Menstrual cycle variations in oestradiol and progesterone have no impact on in vivo medial gastrocnemius tendon mechanical properties

Hormonal Fluctuation and Ankle Instability in Women-Is There a Correlation?

Background

With higher incidences of ankle sprains and chronic ankle instability in women, it has been postulated that hormonal modulation and ligamentous laxity influences injury propensity. The purpose of this study is to investigate the impact of hormonal fluctuation on ankle stability and ligamentous laxity and their potential contribution to injury propensity in the female athlete.

Methods

In November 2023, a systematic review of the MEDLINE, Embase, and Cochrane Library databases was performed following PRISMA guidelines. Articles were included if they were published after the year 2000, evaluated outcomes related to the impact of hormones on ankle stability in healthy patients, and included menstrual tracking. The following search terms were used: "(sex or gender) AND (ankle stability)" and "(hormone) AND (ankle)."

Results

Thirteen articles were included, with 253 (76.4%) women at a weighted mean age of 21.9 ± 2.0 years (range, 20.0-25.9). Five studies evaluated postural sway and balance noting greater sway rates during ovulation compared with the follicular phase. Greater muscle tone (P < .001) was observed in the follicular phase than ovulation for the tibialis anterior, peroneus longus, and lateral gastrocnemius. Significantly higher ankle joint laxity was observed in ovulation (P = .016).

Conclusion

This review found that during ovulation, when estrogen peaks, subjects showed impaired balance with higher postural sway rates, greater ankle joint laxity, and decreased muscle and ligamentous tone and stiffness-an indicator of laxity. An underlying hormonally mediated etiology for the increased propensity to ankle instability in the female athlete is suggested. Syncing an athlete's workout type and intensity around menstrual cycle phase may be an advantageous strategy for injury prevention.

Postural sway is not affected by estrogen fluctuations during the menstrual cycle

When people stand still, they exhibit a phenomenon called postural sway, or spontaneous movement of the body's center of pressure, which is related to balance control. In general females show less sway than males, but this difference only begins to appear around puberty, pointing to different levels of sex hormones as one potential mechanism for sway sex differences. In this study, we followed cohorts of young females using oral contraceptives (n = 32) and not using oral contraceptives (n = 19), to investigate associations between estrogen availability and postural sway. All participants visited the lab four times over the putative 28-day menstrual cycle. At each visit, we performed blood draws to measure plasma estrogen (estradiol) levels, and tests of postural sway using a force plate. During late follicular and mid-luteal phase, estradiol levels were lower in participants using oral contraceptives (mean differences [95% CI], respectively: -231.33; [-800.44, 337.87]; -613.26; [-1333.60, 107.07] pmol/L; main effect p < 0.001), reflecting expected consequences of oral contraceptive use. Despite these differences, postural sway was not significantly different between participants who were using oral contraceptives and participants who were not (mean difference: 2.09 cm; 95% CI = [-1.05, 5.22]; p = 0.132). Overall, we found no significant effects of the estimated menstrual cycle phase-or absolute levels of estradiol-on postural sway.

Sex hormone-mediated change on muscle activation deactivation dynamics in young eumenorrheic women

The goal of the study was to characterize muscle activation/deactivation dynamics across the menstrual cycle in healthy young women. Twenty-two healthy eumenorrheic women (age: 27.0 ± 4.4 years; mean ± SD) were tested every other day for one menstrual cycle. Serum estradiol and progesterone were quantified at the time of testing. Peak torque (PT), time to peak torque (TPT), and half relaxation time (HRT) of soleus muscle twitch were measured. Muscle twitch was elicited by delivering 1 ms width electrical pulses to the tibial nerve at an intensity that generated a maximum motor response (S-100) and at supramaximal intensity (S-120; 1.2 × S-100). The analyses were performed for each menstrual cycle phase: 1) the follicular phase to analyze the effect of estradiol while the progesterone concentrations remained at low concentrations; 2) the luteal phase to analyze the effect of progesterone with background estradiol concentrations. In the follicular phase, there was no association of estradiol for PT, TPT, and HRT. In the luteal phase, while estradiol had no association on PT, TPT, and HRT, progesterone expressed a significant association with HRT reduction but no association on PT or TPT. Also, there was a significant estradiol and progesterone interaction for HRT. However, the regression parameters are nearly zero, suggesting that the change in HRT may not have an impact on muscle performance across the menstrual cycle but implications on other women's health conditions with elevated sex hormone concentrations, such as pregnancy, may prove critical.

