Comparison of anterior knee laxity, stiffness, genu recurvatum, and general joint laxity in the late follicular phase and the ovulatory phase of the menstrual cycle

The Effect of Sex Hormones on Joint Ligament Properties: A Systematic Review and Meta-analysis

BACKGROUND

Sex differences exist in injury rates, and one contributing factor may be sex hormone effects on the musculoskeletal system.

PURPOSE/HYPOTHESIS

The goal of this systematic review and meta-analysis was to understand the effects of sex hormones on ligaments in females as determined by preclinical and clinical studies. The hypothesis was that sex hormones would affect ligament mechanical properties, histological features, cellular function, and clinically measurable outcomes.

STUDY DESIGN

Systematic review and meta-analysis; Level of evidence, 4.

METHODS

A literature search of PubMed, PEDro, CINAHL, and CENTRAL was performed to identify preclinical and clinical studies assessing sex hormone effects on ligament properties. Overall, 2 independent reviewers performed title, abstract, and full-text screening. Rigor and reproducibility were assessed using the ARRIVE guidelines and the modified Downs and Black checklist. Meta-analyses were also performed.

RESULTS

There were 54 articles included in this review. The majority of studies focused on the anterior cruciate ligament (ACL; n = 27), the menstrual cycle (n = 23), and 17β-estradiol (n = 35). Meta-analyses revealed that there was no effect of the menstrual cycle on knee laxity or anterior tibial translation but that 17β-estradiol decreased the production of types I and III procollagen in ACL fibroblasts in vitro. In examining other ligaments, data suggest that sex hormone changes may affect the mechanical and cellular properties of the medial collateral ligament, intrapubic ligaments, hip ligaments, and ligamentum flavum. Additionally, the literature suggests that hormonal shifts that occur with oral contraceptive pill use, pregnancy, and menopause can affect ligament properties. These effects appear to be mediated, at least in part, by the hormone relaxin.

CONCLUSION

Of the sex hormones examined in this body of literature, 17β-estradiol and relaxin appear to have the most effect on both the mechanical and cellular properties of ligaments in females. The ACL, medial collateral ligament, intrapubic ligaments, hip ligaments, and ligamentum flavum may be impacted by changes in sex hormone concentrations. The menstrual cycle does not likely affect ligament laxity in a clinically meaningful way, but pregnancy, oral contraceptive pill use, and menopause may.

Significant differences in knee kinematics of healthy subjects with high and low anterior tibial laxity

BACKGROUND

Anterior tibial laxity is considered to be a risk factor for knee injuries, including anterior cruciate ligament ruptures. The anterior cruciate ligament reconstruction also aims to restore anterior tibial laxity. While anterior tibial laxity is considered to be linked to dynamic knee stability, the mechanisms connecting anterior tibial laxity to these stability issues are not fully understood. The purpose of this study was to investigate the kinematic alterations between different anterior tibial laxity in healthy subjects. We hypothesized that anterior tibial laxity affects the anteroposterior tibial displacement during dynamic movements.

METHODS

This study involved thirty-five healthy subjects. There were twenty males and fifteen females with an average age of 18.91 ± 0.78 years. Their knees were categorized into "Tight" (the smallest 50%) and "Lax" (the largest 50%) groups based on anterior tibial laxity measurements using a Kneelax3 arthrometer. Kinematic data were collected using a three-dimensional motion capture system when they performed level walking, upslope walking, and vertical jumping. The knee kinematics were recorded for statistical analysis. We used independent sample t-tests to analyze key kinematic differences between groups.

RESULTS

The "Lax" group exhibited increased posterior tibial translation during upslope walking (5.4 ± 2.22 mm at swing max flexion, p = 0.018) and vertical jumping (8.5 ± 2.78 mm at propulsion max flexion, p = 0.003; 7.6 ± 3.17 mm at landing max flexion, p = 0.019) than the "Tight" group. Significant differences in tibial internal rotation were observed during initial contact of the gait cycle of level walking (1.9° ± 0.95°, p = 0.049) and upslope walking (2.1° ± 1.03°, p = 0.041) in the "Lax" group compared to the "Tight" group. No significant differences in adduction/abduction or medial/lateral tibial translation were found between groups.

CONCLUSION

The study revealed that high anterior tibial laxity resulted in increased posterior tibial translation and tibial internal rotation. High anterior tibial laxity resulted in dynamic instability of knees during motions, especially in high-demanding activities like upslope or vertical jumping. However, further research is needed to explore the clinical functional effects of knee laxity.

