Injury Incidence Across the Menstrual Cycle in International Footballers

Injury Incidence, Severity, and Type Across the Menstrual Cycle in Female Footballers: A Prospective Three Season Cohort Study

PURPOSE

The aim of the study was to assess the influence of menstrual cycle phase on injury incidence, severity, and type in elite female professional footballers over three seasons.

METHODS

Time-loss injuries and menstrual cycle data were prospectively recorded for 26 elite female football players across three seasons. The menstrual cycle was categorized into four phases using a standardized model: menstruation (phase 1; P1), remainder of follicular phase (phase 2; P2), early luteal (phase 3; P3), and premenstrual phase (phase 4; P4). Injury incidence rates (IIR) and ratios (IIRR) were calculated for overall injuries, injury severity, type, contact vs noncontact, and game/training.

RESULTS

A total of 593 cycles across 13,390 d were tracked during the study, and 74 injuries from 26 players were eligible for analysis. When comparing IIR between phases (reference: P1), overall injury rates were highest in P4 (IIRR, 2.30 (95% confidence interval, 0.99-5.34; P = 0.05)). When examining rates by injury severity and type, IIR values were also highest in P4 for ≤7 d' time-loss (4.40 (0.93-20.76; P = 0.06)), muscle-specific (6.07 (1.34-27.43; P = 0.02)), and noncontact (3.05 (1.10-8.50; P = 0.03)) injuries. Muscle-specific (IIRR P3/P1, 5.07 (1.16-22.07; P = 0.03)) and ≤7 d' time-loss (4.47 (1.01-19.68; P = 0.05)) injury risk was also significantly higher in P3. Muscle injuries were the most prevalent subtype ( n = 41). No anterior cruciate ligament injuries were recorded across the monitoring period.

CONCLUSIONS

Injury risk was significantly elevated during the luteal phase of the menstrual cycle (P3 and P4) among elite female professional footballers. Further research is urgently needed to better understand the influence of the menstrual cycle on injury risk and to develop interventions to mitigate risk.

Ethical Risks of Systematic Menstrual Tracking in Sport

In this article it will be concluded that systematic menstrual tracking in women's sport has the potential to cause harm to athletes. Since the ruling of Dobbs v. Jackson Women's Health Organization (2022) in the United States, concerns regarding menstrual health tracking have arisen. Research suggests that the menstrual tracking of female athletes presents potential risks to "women's autonomy, privacy, and safety in sport" (Casto 2022, 1725). At present, the repercussions of systematic menstrual tracking are particularly under-scrutinized, and this paper seeks to combine novel research in the sport sciences with present ethical debates in the philosophy of sports. Utilizing Beauvoir's feminist philosophy (2011), this paper argues that systematic menstrual tracking may contribute to the wider system of women's oppression by exploiting female athletes, as well as enabling the internalization of submissive behaviour in cultures where athletes are expected to comply unquestioningly. Five policy recommendations are made concerning autonomy, informed consent, education, safeguarding and data access. The overall findings of this paper propose that a more in-depth understanding of the links between data, privacy, and the menstrual cycle are required by sports organizations and governing bodies if athletes are to be protected in a future where systematic menstrual tracking is inevitable.

Attentional, anticipatory and spatial cognition fluctuate throughout the menstrual cycle: Potential implications for female sport

