee
arthrometer test and were randomly assigned into
three groups to begin data collection at the onset of
menses, near ovulation or during the luteal phase of
their menstrual cycle. At each stage of the menstrual
cycle, three measurements of anterior tibial dis-
placement were made with the KT2000™ and blood
was drawn for assay analysis of sex hormone con-
centration during a single testing session. The onset
of menses was defined as day 1 of the menstrual
cycle. Data collection near ovulation was within 24
hours of positive testing with an ovulation kit and
measurements during the luteal phase were taken
between days 22 and 24. Hysteresis curves were
used to determine stiffness between 89N and 134N.
In order to provide a similar comparison between
studies, knee laxity was calculated in a post hoc
analysis of the same subjects and KT2000™ mea-
surements.[23,26]
The means of knee laxity (table I) [menses: mean
= 5.8 ± 1.6mm; near ovulation: 5.7 ± 1.8mm; luteal:
6.1 ± 1.7mm] did not significantly change between
the three stages of the menstrual cycle. However,
Spearman rank (rs) order analysis indicated a signif-
© 2006 Adis Data Information BV. All rights reserved.
Zazulak et al.
icant negative relationship between estradiol con-
centration and stiffness (rs = –0.70, p < 0.001) and a
significant positive relationship between testoster-
one (rs = 0.48, p = 0.03) and free androgen index (rs
= 0.44, p = 0.05) and stiffness. There were no
significant relationships between any of the sex hor-
mones and laxity. A Spearman partial rank (rsp)
order analysis was used to determine the relation-
ship between individual variables and knee laxity
and stiffness while controlling for the influence of
the other sex hormone variables. Estradiol was the
only sex hormone that had a significant relationship
with stiffness (rsp = –0.80, p < 0.001) indicating that
estradiol was the only independent predictor of stiff-
ness.
A limitation of this study was that the data were
only collected over three consecutive menstrual
stages during a single menstrual cycle. Thus, it is not
known whether the relationships between sex hor-
mone concentrations and measurements of ACL
tensile strength over a longer period of time existed.
As the authors pointed out, the term ‘ACL stiffness’
was used to describe the stiffness of the ACL and the
other capsuloligamentous and musculotendinous
structures that also play a role in restraining anterior
tibial translation. In addition, the reported data had
large standard deviations. This variability may have
masked potentially significant differences in knee
laxity between cycle phases.
2.8 Study 8: Shultz et al.
This prospective cohort study, published in two
separate reports,[25,40] monitored non-athletic wo-
men during 20 different days of one menstrual cycle.
The stated objective of this study was to quantify,
through daily serial measures, changes in knee laxi-
ty as a function of changing sex hormone levels
across one complete menstrual cycle. The cohort of
25 ‘non-athletic’ women (n = 22 in the laxity study)
were included in the study while 20 men were used
as a control group. The population of 25 women
(mean age 23 ± 3.5 years) had normal menstrual
cycles. The authors’ definition of ‘normal’ was the
subjects’ report of a 28- to 32-day menstrual cycle
over the past 6 months. Blood was drawn daily in
women and once a week in men for serum assay of
estradiol, progesterone and testosterone.
Sports Med 2006; 36 (10)
Menstrual Cycle Effects on Anterior Knee Laxity
One-day measures within each phase were ex-
amined and statistically compared (table I). Data
were not aligned by day of the cycle but rather by
the actual changes occurring in hormone concentra-
tions. Furthermore, they sampled 5 consecutive days
in each phase. The authors found knee laxity was
significantly greater on day 5 of the 5 days measured
near ovulation when compared with day 3 of the 5
days measured at menses, and days 1–3 of the 5 days
sampled in the early luteal phase compared with all
5 days of menses and day 1 of the 5 days measured
near ovulation. The first article[25] reported that the
cyclic differences in knee laxity in this group of
women correlated to concentrations of all three hor-
mones, based on the cycle phase. Additionally, knee
laxity changed 3, 4 and 5 days after changes in
estradiol, progesterone and testosterone levels, re-
spectively.
One limitation of the study was that the males
had each measurement (laxity, blood draw with
hormone of estrogen, progesterone and testosterone)
taken on four test days, once per week, but a ‘single
representative value for each variable across the four
tests days’ was used for statistical comparison with
the female data. In order to avoid the ‘comfort
effect’ reported by Wroble et al.[42] the authors used
a counterbalanced subject test assignment to begin
and end data collection at three stages of the men-
strual cycle.