Effect of Surgeon Volume on Mechanical Complications after Resection Arthroplasty with Articulating Spacer

Two-stage revision with an antibiotic-loaded cement articulating spacer is a standard treatment for chronic prosthetic knee infection (PKI); however, mechanical complications can occur during the spacer period. There is limited evidence on the association between surgeon volume and mechanical complications after resection arthroplasty (RA) using an articulating spacer. This study aimed to compare the rates of mechanical complications and reoperation after RA with articulating spacers by surgeons with high volumes (HV) and low volumes (LV) of RA performed and analyzed the risk factors for mechanical failure. The retrospective study investigated 203 patients treated with PKIs who underwent RA with articulating spacers and were divided according to the number of RAs performed by the surgeons: HV (≥14 RAs/year) or LV (<14 RAs/year). Rates of mechanical complications and reoperations were compared. Risk factors for mechanical complications were analyzed. Of the 203 patients, 105 and 98 were treated by two HV and six LV surgeons, respectively. The mechanical complication rate was lower in HV surgeons (3.8%) than in LV surgeons (36.7%) (p < 0.001). The reoperation rate for mechanical complications was lower in HV surgeons (0.9%) than in LV surgeons (24.5%) (p < 0.001). Additionally, 47.2% of patients required hinge knees after mechanical spacer failure. Medial proximal tibial angle < 87°, recurvatum angle > 5°, and the use of a tibial spacer without a cement stem extension were risk factors for mechanical complications. Based on these findings, we made the following three conclusions: (1) HV surgeons had a lower rate of mechanical complications and reoperation than LV surgeons; (2) mechanical complications increased the level of constraint in final revision knee arthroplasty; and (3) all surgeons should avoid tibial spacer varus malalignment and recurvatum deformity and always use a cement stem extension with a tibial spacer.

Changes in the mechanical properties of the thigh and lower leg muscle-tendon units during the early follicular and early luteal phases

Background

This study aimed to determine changes in the muscle and tendon stiffness of the thigh and lower leg muscle-tendon units during the early follicular and early luteal phases, and check for possible relations between muscle and tendon stiffness in each phase.

Methods

The sample consisted of 15 female university students with regular menstrual cycles. The basal body temperature method, ovulation kit, and salivary estradiol concentration measurement were used to estimate the early follicular and early luteal phases. A portable digital palpation device measured muscle-tendon stiffness in the early follicular and early luteal phases. The measurement sites were the rectus femoris (RF), vastus medialis (VM), patellar tendon (PT), medial head of gastrocnemius muscle, soleus muscle, and Achilles tendon.

Results

No statistically significant differences in the thigh and lower leg muscle-tendon unit stiffness were seen between the early follicular and early luteal phases. Significant positive correlations were found between the stiffness of the RF and PT (r = 0.608, p = 0.016) and between the VM and PT (r = 0.737, p = 0.002) during the early luteal phase.

Conclusion

The present results suggest that the stiffness of leg muscle-tendon units of the anterior thigh and posterior lower leg do not change between the early follicular and early luteal phases and that tendons may be stiffer in those women who have stiffer anterior thigh muscles during the early luteal phase.

Potential role of physical labor and cultural views of menstruation in high incidence of pelvic organ prolapse in Nepalese women: a comparative study across the menstrual cycle

Introduction

Pelvic organ prolapse (POP) is a significant health concern for young Nepali women, with potential risk factors including pelvic floor trauma from vaginal delivery and heavy lifting. The prevalence of symptomatic POP (SPOP) among nulliparous women in Nepal is 6%, while the general population of Nepali women aged 15-49 years reports a prevalence of 7%. Surprisingly, the average age of SPOP onset in Nepal is 27 years, challenging the assumption that postmenopausal age and vaginal delivery are the sole risk factors. This study aims to investigate the influence of increased intra-abdominal pressure (IAP) during lifting tasks on pelvic organ descent in Nepali women across different menstrual cycle stages.

Methods

The study included 22 asymptomatic Nepali women aged 18-30 years who regularly engage in heavy lifting. Intra-abdominal pressure was measured intra-vaginally during typical and simulated lifting tasks, which encompassed various scenarios such as ballistic lifting, ramped lifting, and pre-contraction of pelvic floor muscles, as well as coughing, Valsalva maneuver, and pelvic floor contractions. Pelvic floor displacement was recorded using transperineal ultrasound during menstruation, ovulation, and the mid-luteal phase.

Results

Results indicated that pelvic floor displacement was greater during menstruation than ovulation when performing a simulated ballistic lifting task (6.0 ± 1.6 mm vs. 5.1 ± 1.5 mm, p = 0.03, d = 0.6). However, there was no significant difference in pelvic floor displacement during lifting when the pelvic muscles were pre-contracted.

Conclusion

These findings suggest that lifting heavy loads during menstruation may increase the risk of stretching and injuring pelvic floor supportive tissues, potentially contributing to SPOP in young Nepali women. Pre-contracting pelvic floor muscles during lifting tasks may offer a protective effect. Understanding these factors could aid in developing targeted preventive measures and raising awareness about the impact of heavy lifting on pelvic floor health among Nepali women.