Current research suggests that menstruating female athletes might be at greater risk of musculoskeletal injury in relation to hormonal changes throughout the menstrual cycle. A separate body of work suggests that spatial cognition might also fluctuate in a similar manner. Changes in spatial cognition could, in theory, be a contributing risk factor for injury, especially in fast-paced sports that require precise, millisecond accuracy in interactions with moving objects in the environment. However, existing theories surrounding causes for increased injury risk in menstruating females largely focus on biomechanical mechanisms, with little consideration of possible cognitive determinants of injury risk. Therefore, the aim of this proof-of-principle study was to explore whether menstruating females exhibit fluctuations in cognitive processes throughout their cycle on a novel sport-oriented cognitive test battery, designed to measure some of the mental processes putatively involved in these sporting situations. A total of 394 participants completed an online cognitive battery, a mood scale and a symptom questionnaire twice, 14 days apart. After exclusions, 248 eligible participants were included in the analyses (mean: 28 ± 6 years) (male = 96, female(menstruating) = 105, female(contraception) = 47). Cycle phase for menstruating females was based on self-reported information. The cognitive battery was designed to measure reaction times, attention, visuospatial functions (including 3D mental rotation) and timing anticipation. Three composite scores were generated using factor analysis with varimax rotation (Errors, Reaction Time, Intra-Individual Variability). Mixed model ANOVAs and repeated measures ANOVAs were performed to test for between and within-subject effects. There was no group difference in reaction times and accuracy between males and females (using contraception and not). However, within subject analyses revealed that regularly menstruating females performed better during menstruation compared to being in any other phase, with faster reaction times (10ms c.ca, p < 0.01), fewer errors (p < 0.05) and lower dispersion intra-individual variability (p < 0.05). In contrast they exhibited slower reaction times (10ms c.ca, p < 0.01) and poorer timing anticipation (p < 0.01) in the luteal phase, and more errors in the predicted ovulatory phase (p < 0.01). Self-reported mood, cognitive and physical symptoms were all worst during menstruation (p < 0.01), and a significant proportion of females felt that their symptoms were negatively affecting their cognitive performance during menstruation on testing day, which was incongruent with their actual performance. These findings suggest that visuospatial and anticipatory processes may fluctuate throughout the menstrual cycle in the general population, with better performance during the menstrual phase and poorer performance during the luteal phase. If these extend to associations between phase-specific cognitive performance and injury incidence, they would support a cognitive theory of determinants of injury risk in cycling female athletes, opening an opportunity to develop mitigation strategies where appropriate.

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.

Oral Contraception Use and Musculotendinous Injury in Young Female Patients: A Database Study

PURPOSE

The purpose of this study is to characterize the effect of sex and the influence of oral contraception usage on musculotendinous injury (MTI). Current literature suggests a disparity in the incidence of MTI between males and females. This may be attributed to inherent biological differences between the sexes, such as in the sex hormonal milieu. There is a lack of information associating sex hormone milieu and MTI.

METHODS

We searched the PearlDiver database (a for-fee healthcare database) for males, females taking oral contraceptives (OC), and eumenorrheic females not taking any form of hormonal contraceptives (non-OC) 18-39 yr old. The three populations were matched by age and body mass index. We queried the database for lower-extremity skeletal MTI diagnoses in these groups.

RESULTS

Each group contained 42,267 patients with orthopedic injuries. There were a total of 1476 (3.49%) skeletal MTI in the male group, 1078 (2.55%) in non-OC females, and 231 (0.55%) in OC females. Both the non-OC and the OC groups had a significantly smaller proportion of MTI than males ( P < 0.0001), and therefore these groups were less likely (adjusted odds ratios, 0.72 and 0.15, respectively) to experience MTI when controlled for potential covariates.

CONCLUSIONS

In this study, we show that females are less likely to develop MTI to total injuries, when compared with males, with OC using females being least likely followed by non-OC females. These results are consistent with other epidemiological studies; however, overall results in the literature are variable. This study adds to the emerging body of literature on sex hormone-influenced musculoskeletal injury but, more specifically, MTI, which have not been rigorously investigated.

'Considering the reality, I am very lucky': how professional players and staff perceive injury prevention and performance protection in women's football

OBJECTIVE

To explore the beliefs and perceptions of professional female footballers and staff regarding injury prevention and performance protection in professional women's football.

METHODS

This qualitative study applied semistructured interviews with 18 participants from 3 top-tier teams from 2 countries (Portugal and England) and 4 nationalities, including 2 physiotherapists, 5 players, 3 team doctors, 2 head coaches, 3 strength and conditioning coaches, 2 managers, and 1 head of performance. Data analysis applied constant comparison analysis, using principles of grounded theory. There were no major differences in the perspectives of players and staff, and the findings are presented together.

RESULTS

Identifying and reporting injuries and recognising potential injury risk factors were mentioned to influence the prevention of injury. Participants stated that the growth and evolution of women's football could influence injury risk. Before reaching the professional level, exposure to potential risk factors, such as lack of recovery, limited awareness and opportunities for prevention (eg, preventive exercises and load management strategies), was believed to impact players' injury risk. Players further described their experiences and the 'bumpy road' to becoming a professional player, their current context and potential future improvements for women's football regarding injury prevention and performance protection.

CONCLUSION

Professional female football players face different injury risks during different moments of their careers. According to elite players and staff, amateur and semiprofessionals have limited resources and lack injury prevention strategies. Professional players and staff perceived the current preventive measures as good and relied on the value of individualised care and a multidisciplinary approach. In the future, more resources and structured injury prevention strategies are needed in youth and non-professional levels of women's football to reduce injury risk and allow more players to reach their maximal performance.