The authors used a self-report of previous men-
strual cycle consistency for inclusion into the study,
but measured sex hormones daily to determine cycle
stage. In addition, the definition of ‘non-athletic’ is
unclear. However, because the subjects were report-
ed to be ‘non-athletic’ women, we may not be able
to generalise these findings to other athletic female
populations at high risk for ACL injury. The authors
acknowledge the potential compromise in
KT2000™ test reliability by using two examiners.
2.9 Study 9: Beynnon et al.
This controlled laboratory cohort study[35] moni-
tored 17 eumenorrheic women during 5 specific
days of one menstrual cycle (early follicular, late
follicular, mid-luteal, late luteal and repeat of early
follicular) and were compared with 17 men. The
stated objective of this study was to determine
whether estradiol and progesterone levels are asso-
© 2006 Adis Data Information BV. All rights reserved.
857
ciated with increased anterior knee laxity. The popu-
lation of 17 women (mean age 21.7 years, range
17–29 years) was described as eumennorrheic, dem-
onstrating a normal monthly menstrual cycle. Ante-
rior-posterior knee laxity (KT1000™) and serum
concentrations of estradiol and progesterone were
measured in the women at the five aforementioned
timepoints matched with corresponding time inter-
vals to the male controls.
During the menstrual cycle before testing, the
women identified the first day of menses, used an
ovulation test to document the day of ovulation and
identified the day of the next cycle. For subjects
with a 28-day cycle length, the testing was per-
formed between day 1 and 3 (early follicular), be-
tween day 11 and 13 (late follicular), between day
20 and 22 (mid-luteal), between day 27 and 28 (late
luteal) and a repeat of day 1–3. Laxity measures
within each phase were examined (late follicular,
cycle days 11–13, was designated as ovulatory
phase for comparative purposes) and statistically
compared (table I). The authors reported no signifi-
cant difference in knee laxity across the menstrual
cycle in women and no change over time in men (p >
0.05). There was no relationship between estradiol
and progesterone fluctuation and knee laxity (p >
0.05). The authors reported greater knee laxity val-
ues in women compared with men (p = 0.01), con-
sistent with previous studies.[27-29]
One limitation of the study is the high rate of
exclusion (11 were excluded due to an anovulatory
cycle), leaving 17 eumenorrheic females. Further-
more, the female data were not randomised (which,
as described earlier, may have effects on serial KT
testing),[42] nor were the women randomly entered
into testing. Another potential restriction for result
interpretation was the self-report of menstrual histo-
ry. In addition, the use of ‘non-athletic’ women may
limit the ability to generalise these findings to the
athletic female population, which is the population
at increased risk for ACL injury. One examiner
made most, but not all, of the laxity measures. There
tends to be relatively high inter-rater variability in
KT arthrometer measurements.[42] Moreover, the au-
thors did not document the menstrual cycle during
the month of study with an ovulation kit. Consider-
ing variability between monthly menstrual cycles,
this method does not ensure that the cycles are the
Sports Med 2006; 36 (10)
858
same from one cycle to the next and that the mea-
surements were performed at peak estradiol concen-
trations. Lastly, the inter- and intra-rater error may
be increased with the KT1000™ knee arthrometer
compared with more recent arthrometers.[44,45] This
study did not report variability in the text; however,
error bars in the figures were indicative of low
variability and decreased chance of beta error.
3. Discussion
Six of nine studies reported no significant effect
of the menstrual cycle on ACL laxity as measured
by knee anterior motion using an instrumented ar-
thrometer.[26,33-37] However, the majority of studies
that did not find an effect either based their findings
on a single sampled day of the cycle, or randomly
sampled across the cycle without hormonal or cycle
landmark confirmation. This approach makes the
assumption that within a cycle all days represent an
equitable hormone milieu. Individual variation in
hormonal status was likely the greatest confounding
factor that obscured potential positive findings. Fur-
thermore, some women’s ligaments may be more
responsive to hormones than others, and this indi-
vidual variation may also have masked possible
significant findings.[46] However, despite these po-
tential sources of beta error, three studies did show
significant associations between the menstrual cycle
and anterior knee laxity.[25,38-40]
Three of the nine authors, Heitz et al.,[38] Deie et
al.[39] and Schultz et al.,[25,40] observed significant
positive effects of the menstrual cycle on knee laxity
(table I). Interestingly, these studies all reported the
same basic findings; that laxity increased during the
post-ovulatory phases of the cycle. This consistency
in finding is compelling considering the inter-indi-
vidual differences in hormonal fluctuation during a
so-called ‘normal’ cycle. Although these three stud-
ies make similar conclusions, there are consistent
limitations to these studies that limit the interpreta-
tion of their positive findings. Two of these three
studies are the earliest and most weakly designed
studies of those reviewed.[38,39]
A meta-analysis, which included data from all
nine reviewed studies, demonstrated a significant
effect of cycle phase on knee laxity (F-value =
56.59, p = 0.0001). The laxities measured at the
three menstrual cycle times were significantly dif-
© 2006 Adis Data Information BV. All rights reserved.