Case Studies in Physiology: Adaptation of Loading-Bearing Tendons during Pregnancy

Pregnancy is characterized by hormone changes that could alter musculoskeletal (MSK) properties and temporarily increase soft tissue injury risk. Whilst the prevalence of MSK injuries in pregnancy has not yet proven itself to be a widespread problem, indirect evidence indicates an uptake in the prevalence of strength training and vigorous-intensity activity during pregnancy, which may result in increased MSK injury incidence. Combining this evidence with the association between sex hormones and MSK injury risk, we recognize the potential importance of this research area and believe the (prospective) examination of connective tissue properties in relation to hormonal changes in pregnancy are appropriate. Given the dearth of information on MSK adaptations to pregnancy, we present a variety of morphological, mechanical and functional tendon data from two consecutive pregnancies in one woman as a means of highlighting this under-researched topic. This data may be representative of the general pregnant population, or it may be highly individualized - more research is required for a better understanding of MSK adaptation and injury risk during and after pregnancy.

Acute Achilles Tendon Ruptures

There is an ever-evolving debate about the best treatment option for Achilles tendon ruptures. There was a relative consensus that operative treatment yielded the best outcomes. Much of this is based on results in athletic populations. Conservative treatment was considered only for the elderly and those with very inactive lifestyles. There has been an evolution, however, with more surgeons utilizing an aggressive functional rehabilitation with conservative management. Surgical intervention still is the treatment of choice for elite-level athletes. The treatment of choice for patient populations other than elite athletes remains an individual choice between patient and physician.

Injury Incidence Across the Menstrual Cycle in International Footballers

Objectives: This study aimed to assess how menstrual cycle phase and extended menstrual cycle length influence the incidence of injuries in international footballers.

Methods: Over a 4-year period, injuries from England international footballers at training camps or matches were recorded, alongside self-reported information on menstrual cycle characteristics at the point of injury. Injuries in eumenorrheic players were categorized into early follicular, late follicular, or luteal phase. Frequencies were also compared between injuries recorded during the typical cycle and those that occurred after the cycle would be expected to have finished. Injury incidence rates (per 1,000 person days) and injury incidence rate ratios were calculated for each phase for all injuries and injuries stratified by type.

Results: One hundred fifty-six injuries from 113 players were eligible for analysis. Injury incidence rates per 1,000 person-days were 31.9 in the follicular, 46.8 in the late follicular, and 35.4 in the luteal phase, resulting in injury incidence rate ratios of 1.47 (Late follicular:Follicular), 1.11 (Luteal:Follicular), and 0.76 (Luteal:Late follicular). Injury incident rate ratios showed that muscle and tendon injury rates were 88% greater in the late follicular phase compared to the follicular phase, with muscle rupture/tear/strain/cramps and tendon injuries/ruptures occurring over twice as often during the late follicular phase compared to other phases 20% of injuries were reported as occurring when athletes were “overdue” menses.

Conclusion: Muscle and tendon injuries occurred almost twice as often in the late follicular phase compared to the early follicular or luteal phase. Injury risk may be elevated in typically eumenorrheic women in the days after their next menstruation was expected to start.

Comparison of the relative muscle volume of triceps surae among sprinters, runners, and untrained participants

Muscle hypertrophy is considered more prominent in fast‐twitch than in slow‐twitch muscles. This leads to the hypothesis that the relative muscle volume of the medial gastrocnemius (MG) and lateral gastrocnemius (LG) becomes larger than that of the soleus (SOL) in highly trained participants because MG and LG include more fast‐twitch muscles than SOL. Thus, we compared relative muscle volume among highly trained sprinters, long‐distance runners, and untrained participants to examine whether the above hypothesis is correct. Magnetic resonance imaging was used to calculate the muscle volume of MG, LG, and SOL from 126 participants. The total muscle volume of the three muscles and the relative muscle volume of each muscle with respect to the total muscle volume were calculated. The total muscle volume was significantly larger in the sprinters than in the long‐distance runners and untrained participants. The relative muscle volume of MG was significantly larger in the sprinters than in the long‐distance runners and untrained participants and that of SOL was significantly smaller in the sprinters than in the long‐distance runners and untrained participants. These results indicate that the relative muscle volume can vary among participants, possibly due to fiber type‐dependent muscle hypertrophy.