Players', Head Coaches', And Medical Personnels' Knowledge, Understandings and Perceptions of Injuries and Injury Prevention in Elite-Level Women's Football in Ireland

BACKGROUND

To manage injuries effectively, players, head coaches, and medical personnel need to have excellent knowledge, attitudes, and behaviours in relation to the identification of risk factors for injuries, the implementation of injury prevention initiatives, as well as the implementation of effective injury management strategies. Understanding the injury context, whereby specific personal, environmental, and societal factors can influence the implementation of injury prevention initiatives and injury management strategies is critical to player welfare. To date, no qualitative research investigating the context of injuries, has been undertaken in elite-level women's football. The aim of our study was to explore the knowledge, attitudes, and behaviours of players, head coaches, and medical personnel in the Irish Women's National League (WNL) to injury prevention and injury management.

METHODS

We used qualitative research methods to explore the knowledge, attitudes, and behaviours of players, head coaches, and medical personnel in the Irish WNL to injury prevention and injury management. Semi-structured interviews were undertaken with 17 players, 8 medical personnel, and 7 head coaches in the Irish WNL. The data were analysed using thematic analysis. Our study is located within an interpretivist, constructivist research paradigm.

RESULTS

The participants had incomplete knowledge of common injuries in elite-level football, and many held beliefs about risk factors for injuries, such as menstrual cycle stage, which lacked evidence to support them. Jumping and landing exercises were commonly used to reduce the risk of injuries but evidence-based injury prevention exercises and programmes such as the Nordic hamstring curl, Copenhagen adduction exercise, and the FIFA 11+ were rarely mentioned. Overall, there was dissatisfaction amongst players with their medical care and strength and conditioning (S & C) support, with resultant inadequate communication between players, head coaches, and medical personnel.

CONCLUSION

Poor quality and availability of medical care and S & C support were considered to be a major obstacle in the effective implementation of injury risk reduction strategies and successful return-to-sport practices. More original research is required in elite-level women's football to explore injury risk factors, injury prevention initiatives, and contextual return-to-sport strategies, so that players, head coaches, and medical personnel can use evidence that is both up-to-date and specific to their environment.

"I hardly have a problem […] I have my period quite rarely too": Female football players' and their coaches' perceptions of barriers to communication on menstrual cycle

Introduction

Symptoms related to the menstrual cycle (MC) affect the performance level and health of female athletes in various ways. Previous research has reported MC symptoms such as pain, mood disturbance, reduced coordination and competition distraction as well as diminished performance levels and an increased injury risk among female elite athletes. Despite this, the coach-athlete communication related to the female hormonal cycle is limited. The aim of the present study was to explore the perceptions of MC communication in a group of junior elite football players and their male coaches in a case study of one youth football team in a specific club in Norway.

Methods

The study used a qualitative approach with semi-structured interviews. In total, 8 female junior elite players (aged 16-20) from a Norwegian football team and 2 of their male coaches participated in the study.

Results

The data analysis revealed two main communication barriers: 1. interpersonal barriers (e.g., false assumptions about the coach/athletes and social discomfort) and 2. knowledge barriers (e.g., unaware/perceptions of insufficient knowledge levels).

Discussion

As the players seemed to be unaware of their insufficient MC knowledge (e.g., failed to see a connection between the MC and their health and performance level), the coaches perceived their knowledge as insufficient and coped mainly by outsourcing MC communication to female staff and apps. Hence, the MC communication was hindered by both the athletes and the coaches (e.g., mutual avoidance). In line with previous research, this study supports that there is a need for developing effective strategies to overcome the interpersonal barriers and knowledge gaps.

The menstrual cycle and football: The experiences of African women football players

BACKGROUND

The menstrual cycle is a normal biological process in women and girls. However, it is often the reason why they tend to be excluded from football medicine research. Consequently, our understanding of the menstrual cycle and football performance is still limited, especially in African women football players.

AIM

The study aimed to explore African women football players' current and historical menstrual cycle status, menstrual symptoms, lived experiences, and perceptions of the menstrual cycle.

METHODS

Women football players at the COSAFA Women's Championship 2020 completed demographic questionnaires and the Moos Menstrual Distress Questionnaire.

RESULTS

The main findings were that 90% of the players did not use contraceptives, . Most of the players had access to their preferred choice of sanitary product; however, 36% used alternatives such as old rags during their periods, . The most commonly reported symptoms during menses were abdominal cramps (53%), headache (41%), mood swings (41%) and irritability (47%). Further, players reported irritability (48%), mood swings (52%), and breast tenderness (48%) in the week before their period.