Zazulak et al.
ferent. In the analyses, the knee laxity data measured
at 10–14 days was >15–28 days, which was >1–9
days. However, the power to demonstrate these dif-
ferences is greatly increased by pooling the study
data and increasing the overall sample number. This
analysis is a very rudimentary approach because the
data represent repeat measures and we do not know
the intercorrelations of the three knee laxity out-
comes, since we grouped mean values for the data. It
is difficult to determine whether we would arrive at
the same conclusion if we were able to treat these
data as repeated measurements in the meta-analysis.
All three studies that reported significant associa-
tions between the menstrual cycle and anterior knee
laxity found the increased laxity during the ovulato-
ry and post-ovulatory (luteal) phases. The observed
increase in anterior translation does not coincide
with the majority of the published studies regarding
increased ACL injuries during the pre-ovulatory to
ovulatory phases of the menstrual cycle (figure
1).[1,6-10] The timing of increased laxity during mid-
cycle reported in these three studies[25,38,39] is consis-
tent with the epidemiological studies by Wojtys et
al.[9,10] who found an increased injury rate near mid-
cycle. Shultz et al.[25] discuss the hormonal influence
on ligaments and speculate that there may be a
possible delayed effect due to the turnover time of
the collagen fibrils. However, a direct connection
between anterior knee laxity and increased ACL
injury risk is not well established in the literature.[31]
Two additional studies, one that did find effects
of the cycle on laxity and one that did not, examined
the relationship between sex hormones and stiff-
ness.[23,25,26,40] There was not a consistent association
between stiffness and menstrual phase. However,
there were significant associations between the hor-
mone concentrations within an individual and that
individual’s knee stiffness or laxity as calculated by
an arthrometer measurement. In addition, despite
being very well conceived studies, the calculation of
stiffness used only two force values and was essen-
tially a stiffness index, or the reverse of the compli-
ance index often calculated with data from the
KT2000™ to determine the integrity of the ACL. As
such, the calculation of stiffness based only on this
difference in force divided into the change in trans-
lation between the two forces is an important limita-
tion of the studies.[23,26]
Sports Med 2006; 36 (10)
Menstrual Cycle Effects on Anterior Knee Laxity
Individual variation in the hormonal milieu with-
in a menstrual cycle and responsiveness to hor-
mones may be a factor in the reviewed studies. It is
possible that some women demonstrate large altera-
tions in laxity through the cycle while others demon-
strate little or none.[25] This would explain the corre-
lations observed between hormonal levels and knee
stiffness, and lack of statistically significant group
differences in anterior laxity observed across the
specific phases of the menstrual cycle. Any individ-
uality in how women respond to fluctuating concen-
trations of sex hormones would be especially impor-
tant in female athletes with menstrual dysfunction or
inconsistent cycles.[47] If menstrual dysfunction oc-
curs more frequently in female athletes than in the
normal population of women, comparing the results
of studies completed on non-athletic populations or
on women with ‘normal’, consistent menstrual cy-
cles may be unrealistic in a competitive athletic
population. All nine studies in this review included
only women with ‘normal’ cycles defined by some
range of days for the cycle. This criterion resulted in
a high number of subjects excluded due to irregular
cycles or anovulatory cycles. The reported range of
dysfunction is 3.4–66% in athletes, whereas rates of
2–5% have been reported in non-athletic women.[47]
The nine studies reviewed varied widely in the
athletic status of the women studied, which compro-
mised the homogeneity of the results of our system-
atic review. However, several studies had to exclude
a high number of women due to irregular cycles,
which necessitates further investigations on athletic
females to delineate potential menstrual cycle dif-
ference in athletes compared with those with cycles
closer to the mean length. This would help deter-
mine if the results measured in ‘non-athletic’ popu-
lations may be generalised to female athletes who
are at high risk of ACL injury. Ideally, future inves-
tigations would include women with varying cycle
lengths compared with controls on oral contracep-
tion to provide a clearer picture of how sex hor-
mones or menstrual cycle stage in a competitively
athletic population may influence knee laxity and
stiffness.
