Changes in the Width of the Tibiofibular Syndesmosis Related to Lower Extremity Joint Dynamics and Neuromuscular Coordination on Drop Landing During the Menstrual Cycle

Abstract

Background:Many injuries of the lower extremities, especially the knee and ankle, occur during sports activity, and the incidence rate is higher in women than in men.Hypothesis:The hypothesis was that phases of the menstrual cycle affect the width of the tibiofibular syndesmosis during drop landing in healthy young women and that such changes at the tibiofibular joint also affect the dynamics and neuromuscular coordination of the lower extremities.Study Design:Descriptive laboratory study.Methods:Participants included 28 healthy young women (mean age, 21.0 ± 0.8 years). Blood samples were collected to determine plasma levels of estradiol and progesterone immediately before the performance of the task: drop landing on a single leg from a 30-cm platform. Using ultrasonography, the distance between the tibia and the distal end of the fibula, regarded as the width of the tibiofibular syndesmosis, was measured in an upright position without flexion of the ankle. The peak ground-reaction force (GRF) on landing was measured using a force platform. The time to peak GRF (Tp-GRF) was measured as the time from initial ground contact to the peak GRF. Hip, knee, and ankle joint angles during the single-leg landing were calculated using a 3-dimensional motion analysis system. Muscle activities of the lower extremities were measured using surface electromyography.Results:The width of the tibiofibular syndesmosis was significantly greater in the luteal phase when compared with the menstrual, follicular, and ovulation phases (by 5%-8% of control). Also, during the luteal phase, the Tp-GRF was significantly shorter than in the follicular phase (by 6%); hip internal rotation and knee valgus were significantly greater than in the menstrual phase (by 43% and 34%, respectively); knee flexion was significantly less than in the menstrual and follicular phases (by 7%-9%); ankle dorsiflection was significantly less than in the follicular phase (by 11%); ankle adduction and eversion were significantly greater than in the menstrual and follicular phases (by 26%-46%, and 27%-33%, respectively); and activation of the gluteus maximus before landing was significantly lower than in the menstrual and follicular phases (by 20%-22%).Conclusion:The luteal phase appears to be associated with decreased strength and laxity of the ankle as well as lower extremity muscle activity in women. The changes presumably represent a greater risk for sports injuries.Clinical Relevance:The results of this study suggest that the luteal phase may be related to the greater incidence of lower extremity injuries in women.

Effects of the menstrual cycle phase on anterior cruciate ligament neuromuscular and biomechanical injury risk surrogates in eumenorrheic and naturally menstruating women: A systematic review

“…Seven studies met the inclusion criteria for this review [ 33 – 35 , 62 – 65 ]. An overview of the methodological quality assessment is provided in Table 2 , while study characteristics and findings are presented in Tables 3 and 4 .…”

“…An overview of the methodological quality assessment is provided in Table 2 , while study characteristics and findings are presented in Tables 3 and 4 . Sample sizes ranged from 10 to 71 [ 33 – 35 , 62 , 64 , 65 ], with Shultz et al [ 63 ] examining a substantially larger sample size of 71 compared to the next highest ( n = 28). Participant characteristics were generally poorly described across all studies with no study providing any information pertaining to specific sports, skill level, or resistance training history.…”

“…With respect to the effect of MC phase on neuromuscular and biomechanical non-contact ACL injury risk surrogates, four studies observed no significant or meaningful differences between MC phases [ 33 , 34 , 62 , 65 ], while two studies [ 35 , 64 ] showed evidence that the mid-luteal phase may predispose women to greater risk of non-contact ACL injury compared to the early and late follicular phase based on neuromuscular activity and landing kinematics. Two studies [ 33 , 34 ] showed that knee laxity fluctuated throughout the MC phases and the change in knee laxity was associated with changes in KJLs; however, considerable individual variation was observed with respect to the MC phase which elicited the greatest knee laxity and KJL.…”

“…Only one study randomised the testing order across MC phases [ 64 ], with three studies confirming that testing order was non-randomised [ 33 , 34 , 62 ]. The remaining studies did not verify if the testing order was randomised [ 35 , 63 , 65 ]. Only one study clearly stated that testing conditions were standardised between MC phases [ 65 ], while one study confirmed that the examiner was blinded to MC phase [ 35 ].…”

“…During ovulation (Phase 3; days 13–15), oestrogen is lower (medium concentration) than phase 2 but higher than phase 1 with low progesterone levels, whereas the mid-luteal days 20–23 (Phase 4; ~7 days post ovulation) contains the highest progesterone concentrations, with relatively high oestrogen levels (> phase 1 and 3 but < than 2) [ 25 , 26 , 30 ]. Due to the different concentrations of ovarian sex hormonal profiles throughout the MC, phases associated with increased oestrogen may impact soft tissue compliance [ 31 , 32 ], influence collagen formation and the tensile properties and integrity of ligaments (i.e., mechanical load tolerance) [ 33 – 35 ], impacting ligamentous and knee laxity [ 33 , 34 , 36 ], and neuromuscular function [ 24 , 27 , 30 , 37 , 38 ], and thus potentially increasing ACL injury susceptibility [ 39 , 40 ].…”