Supraspinatus Tendons Have Different Mechanical Properties Across Sex

Sex differences in the mechanical properties of different musculoskeletal tissues and their impact on tendon function and disease are becoming increasingly recognized. Tendon mechanical properties are influenced by the presence or absence of sex hormones and these effects appear to be tendon- or ligament-specific. The objective of this study was to determine how sex and hormone differences in rats affect supraspinatus tendon and muscle properties. We hypothesized that male supraspinatus tendons would have increased cross-sectional area but no differences in tendon material properties or muscle composition when compared to supraspinatus tendons from female or ovariectomized (OVX) female rats. Uninjured supraspinatus tendons and muscles from male, female, and OVX female rats were collected and mechanical and histological properties were determined. Our analysis demonstrated decreased dynamic modulus and increased hysteresis and cross-sectional area in male tendons. We found that male tendons exhibited decreased dynamic modulus (during low strain frequency sweep and high strain fatigue loading), increased hysteresis, and increased cross-sectional area compared to female and OVX female tendons. Despite robust mechanical differences, tendon cell density and shape, and muscle composition remained unchanged between groups. Interestingly, these differences were unique compared to previously reported sex differences in rat Achilles tendons, which further supports the concept that the effect of sex on tendon varies anatomically. These differences may partially provide a mechanistic explanation for the increased rate of acute supraspinatus tendon ruptures seen in young males.

Tissue biomechanical behavior should be considered in the risk assessment of perineal trauma at childbirth

Perineal trauma at childbirth is associated with strong negative impacts on a woman's health but remains unpredictable. Pregnancy induces several changes in biomechanical behavior in humans as in animals, namely, an increase in ligamentous laxity and an increase in vaginal distensibility. Pelvic floor muscles in rats are reported to exhibit specific behaviors during pregnancy. Increases in both stiffness and the number of sarcomeres in series are observed and might process that protect against perineal trauma at childbirth. Some data in humans have shown that the risk of perineal trauma is highly linked to the intrinsic characteristics of the tissue, suggesting the potential benefit of incorporating intrinsic biomechanical characteristics in the risk prediction for perineal trauma. Shear wave elastography might be a useful noninvasive tool to investigate the elastic properties of these tissues in pregnant women in vivo, with the goal of implementing these properties as a predictive strategy.

Menstrual cycle variation and gender difference in muscle stiffness of triceps surae

BACKGROUND

We aimed to investigate the menstrual cycle variation and the gender difference of the triceps surae muscle stiffness and passive stiffness of the ankle joint.

METHODS

The subjects of the study included 12 healthy young women and 12 healthy young men. Shear elastic moduli of the lateral gastrocnemius, medial gastrocnemius, and soleus muscles were measured as an index of muscle stiffness using shear wave elastography. The passive stiffness of the ankle joint was calculated from passive torque when the ankle joint was passively dorsiflexed. Measurements were conducted in the follicular, ovulatory, and luteal phases to examine the menstrual cycle variation.

FINDINGS

There was no difference noted in the passive stiffness or triceps surae muscle stiffness for young women in the menstrual cycle. As for gender differences, passive stiffness in all menstrual phases in women was lower while the soleus muscle stiffness in women was higher, compared to that in men.

INTERPRETATION

Our findings suggest that passive stiffness and muscle stiffness did not differ in the menstrual cycle. In addition, the measured part of the soleus was more tensioned in women than in men.

Constant performance in balance and proprioception tests across the menstrual cycle - a pilot study in well trained female ice hockey players on hormonal contraception

INTRODUCTION

It has yet to be explained why female athletes appear to suffer more often from non-contact ligament injuries during the first half of the menstrual cycle. Fluctuations in balance, caused by impaired proprioception due to increased fluid retention, may be relevant factors contributing to this anomaly in distribution. The aim of this study was therefore to uncover relationships between dynamic stability, proprioception and fluid retention in association with the menstrual cycle as a possible explanation for the observed changes in injury rates.