Menstrual Cycle and Sport Injuries: A Systematic Review

The presence of female athletes has only increased in recent years, as has the incidence of injuries in female sports activities. These injuries are conditioned by multiple factors, including hormonal agents. It is estimated that the menstrual cycle may be related to the predisposition to suffer an injury. However, a causal relationship has not yet been established. The aim of this study was to analyse the relationship between the menstrual cycle and injuries in female sports practice. A systematic search of the scientific literature available in PubMed, Medline, Scopus, Web of Science, and Sport Discus was carried out in January 2022. With 138 articles, only eight studies were found that met the selection criteria for this study. Peak estradiol is associated with increased laxity, strength, and poor use of neuromuscular control. Thus, the ovulatory phase is associated with an increased risk of injury. In conclusion, it seems that hormonal fluctuations throughout the menstrual cycle alter values such as laxity, strength, body temperature, and neuromuscular control, among others. This fact causes women to constantly adapt to hormonal variations, which exposes them to a higher risk of injury.

Sex differences in musculoskeletal injury and disease risks across the lifespan: Are there unique subsets of females at higher risk than males for these conditions at distinct stages of the life cycle?

Sex differences have been reported for diseases of the musculoskeletal system (MSK) as well as the risk for injuries to tissues of the MSK system. For females, some of these occur prior to the onset of puberty, following the onset of puberty, and following the onset of menopause. Therefore, they can occur across the lifespan. While some conditions are related to immune dysfunction, others are associated with specific tissues of the MSK more directly. Based on this life spectrum of sex differences in both risk for injury and onset of diseases, a role for sex hormones in the initiation and progression of this risk is somewhat variable. Sex hormone receptor expression and functioning can also vary with life events such as the menstrual cycle in females, with different tissues being affected. Furthermore, some sex hormone receptors can affect gene expression independent of sex hormones and some transitional events such as puberty are accompanied by epigenetic alterations that can further lead to sex differences in MSK gene regulation. Some of the sex differences in injury risk and the post-menopausal disease risk may be "imprinted" in the genomes of females and males during development and sex hormones and their consequences only modulators of such risks later in life as the sex hormone milieu changes. The purpose of this review is to discuss some of the relevant conditions associated with sex differences in risks for loss of MSK tissue integrity across the lifespan, and further discuss several of the implications of their variable relationship with sex hormones, their receptors and life events.

Relationship between Changes in Foot Arch and Sex Differences during the Menstrual Cycle

This study investigated the relationship between changes in foot characteristics and sex differences during the menstrual cycle in healthy male and female university students. We examined 10 female subjects and 14 male subjects. The menstrual cycle was divided into the three phases: the early follicular phase, ovulatory phase, and luteal phase via basal body temperature, an ovulation kit, and salivary estradiol and progesterone concentration measurements. Foot characteristics required for the calculation of the arch height index (AHI) were measured using a three-dimensional foot scanner under conditions of 10% and 50% weight-bearing loads. Arch height at 50% of foot length and truncated foot length were measured, and AHI was calculated by dividing arch height by truncated foot length. Arch height flexibility (AHF) was defined as the change in arch height from 10% weight-bearing load to 50% weight-bearing load. AHI was significantly lower in females than in males in the early follicular and ovulatory phases but did not differ significantly between males and females in each phase. AHF did not differ significantly between males and females in each phase. AHI and AHF showed no periodic fluctuation, suggesting that sex differences in AHF may be absent.

Menstrual Cycle Changes Joint Laxity in Females—Differences between Eumenorrhea and Oligomenorrhea

The purpose of this study was to investigate the changes in anterior knee laxity (AKL), stiffness, general joint laxity (GJL), and genu recurvatum (GR) during the menstrual cycle in female non-athletes and female athletes with normal and irregular menstrual cycles. Participants were 19 female non-athletes (eumenorrhea, n = 11; oligomenorrhea, n = 8) and 15 female athletes (eumenorrhea, n = 8; oligomenorrhea, n = 7). AKL was measured as the amount of anterior tibial displacement at 67 N–133 N. Stiffness was calculated as change in (Δ)force/Δ anterior displacement. The Beighton method was used to evaluate the GJL. The GR was measured as the maximum angle of passive knee joint extension. AKL, stiffness, GJL, and GR were measured twice in four phases during the menstrual cycle. Stiffness was significantly higher in oligomenorrhea groups than in eumenorrhea groups, although no significant differences between menstrual cycle phases were evident in female non-athletes. GR was significantly higher in the late follicular, ovulation, and luteal phases than in the early follicular phase, although no significant differences between groups were seen in female athletes. Estradiol may affect the stiffness of the periarticular muscles in the knee, suggesting that GR in female athletes may change during the menstrual cycle.