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Neuromuscular and Hormonal Factors Associated With Knee Injuries in Female Athletes

Strategies for Intervention

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Abstract

Female athletes who participate in jumping and cutting sports are 4 to 6 times more likely to sustain a serious knee injury than male athletes participating in the same sports. More than 30 000 serious knee injuries are projected to occur in female intercollegiate and high school athletics in the US each year. The majority of these injuries occur by non-contact mechanisms, most often during landing from a jump or making a lateral pivot while running. Knee instability, due possibly to decreased neuromuscular strength and coordination or increased ligamentous laxity, may underlie the increased incidence of knee injury in females. Neuromuscular training can significantly increase dynamic knee stability in female athletes. Female sex hormones (i.e. estrogen, progesterone and relaxin) fluctuate radically during the menstrual cycle and are reported to increase ligamentous laxity and decrease neuromuscular performance and, thus, are a possible cause of decreases in both passive and active knee stability in female athletes. Oral contraceptives stabilise hormone levels during the menstrual cycle and may function to either passively or actively stabilise the knee joint.

The long term objective of clinicians and researchers should be to determine the factors that make women more susceptible than men to knee ligament injury and to develop treatment modalities to aid in the prevention of these injuries. The immediate objectives of this review are to examine how female and male athletes differ in neuromuscular and ligamentous control of the lower extremity. The review will examine the effects of neuromuscular training on knee stability. The effects of female hormone levels and oral contraceptives on neuromuscular control of the female athletes’ knee will also be discussed.

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References

  1. Chandy TA, Grana WA. Secondary school athletic injury in boys and girls: a three-year comparison. Physician Sports Med 1985; 13 (3): 106–11

    Google Scholar 

  2. Ferretti A, Papandrea P, Conteduca F, et al. Knee ligament injuries in volleyball players. Am J Sports Med 1992; 20 (2): 203–7

    Article  PubMed  CAS  Google Scholar 

  3. Gerberich SG, Luhmann S, Finke C, et al. Analysis of severe injuries associated with volleyball activities. Physician Sports Med 1987; 15 (8): 75–9

    Google Scholar 

  4. Gray J, Taunton JE, McKenzie DC, et al. A survey of injuries to the anterior cruciate ligament of the knee in female basketball players. Int J Sports Med 1985; 6: 314–6

    Article  PubMed  CAS  Google Scholar 

  5. Hewett TE, Stroupe AL, Nance TA, et al. Plyometric training in female athletes: decreased impact forces and increased hamstring torques. Am J Sports Med 1996; 24 (6): 765–73

    Article  PubMed  CAS  Google Scholar 

  6. Huston LJ, Wojtys EM. Neuromuscular performance characteristics in elite female athletes. Am J Sports Med 1996; 24 (4): 427–36

    Article  PubMed  CAS  Google Scholar 

  7. Whiteside PA. Men’s and women’s injuries in comparable sports. Physician Sports Med 1980; 8 (3): 130–40

    Google Scholar 

  8. Zelisko JA, Noble HB, Porter M. A comparison of men’s and women’s professional basketball injuries. Am J Sports Med 1982; 10 (5): 297–9

    Article  PubMed  CAS  Google Scholar 

  9. 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): 694–701

    Article  PubMed  CAS  Google Scholar 

  10. The National Federation of State High School Associations. The 1996 National High School Sports Participation Survey. Kansas City (MO): The National Federation of State High School Associations, 1996

    Google Scholar 

  11. National Collegiate Athletic Association. NCAA injury surveillance system. Overland Park (KS): National Collegiate Athletic Association, 1993

    Google Scholar 

  12. Albohm M. How injuries occur in girls sports. Physician Sports Med 1976; 2: 46–8

    Google Scholar 

  13. Baratta R, Solomonow M, Zhou BH, et al. Muscular coactivation: the role of the antagonist musculature in maintaining knee stability. Am J Sports Med 1988; 16 (2): 113–22

    Article  PubMed  CAS  Google Scholar 

  14. Lindenfeld TN, Schmitt DJ, Hendy MP, et al. Incidence of injury in indoor soccer. Am J Sports Med 1994; 22 (3): 364–71

    Article  PubMed  CAS  Google Scholar 

  15. Malone TR, Hardaker WT, Garrett WE, et al. Relationship of gender to anterior cruciate ligament injuries in intercollegiate basketball players. J South Orthop Assoc 1993; 2 (1): 36–9

    Google Scholar 

  16. Freedman KB, Glasgow MT, Glasgow SG, et al. Anterior cruciate ligament injury and reconstruction among university students. Clin Orthop 1998; 356: 208–12

    Article  PubMed  Google Scholar 

  17. Hewett TE, Lindenfeld TN, Riccobene JV, et al. The effect of neuromuscular training on the incidence of knee injury in female athletes: a prospective study. Am J Sports Med 1999; 27 (6): 699–706