METHODS

Nine healthy, female, well trained ice hockey players on hormonal contraception with regular cycles were tested at least twelve times during one menstrual cycle. Bioimpedance analysis was applied to investigate body composition and fluid distribution. A joint position sense test was performed to characterize changes in proprioception, while unexpected perturbations on a balance board were used to obtain measures for dynamic postural control.

RESULTS

No distinct changes in proprioception, dynamic stability and fluid retention were identified across the menstrual cycle in this population. Weak correlations were found between parameters for dynamic stability and proprioception.

CONCLUSION

Variations in proprioception, dynamic stability and fluid retention seem unlikely to be major contributors to injury risk peaks, at least in this population of healthy trained athletes using hormonal contraception.

The effects of the menstrual cycle on the static balance in healthy young women

[Purpose] The purpose of this study was to investigate the effects of the menstrual cycle on the static balance of healthy young women. [Subjects and Methods] Eighteen healthy young subjects (mean age 19.1 years; weight 57.5 kg; height 159.9 cm) participated in this study. The Good Balance system was used to measure the postural sway speed and velocity moment of subjects in the static standing posture. Subjects were measured for static balance between 1 and 3 days after menstruation and 13 days after menstruation. [Results] The velocity moment of postural sway was significantly higher at 13 days after menstruation. [Conclusion] Our results indicate that the menstrual cycle affects the static balance of healthy subjects. During the menstrual cycle, intensity for balance exercises in females should be carefully controlled for injury prevention.

The effect of estrogen on tendon and ligament metabolism and function

Tendons and ligaments are crucial structures inside the musculoskeletal system. Still many issues in the treatment of tendon diseases and injuries have yet not been resolved sufficiently. In particular, the role of estrogen-like compound (ELC) in tendon biology has received until now little attention in modern research, despite ELC being a well-studied and important factor in the physiology of other parts of the musculoskeletal system. In this review we attempt to summarize the available information on this topic and to determine many open questions in this field.

Hormones and tendinopathies: the current evidence

BACKGROUND

Tendinopathies negatively affect the quality of life of millions of people, but we still do not know the factors involved in the development of tendon conditions.

SOURCES OF DATA

Published articles in English in PubMed and Google Scholar up to June 2015 about hormonal influence on tendinopathies onset. One hundred and two papers were included following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines.

AREAS OF AGREEMENT

In vitro and in vivo, tenocytes showed changes in their morphology and in their functional properties according to hormonal imbalances.

AREAS OF CONTROVERSY

Genetic pattern, sex, age and comorbidities can influence the hormonal effect on tendons.

GROWING POINTS

The increasing prevalence of metabolic disorders prompts to investigate the possible connection between metabolic problems and musculoskeletal diseases.

AREAS TIMELY FOR DEVELOPING RESEARCH

The influence of hormones on tendon structure and metabolism needs to be further investigated. If found to be significant, multidisciplinary preventive and therapeutic strategies should then be developed.

Achilles tendon biomechanics in response to acute intense exercise

Achilles tendinopathy is a common disorder and is more prevalent in men. Although differences in tendon mechanics between men and women have been reported, understanding of tendon mechanics in young active people is limited. Moreover, there is limited understanding of changes in tendon mechanics in response to acute exercise. Our purpose was to compare Achilles tendon mechanics in active young adult men and women at rest and after light and strenuous activity in the form of repeated jumping with an added load. Participants consisted of 17 men and 14 women (18-30 years) who were classified as being at least moderately physically active as defined by the International Physical Activity Questionnaire. Tendon force/elongation measures were obtained during an isometric plantarflexion contraction on an isokinetic dynamometer with simultaneous ultrasound imaging of the Achilles tendon approximate to the soleus myotendinous junction. Data were collected at rest, after a 10-minute treadmill walk, and after a fatigue protocol of 100 toe jumps performed in a Smith machine, with a load equaling 20% of body mass. We found greater tendon elongation, decreased stiffness, and lower Young's modulus only in women after the jumping exercise. Force and stress were not different between groups but decreased subsequent to the jumping exercise bout. In general, women had greater elongation and strain, less stiffness, and a lower Young's modulus during plantarflexor contraction. These data demonstrate differences in tendon mechanics between men and women and suggest a potential protective mechanism explaining the lower incidence of Achilles tendinopathy in women.