CONCLUSION

The low use of contraceptives is likely due to community level socio-cultural factors. While the use of old rags as impromptu sanitary products is likely because they cannot always afford their preferred choice. Menstrual symptoms can affect training and competition; therefore, team support personnel should be aware of the menstrual cycle's implications for African women football players and their effect on athletic performance and well-being. Additionally, team support personnel ought to be mindful of African women football players' socio-economic and religio-cultural contexts and their interaction with biological processes such as the menstrual cycle and contraceptive use.

Factors influencing performance and injury risk in elite female Gaelic team sport players and future research directions: a narrative review

Background

Sports science research in elite female Gaelic team sports has increased in recent years, but still a large disparity exists between the volume of studies involving male and female players. As a consequence of this, it is difficult for practitioners to develop an evidence-based approach when working with female players.

Main body

In this review, we discuss the current research available in elite female Gaelic team sports with focus on seven specific areas including physical and physiological demands, anthropometric and performance characteristics, injury risk, nutritional considerations, and female physiology. There appears to be unique physical demands data in match play across positions in Camogie, however, there is currently no comparative data available in ladies Gaelic football. Similarly, there is no research available on the physiological demands of both elite female Gaelic team sports. According to existing literature, performance characteristics such as speed and power are lower in this population compared to other elite female team sports. Although data is limited, the anthropometric characteristics of elite female Gaelic team sport players appear homogenous with some positional differences observed at a sub-elite level. Previous research has demonstrated a high prevalence of lower limb injuries in female elite Gaelic team sports and the provision of quality, evidence-based strength & conditioning could help mitigate these injury risks. Female Gaelic team sport players have been shown to have poor nutrition knowledge and inadequate intakes of micronutrients. Finally, although menstrual cycle phase and oral contraceptives have been shown to influence performance in other female intermittent sports, to date there has not been any research carried out in elite female Gaelic team sport players.

Conclusions

It is evident that limited research has been carried out on elite female Gaelic sport players. More up-to-date, high-quality investigations are needed to address the research gaps, which in turn should enable practitioners in the field to apply sound, evidence-based practice/theory when working with this population.

Tendinopathy: sex bias starts from the preclinical development of tendon treatments. A systematic review

Tendinopathies are common overuse disorders that arise both in athletes and the general population. Available tendon treatments are used both for women and men without distinction. However, the existence of a sex-based difference in tendon biology is widely demonstrated. Since basic research represents the foundation for treatment development, an equal female–male representation should be pursued in preclinical studies. This systematic review quantified the current evidence by analyzing 150 studies on 8231 animals. Preclinical studies largely neglected the importance of sex, none analyzed sex-based differences, and only 4% of the studies reported disaggregated data suitable for the analysis of treatment results in males and females. There is an alarming female under-representation, in particular in the field of injective therapies. Despite the growing awareness on the importance of investigating treatments in both males and females, the investigated field proved resistant from properly designing studies including both sexes, and the lack of sex-representation remains critical.

Tendinopathy has sex-specific features, with sex hormones affecting tendon metabolism, structure, biomechanical properties, and injury risk.

The preclinical research on tendinopathy treatments still neglects sex-based differences, leading to translation of male data to females which may affect clinical effectiveness in women.

None of the reviewed studies looked at differences between sexes, and only 4% of the studies reported disaggregated data. Besides, female animals are under-represented.

The lack of sex-representation in tendinopathy research remains critical.

Relationship between Muscle Flexibility and Characteristics of Muscle Contraction in Healthy Women during Different Menstrual Phases

OBJECTIVE

Skeletal muscle function is vital for preventing injury during exercise. It has been reported that skeletal muscle function fluctuates with the menstrual cycle and is considered one of the causes of injury. This study aimed to clarify the relationship between muscle flexibility and muscle contraction characteristics and their changes with the menstrual cycle.

METHODS

The subjects were healthy women who voluntarily participated in the study through recruitment posters. Muscle flexibility was measured with the passive knee extension (PKE) test, isokinetic knee flexor strength, and the maximum muscle strength exertion angle under two conditions of 60°/s and 120°/s in dominant hamstrings. Additionally, their correlations were analyzed and compared between the menstrual and ovulatory phases.

RESULTS

Sixteen subjects (mean age: 20.56 ± 0.73 years; body mass index: 20.21 ± 1.60) participated in the study. Correlation analysis showed a significant negative correlation between PKE and the maximum muscle strength exertion angle under the condition of 60°/s during the menstrual phase (r = -0.54; p = 0.03). No significant difference was observed in the two-group comparison of the variables measured during the menstrual and ovulatory phases.