    PubMed  CAS  Google Scholar 

  18. Emerson RJ. Basketball injuries and the anterior cruciate ligament. Clin Sports Med 1993; 12 (2): 317–28

    PubMed  CAS  Google Scholar 

  19. Gomez E, DeLee JC, Farney WC. Incidence of injury in Texas girls’ high school basketball. Am J Sports Med 1996; 24 (5): 684–7

    Article  PubMed  CAS  Google Scholar 

  20. Haycock CE, Gillette JV. Susceptibility of women athletes to injury: myth vs. reality. JAMA 1976; 236 (2): 163–5

    Article  PubMed  CAS  Google Scholar 

  21. Hutchinson MR, Ireland ML. Knee injuries in female athletes. Sports Med 1995; 19 (4): 288–302

    Article  PubMed  CAS  Google Scholar 

  22. Shelbourne K, Davis T, Klootwyk T. The relationship between intercondylar notch width of the femur and the incidence of anterior cruciate ligament tears. Am J Sports Med 1998; 26: 402–8

    PubMed  CAS  Google Scholar 

  23. Daniel DM, Malcom LL, Losse G, et al. Instrumented measurement of anterior laxity of the knee. J Bone Joint Surg Am 1985; 67 (5): 720–6

    PubMed  CAS  Google Scholar 

  24. Weesner CL, Albohm MJ, Ritter MA. A comparison of anterior and posterior cruciate ligament laxity between female and male basketball players. Physician Sports Med 1986 14: 149–54

    Google Scholar 

  25. Sarwar R, Beltran NB, Rutherford OM. Changes in muscle strength, relaxation rate and fatiguability during the human menstrual cycle. J Physiol 1996; 493 (1): 267–72

    PubMed  CAS  Google Scholar 

  26. Booth FW, Tipton CM. Ligamentous strength measurements in pre-pubescent and pubescent rats. Growth 1970; 34 (2): 177–85

    PubMed  CAS  Google Scholar 

  27. Sanborn CF. Menstrual dysfunction in the female athlete. In: Teitz CC, editor. Scientific foundations of sports medicine. Philadelphia (PA): BC Decker, Inc., 1989: 117–34

    Google Scholar 

  28. Lebrun CM. The effect of the phase of the menstrual cycle and the birth control pill in athletic performance. Clin Sports Med 1994; 13 (2): 419–41

    PubMed  CAS  Google Scholar 

  29. Posthuma BW, Bass MJ, Bull SB, et al. Detecting changes in functional ability in women with premenstrual syndrome. Am J Obstet Gynecol 1987; 156 (2): 275–8

    PubMed  CAS  Google Scholar 

  30. Noyes FR, Mooar PA, Matthews DS, et al. The symptomatic anterior cruciate-deficient knee. Part I: the long-term functional disability in athletically active individuals. J Bone Joint Burg Am 1983; 65 (2): 154–62

    CAS  Google Scholar 

  31. Dufek JS, Bates BT. Biomechanical factors associated with injury during landing in jumping sports. Sports Med 1991; 12 (5): 326–37

    Article  PubMed  CAS  Google Scholar 

  32. More RC, Karras BT, Neiman R, et al. Hamstrings: an anterior cruciate ligament protagonist. An in vitro study. Am J Sports Med 1993; 21 (2): 231–7

    Article  PubMed  CAS  Google Scholar 

  33. Wojtys EM, Huston LJ, Lindenfeld TN, et al. Association between the menstrual cycle and anterior cruciate ligament injuries in female athletes. Am J Sports Med 1998; 26 (5): 614–9

    PubMed  CAS  Google Scholar 

  34. 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): 149–53

    Article  PubMed  CAS  Google Scholar 

  35. Moller-Nielson J, Hammar M. Women’s soccer injuries in relation to the menstrual cycle and oral contraceptive use. Med Sci Sports Exerc 1989; 21 (2): 126–9

    Google Scholar 

  36. Moller-Nielson J, Hammar M. Sports injuries and oral contraceptive use: is there a relationship? Sports Med 1991; 12 (3): 152–60

    Article  Google Scholar 

  37. Barrett GR, Hartzog CW Jr, Ruff CG. Clinical comparison of intra-articular anterior cruciate ligament reconstruction using autogenous semitendinous tendon in males versus females. 23rd Annual Meeting of the American Orthopaedic Society for Sports Medicine; 1997 Jun 22–25; Sun Valley (ID), 809–10

  38. Aglietti P, Buzzi R, Zaccherotti G, et al. Patellar tendon versus doubled semitendinosus and gracilis tendons for anterior cruciate ligament reconstruction. Am J Sports Med 1994; 22 (2): 211–8

    Article  PubMed  CAS  Google Scholar 

  39. Dunnam LO, Hunter GR, Williams BP, et al. Comprehensive evaluation of the University of Alabama at Birmingham women’s volleyball training program. NSCA J 1988; 10 (1): 50–2