The timing of the potential effects of these sex
hormones on the physical properties of the ACL is
also not defined. For example, although collagen
turnover is relatively rapid, it remains unknown how
© 2006 Adis Data Information BV. All rights reserved.
859
long it takes the ACL to remodel and to effect a
change in strength, stiffness or laxity. Studies 7 and
8 reported relationships between estradiol and liga-
ment mechanical properties. The high inter-individ-
ual variability in the levels of hormone concentra-
tion and ACL/knee connective tissue strength lead
these authors to postulate that the relationship be-
tween sex hormones and strength/stiffness may be
due to fluctuating concentrations of circulating hor-
mones.[23,25,26,40] Therefore, a significant change in
an athlete’s hormonal milieu (e.g. amenorrhoea, oral
contraceptive use, menopause), may alter ACL
strength characteristics after a period of exposure to
that altered milieu. The rabbit data from Slauterbeck
et al.[18] support this theory. The treatment group of
ovariectomised white rabbits was exposed to high
levels of estrogen through silastic implants for ap-
proximately 1 month. Rabbits exposed to estradiol
had a lower load to failure than controls without
estradiol. Unfortunately, the timeframe required to
alter the strength characteristics of the ligament and
the potential relationship between ACL laxity and
failure strength are to date uncharacterised.
One strength of this systematic review was that a
KT1000™ or KT2000™ arthometer was used as the
measurement device in all nine of these studies.
However, a weakness of the comparison of these
different data sets is that the KT1000™ uses no
plotter and requires the examiner to compare tones
(indicating a specific load) with values on an ana-
logue dial. The KT2000™ uses the XY plotter with
the latest derivation (the Compu-KT) using comput-
er software. The literature demonstrates the KT is
reliable if used by experienced examiners and with
appropriate subject set-up and education.[42] Howev-
er, KT arthrometers have the potential to provide
variable findings from the same individual subject.
Wroble et al.[42] demonstrated a modified ‘learning
effect’, due presumably to muscular ‘guarding’ dur-
ing initial testing. As the patient is repeatedly tested,
they tend to relax and greater translation can result.
Therefore, the finding of increases at later stages in
the cycle may have been due to this effect, if the
testing order among phases of the cycle was not
randomised. Only one study randomised phase test-
ing order, [26] one counterbalanced,[25] while seven
of nine did not randomise testing order. Further-
more, the reliability of the testers was not consistent-
Sports Med 2006; 36 (10)
860
ly reported in all studies. Only one[25] of the three
studies[25,38,39] that found a statistically significant
association between laxity and cycle phase reported
reliability, while three[26,34,37] of six[26,33-37] that did
not find an association reported moderate to good
reliability.
There are several limitations to this systematic
review. For example, there were nine different study
designs that increased heterogeneity between stud-
ies. In addition, millimetres of laxity was not report-
ed in all nine studies. Two of the studies chose not to
report this parameter.[23,25,26,40] The two most recent
studies published stiffness indices, rather than laxity
measures.[23,25,26,40] The utility of a stiffness index
versus laxity taken at a specific load (which is
essentially stiffness at one force value) is that move-
ment in the toe region may not be indicative of the
tensile property but may be indicative of more about
the length of the ligaments, capsule, etc. What is
interesting is that when Shultz et al.,[25,40] eliminated
the total laxity and used only the ‘change’ in laxity,
they had a better fit for their model. This ‘change’
measure may actually be indicative of the tensile
properties of later linear region of the length tension
curve and may be more indicative of the property of
the tissue than laxity or length alone. However,
these authors are alone in their choice to look at
stiffness.[23,25,26,40]
4. Conclusions
This systematic review of the literature indicates
that the menstrual cycle may have a significant
effect on anterior knee laxity. Although six of nine
studies observed no significant effect of the cycle on
ligament laxity,[26,33-37] this lack of positive evidence
does not preclude potential effects of sex hormones
on ligament integrity. A meta-analysis, which in-
cluded data from all nine reviewed studies, demon-
strated a significant effect of cycle phase on knee
laxity (F-value = 56.59, p = 0.0001). The laxities
measured at the three menstrual cycle times were
significantly different, after taking into account the
study and the force. In the analyses, the knee laxity
data measured at 10–14 days was >15–28 days
which was >1–9 days.