CONCLUSION

This study confirmed that the more flexible muscles generate the maximum strength at a more contracted position during the menstrual phase in women. In the future, it is necessary to examine the relationship between the results of this study and exercise performance and injury occurrence.

Screening Tests for Assessing Athletes at Risk of ACL Injury or Reinjury-A Scoping Review

Various tests are available to assess athletes for factors associated with their susceptibility and risk of anterior cruciate ligament (ACL) injury or reinjury; however, it is unclear which tests are clinically meaningful and what should be considered when using them. Therefore, the aim of this scoping review was to screen and summarize testing and to derive evidence-based recommendations for clinicians, practitioners and future research. Five databases were searched to identify studies addressing musculoskeletal morphology or functional-performance-related screening tests with a clear conceptual link or an evidence-based relationship to ACL (re)injury. A quality rating was carried out using the National Institutes of Health (NIH) Study-Quality Assessment Tool. Six different categories of common screening tests were identified: balance and postural control, gait- and running-related tests, joint laxity, joint morphology and anthropometrics, jump tests and strength tests. Predicting future injury in a complex, dynamic system based on a single screening test is methodologically challenging, which is also reflected in the highly controversial findings in the literature regarding potential associations between specific screening tests and the occurrence of ACL injuries and reinjuries. Nonetheless, various screening tests can provide clinically relevant information on ACL-(re)injury-related factors and help to provide tailored preventive measures. A selection of corresponding evidence-based recommendations is derived and presented in this scoping review.

Insights in the Effect of Fluctuating Female Hormones on Injury Risk—Challenge and Chance

It is time to take on the challenge of investigating the complex effect of fluctuating female hormones on injury risk as this offers a chance to improve female athletes’ health and performance. During the recent decade, the body of knowledge on female hormones and injury risk has largely been increased. New insights have been offered regarding the association of certain phases of the menstrual cycle and injury prevalence as well as regarding relationships between hormone levels and musculoskeletal changes such as, for example, ligamentous stiffness and knee laxity. However, current research often follows the theme of a causal relationship between estrogen levels and musculoskeletal function or injury and thus—one might argue—further enhances a rather simplistic approach, instead of uncovering complex relationships which could help in establishing more nuanced ways of preventing female injuries. To uncover real effects and to truly understand the physiological responses, we suggest to reflect on potential bias regarding research questions and current approaches. It may enhance future studies to apply a more nuanced approach to causation, to include multidimensional perspectives and to implement an interdisciplinary methodology.

The Rise of the Female Warfighter: Physiology, Performance, and Future Directions

ABSTRACT

Since 1948, the United States military has been open to both men and women as permanent party service members. However, in the majority of the time since, there have been a subset of military occupational specialties (MOS), or job descriptions, open only to men. In particular, jobs requiring more intense physical and/or environmental strain were considered to be beyond the physiological capabilities of women. In the present analysis, we review the literature regarding neuromuscular, physical performance, and environmental physiology in women, to highlight that women have no inherent limitation in their capacity to participate in relevant roles and jobs within the military, within accepted guidelines to promote risk mitigation across sexes. First, we discuss performance and injury risk: both neuromuscular function and physical capabilities. Second, physiological responses to environmental stress. Third, we discuss risk as it relates to reproductive health and nutritional considerations. We conclude with a summary of current physiological, performance and injury risk data in men and women that support our overarching purpose, as well as suggestions for future directions.

Follicular phase of menstrual cycle is related to higher tendency to suffer from severe injuries among elite female futsal players

OBJECTIVE

To describe the injury incidence according to each phase of menstrual cycle (MC) in professional futsal players along two consecutive season and, secondly, to compare the injury incidence and frequency between different phases of the MC.

DESIGN

Prospective cohort study.

SETTINGS

Elite futsal players.

PARTICIPANTS

179 players.

MAIN OUTCOME MEASURE

Players were registered along two consecutive seasons.

RESULTS

191 injuries were reported throughout both seasons. The injury incidence was 30.63 days-off during the follicular phase, 23.6 during ovulatory phase and 17.59 days-off in luteal phase, showing higher incidence during the follicular phase. No statistical differences (p > 0.05) were reported for any variable comparing among the three phases of MC.

CONCLUSIONS

This study suggests the relevance to track the MC, but reduces its possible relationship or influence on the injury distribution during each phase of the MC. The knowledge of injury incidence, burden and etiology is a key factor to design injury prevention programs with the focus on the most common injuries, where MC could be included as a complementary factor.