Characteristics and stimulation potential with BMP-2 and BMP-7 of tenocyte-like cells isolated from the rotator cuff of female donors

Tendon bone healing of the rotator cuff is often associated with non-healing or recurrent defects, which seems to be influenced by the patient’s age and sex. The present study aims to examine cellular biological characteristics of tenocyte-like cells that may contribute to this impaired rotator cuff healing. Moreover, a therapeutic approach using growth factors could possibly stimulate tendon bone healing. Therefore, our second aim was to identify patient groups who would particularly benefit from growth factor stimulation. Tenocyte-like cells isolated from supraspinatus tendons of female donors younger and older than 65 years of age were characterized with respect to different cellular biological parameters, such as cell density, cell count, marker expression, collagen-I protein synthesis, and stem cell potential. Furthermore, cells of the donor groups were stimulated with BMP-2 and BMP-7 (200 and 1000 ng/ml) in 3D-culture and analyzed for cell count, marker expression and collagen-I protein synthesis. Female donors older than 65 years of age showed significantly decreased cell count and collagen-I protein synthesis compared to cells from donors younger than 65 years. Cellular biological parameters including cell count, collagen-I and –III expression, and collagen-I protein synthesis of cells from both donor groups were stimulated with BMP-2 and BMP-7. The cells from donors older than 65 years revealed a decreased stimulation potential for cell count compared to the younger group. Cells from female donors older than 65 years of age showed inferior cellular biological characteristics. This may be one reason for a weaker healing potential observed in older female patients and should be taken into consideration for tendon bone healing of the rotator cuff.

Achilles tendon rupture in women

BACKGROUND

The incidence of Achilles rupture appears to be less in women, although this notion has not been specifically investigated in the literature.

METHODS

The medical records of 7 foot-and-ankle orthopaedic surgeons at 1 institution were reviewed by Current Procedural Terminology (code 27650) and International Classification of Diseases-9 (code 727.67) to establish all Achilles tendon ruptures seen and/or treated by these surgeons. Sex, age, side, and mechanism of injury were recorded. Whether the patient had an acute Achilles tendon rupture or nonacute Achilles pathology was also noted.

RESULTS

A total of 468 patients were identified, of whom 358 had acute ruptures: 302 male and 56 female (5.39:1). Patients with acute ruptures were significantly younger than those with nonacute pathology (43.8 vs 55.1, P < .001). For acute ruptures, the mean age was not significantly different between men and women (43.9 vs 43.2; P = .780). Athletic activity was causative in 243 of 302 men (80.5%) and in 40 of 56 women (71.4%). This difference was not statistically significant (P = .130). Six men (2.0%) and 6 women (10.7%) had comorbidities that were thought to increase their risk of rupture (P = .005).

CONCLUSION

Achilles tendon rupture is more common in men than women. Previous studies using the aforementioned codes to identify patients without chart review may have overestimated the number of women with acute Achilles tendon rupture.

LEVEL OF EVIDENCE

Level III, retrospective comparative series.

Serum relaxin levels affect the in vivo properties of some but not all tendons in normally menstruating young women

Relaxin (hRLX) is a hormone reported to affect collagen synthesis. Its effects are also thought to be modulated by other sex hormones, including oestrogen, which has previously been found to be associated with alterations of in vivo tendon properties. There is thus a potential for hRLX to impact on collagen, which could result in tendon structural and mechanical properties being modified. The present study therefore aimed to determine any interaction between hRLX and tendon stiffness, in normally menstruating women (n = 12). Tendon properties were determined using a combination of dynamometry and B-mode ultrasound, whilst serum hRLX levels were established by ELISA. Serum hRLX level was seen to be negatively associated with patellar tendon stiffness (r = -0.56; P < 0.001), explaining 31% of the variance in this parameter. There was no association between hRLX and gastrocnemius tendon stiffness (P > 0.05), or with the cross-sectional area of either of the two tendons (P > 0.05). In young, normally menstruating women, hRLX appears to have a significant effect on the patellar but not the gastrocnemius tendon stiffness. Where it has an effect, this appears to be on the intrinsic properties rather than on the dimensions of said tendon. Future work to elucidate the physiological cause of this selectivity in the impact of relaxin will be key to mapping the impact of the endocrine system on the phenotype of tendinous tissue.