    Google Scholar 

  40. Marsit JL, Kraemer WJ. Beginning off-season workout for high school volleyball. NSCA J 1992; 14 (3): 62–6

    Google Scholar 

  41. McGown CM, Coulee RK, Sucec AA, et al. Gold medal volleyball: the training program and physiological profile of the 1984 Olympic champions. Res Q Exerc Sport 1990; 61 (2): 196–200

    PubMed  CAS  Google Scholar 

  42. Traina SM, Bromberg DF. ACL injury patterns in women. Orthopedics 1997; 20 (6): 545–9

    PubMed  CAS  Google Scholar 

  43. Skelly WA, DeVita P. Compressive and shear forces on the tibia and knee during landing. In: Proceedings of the 6th Biennial Conference of the Canadian Society for Biomechanics. Montreal (QC): Canadian Society for Biomechanics, 1990: 59–60

    Google Scholar 

  44. Tibone JE, Antich TJ, Fanton GS, et al. Functional analysis of anterior cruciate ligament instability. Am J Sports Med 1986; 14 (4): 276–84

    Article  PubMed  CAS  Google Scholar 

  45. Knapik JJ, Bauman CL, Jones BH, et al. Preseason strength and flexibility imbalances associated with athletic injuries in female collegiate athletes. Am J Sports Med 1991; 19 (1): 76–81

    Article  PubMed  CAS  Google Scholar 

  46. Davies G. Compendium of isokinetics in clinical usage. 4th ed. La Crosse (WI): S&S Publishers, 1984

    Google Scholar 

  47. Schlinkman B. Nouns for high school football players derived from Cybex data reduction computer. J Orthop Sports Phys Ther 1984; 5 (5): 243–5

    PubMed  CAS  Google Scholar 

  48. Noyes FR, Schipplein OD, Andriacchi TP, et al. The anterior cruciate ligament-deficient knee with varus alignment: an analysis of gait adaptations and dynamic loadings. Am J Sports Med 1992; 20 (6): 707–16

    Article  PubMed  CAS  Google Scholar 

  49. Markolf KL, Graff-Redford A, Amstutz HC. In vivo knee stability: a quantitative assessment using an instrumented clinical testing apparatus. J Bone Joint Surg Am 1978; 60 (5): 664–74

    PubMed  CAS  Google Scholar 

  50. De Cree C, Ball P, Seidlitz B, et al. Responses of catecholestrogen metabolism to acute and graded exercise in normal menstruating women before and after training. J Clin Endocrinol Metab 1997; 82 (10): 3342–8

    Article  PubMed  Google Scholar 

  51. De Cree C, Ball P, Seidlitz B, et al. Effects of a training program on resting plasma 2-hydroxycatecholestrogen levels in eumenorrheic women. J Appl Physiol 1997; 83 (5): 1551–6

    PubMed  Google Scholar 

  52. Montagnani CF, Arena B, Maffulli N. Estradiol and progesterone during exercise in healthy women. Med Sci Sports Exerc 1992; 24 (7): 764–8

    PubMed  CAS  Google Scholar 

  53. Broocks A, Pirke KM, Schweiger U, et al. Cyclic ovarian function in recreational athletes. J Appl Physiol 1990; 68 (5): 2083–6

    PubMed  CAS  Google Scholar 

  54. 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): 3884–90

    Article  PubMed  CAS  Google Scholar 

  55. 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 (4): 526–33

    Article  PubMed  CAS  Google Scholar 

  56. Gill GN. Hormonal regulation of the ovary. In: West JB, editor. Best and Taylor’s physiological basis of medical practice. Baltimore (MD): Williams and Wilkins, 1985: 921–33

    Google Scholar 

  57. Florini JR. Hormonal control of muscle growth. Muscle Nerve 1986; 10: 577–98

    Article  Google Scholar 

  58. Lebrun CM. Effect of the different phases of the menstrual cycle and oral contraceptives on athletic performance. Sports Med 1993; 16 (6): 400–30

    Article  PubMed  CAS  Google Scholar 

  59. Hatcher RA. Contraceptive technology. 16th ed. New York (NY): Irvington Publishers Inc., 1994: 109–10

    Google Scholar 

  60. Caraffa A, Cerulli G, Projetti M, et al. Prevention of anterior cruciate ligament injuries in soccer: a prospective controlled study of proprioceptive training. Knee Surg Sports Traumatol Arthroscopy 1996; 4 (1): 19–21

    Article  CAS  Google Scholar 

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Acknowledgements

The author would like to thank Greg Myer for his critical reading of this manuscript, and Frank Noyes for his invaluable input and support.

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  1. Cincinnati Sportsmedicine Research and Education Foundation, Deaconess Hospital and University of Cincinnati, 311 Straight Street, Cincinnati, Ohio, 45219, USA

    Timothy E. Hewett

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Correspondence to Timothy E. Hewett.

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Hewett, T.E. Neuromuscular and Hormonal Factors Associated With Knee Injuries in Female Athletes. Sports Med 29, 313–327 (2000). https://doi.org/10.2165/00007256-200029050-00003

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