Interindividual variation in cycle hormone fluc-
tuation may be the greatest challenge in performing
unbiased studies with minimal confounding vari-
© 2006 Adis Data Information BV. All rights reserved.
Zazulak et al.
ables to develop consistent and valid conclusions.
Most of the studies reviewed reported data that had
relatively high standard deviations, while three stud-
ies did not report their inter-subject variability.[34-36]
This variability may have masked potential positive
effects. Interestingly, all three studies that observed
differences in cycle phases reported increased laxity
during the ovulatory and luteal phases relative to the
follicular phase (table I).[8,13,38] This consistency of
finding is intriguing and may indicate that there is a
difference between the pre-ovulatory and post-ovu-
latory halves of the menstrual cycle. This finding
shows a mixed relationship to the injury data (figure
1). The injury data are more indicative of injuries
occurring during the pre-ovulatory half of the cy-
cle,[19,48] when the ACL (or knee) would be less lax
or demonstrate greater stiffness. However, the fol-
licular phase data of increased knee laxity do not
agree with the injury data. This contradictory rela-
tionship between the follicular phase laxity and inju-
ry findings may be further evidence that cycle-
dependent changes in hormone concentrations may
not consistently influence knee laxity, or possibly
that more injuries occur when the ligament is stiffer
rather than more lax. The effect may be variable
between individuals. Alternatively, the effects of the
menstrual cycle may be on the active restraints
(neuromuscular in nature) rather than the passive
restraints (ligament) on knee stability.
This systematic review of the literature shows
evidence of a menstrual cycle effect on anterior-
posterior laxity of the knee, though an unequivocal
test of this hypothesis has yet to be performed.
Future studies testing the relationship between the
menstrual cycle and potentially associated parame-
ters such as laxity, injury and neuromuscular control
should consider the limitations outlined in this sys-
tematic review and control for the many potential
biases and confounding factors. Power analyses
should be utilised in order to ensure that the chance
of beta error, or the acceptance of a negative finding
that is actually positive, is minimised. In addition,
measures that can have high inter-rater variability,
such as knee arthrometer measures, should employ a
single examiner. Appropriate control subjects
should be utilised, for example, women on oral
contraceptives, or pre-pubertal females who are not
experiencing the cyclic effects of hormonal fluctua-
Sports Med 2006; 36 (10)
Menstrual Cycle Effects on Anterior Knee Laxity
tion, could be used as negative controls. The sub-
jects should be entered into the studies at random
times in the cycle and standard and consistent data
acquisition and reporting methods should be
utilised, including serum analysis of hormone con-
centrations for the determination of cycle phase to
account for the wide cycle variability within and
between individuals, which is especially relevant for
the athletic population. Future studies should incor-
porate statistical models that do not require exclu-
sion of individuals based on cycle length and ran-
domly test for peak hormone concentrations. Using
these methods, new studies may unequivocally de-
termine the contributions of cyclic fluctuations of
hormones to knee ligament laxity.
Acknowledgements
The authors would like to acknowledge funding support
from National Institutes of Health Grant R01-AR049735-
01A1 (TEH). The authors would like to acknowledge the
assistance of Paul Succop, PhD, for statistical consultation
with the meta-analysis, Thom Guidone, PT, Carrie-Lynn
O’Donell, Tiffany Evans, Carmen Booth, DVM, PhD, and
Jeanette Vitello, PT, for assistance with the preparation and
review of the manuscript. The authors would also like to
thank the authors of these nine studies for their contributions
to answering this important question. The authors have no
conflicts of interest that are directly relevant to the content of
this review.
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Correspondence and offprints: Dr Timothy E. Hewett, Cin-
cinnati Children’s Hospital Research Foundation, MLC
10001, Sports Medicine Biodynamics Center, 3333 Burnet
Avenue, Cincinnati, OH 45229, USA.
E-mail: tim.hewett@cchmc.org
Sports Med 2006; 36 (10)