Periods & ACL Tears: Must Know Info To Reduce Injury
In this episode of the Unreal Results podcast, I’m talking about a topic that’s been on my mind as of late: the connection between the menstrual cycle and ACL tears. First & foremost, I truly believe that everyone, including non-healthcare providers & men, should understand the menstrual cycle and how it affects the body’s hormones. I challenge the general assumptions made about ligament laxity and when ligamentous injuries frequently occur by analyzing what’s actually happening during the menstrual cycle. I also talk about ALL of the ways that female athletes can reduce their risk of ACL tears and other ligamentous injuries. I hope that you’re able to have some excellent takeaways from this episode and share them with anyone that has a female in their life!
Resources Mentioned In This Episode:
The Period Repair Manual by Lara Briden*
Tina Haupert - CarrotsnCake on IG
Episode 58: The Whole Organism Approach w/ Dr. Nicole Cozean
Episode 49: Pain On The Sacrum
Episode 25: The Peripheral Heart
Episode 20: Reflexive Core Stability: Lessons From My Back Surgery - Part 3
Sacrum Pain - Relief Exercises You Haven't Tried... - YouTube Video
Research Articles
- Sensitivity of the fasciae to sex hormone levels: Modulation of collagen-I, collagen-III and fibrillin production
- The Menstrual Cycle, Sex Hormones, and Anterior Cruciate Ligament Injury
- Cyclic variations in multiplanar knee laxity influence landing biomechanics
- Sex differences in knee joint laxity change across the female menstrual cycle
- The effects of the menstrual cycle on anterior knee laxity: a systematic review
*This link is an Amazon affiliate link, meaning I earn a commission from any qualifying purchases that you make
Considering the viscera as a source of musculoskeletal pain and dysfunction is a great way to ensure a more true whole body approach to care, however it can be a bit overwhelming on where to start, which is exactly why I created the Visceral Referral Cheat Sheet. This FREE download will help you to learn the most common visceral referral patterns affecting the musculoskeletal system. Download it at www.unrealresultspod.com
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Anna Hartman: Hey there, and welcome. I'm Anna Hartman, and this is Unreal Results, a podcast where I help you get better outcomes and gain the confidence that you can help anyone, even the most complex cases. Join me as I teach about the influence of the visceral organs and the nervous system on movement, pain, and injuries, all while shifting the paradigm of what whole body assessment and treatment really looks like.
I'm glad you're here. Let's dive in.
Hello, hello, and welcome to another episode of the Unreal results podcast. Had a little unexpected week break because of audio issues. So sometimes things like that happen. I did send an email out to my list. So if you're on my list, you already heard the story, so it'll be quick. But, um, sometimes when tech things like that happen, You have two choices, right?
You can get all pissed and try to sit down and force it out and re record, force the content, force the content creation and um, be frustrated about it. Or you can Take a deep breath and realize that maybe it's the universe telling you that you can do better. I know that's sort of harsh, but I really believe that sometimes when things get deleted or not recorded, it's just because I, you know, can have the opportunity to do even better.
So I also took that as a sign of, You know what? I, it was kind of forced. I was squeezing it in last week, which, which also, like, re recording it would have been even more squeezed in, and just, uh, It was a busy week. Um, every week is a busy week, but I just waited until the last minute and, uh, decided, you know what?
I just need to take some time and space and like recollect my thoughts and we'll just take a week off and do it this week. So I'm hoping that this episode ends up better for you. Anyways, I'm going to talk about the same thing. It's still on my mind. It's been on my mind. I don't think it's necessarily like not going to be on my mind for a while.
It's a, big topic as well as I don't think that this necessarily this podcast is going to be a solution to the topic. It's hopefully going to provide you some insight with things maybe you didn't consider before and maybe, um, some thought processes on like, Where research could be directed. So if you work at a university or you collaborate with the university on studies like this, like you might want to listen to this podcast because it might consider a lens of you you've not considered before.
Right. That's, this is the whole purpose of this podcast is to expose athletic trainers and physical therapists and rehabilitation, you know, practitioners, coaches, everybody to a. true whole organism lens of view, one that considers the viscera and the nervous system as primary drivers for how the musculoskeletal system is functioning.
adapting is performing is like organizing itself. And so this topic this week, I'm going to be talking about, um, the incidence of ACL tears in female athletes and what role hormones and the, the pelvic viscera in general may play in leading to a lot of those You know, non contact ACL tears. I mean, it is, uh, I don't know if the right word is endemic and epidemic.
It is like a big problem. Despite, you know, the push towards ACL prevention programs, like You know, I first heard of an ACL prevention program looking at jumping and landing mechanics back in the early two thousands when I started my career. And so that's not new. I think it's still taking time to like roll out and get kids to buy into and like get parents to buy into and get the coaches to buy into, um, but those are, you know, and that's a whole nother conversation.
Is just because those programs are out there or the kids actually doing them and going through with them. I don't know that I don't work with, um. youth populations very often. I don't work even with female populations, to be frankly honest, like full disclaimer, I have very few female athletes. Um, but I am consulting right now for a soccer club in San Antonio, shout out Soccer Central, San Antonio.
And, um, one of their coaches, um, director of performance, or I'm not sure what her title is, but, uh, Nicole Rodriguez Who was a colleague of mine at exos. She was asking me questions around this because she's also working with the U S women's national team, and they obviously have players from multiple different teams across the world.
And so, you know, women are coming in with directions from their professional teams about how to adapt training loads and training competition around the menstrual cycle. And so she was asking me questions about it and I found it fascinating because Two, the other sort of like piece of this and why I'm interested in it is in 2018, I believe, yeah, 2018 at the Fascia Research Congress in Berlin, Carla Stecco presented her research on the estrogen receptors within the fascia, how the fascia was responding and In response to different hormones like estrogen, estradiol, fibrillin, and um, elastin, and what that meant from a myofascial pain standpoint, what that meant from a perhaps from a, um, stability or stiffness standpoint.
And so, you know, that was really interesting work to really powerful work. Um, she was not the first person to talk about estrogen receptors, sex hormone receptors being in the tissue. It was already found that, um, those receptors are in ligaments in muscles in, um, tendons. Um, but this obviously her work was talking about this role in the fascia as well.
So, you know, there, there's, it's information, interesting information around that, that I want to present to. And then I think another piece of this and why I wanted to do a podcast is there's just a, also a underlying Misunderstanding of the menstrual cycle in general, and you may be surprised to learn how few females and males know what a normal menstrual cycle is.
And to me, this is like, Fundamental biology, biological information that we should all know because either one, it's affecting your own body to you're a male who it's affecting the bodies of your, the females in your life, whether that be family members or whether that be athletes that you're coaching.
And so it's to me, I think, like, why wouldn't you want to understand it, you know? And so, there's a fundamental misunderstanding of what the menstrual cycle is. Often, I think, when you say menstrual cycle, people think that that is the days you are on your period, right? That you're actually bleeding. And your menstrual cycle is the cycle that the hormones go through throughout our whole month, right?
Our menstrual cycle is a monthly cycle. Cycle similar to like the lunar cycle. It's anywhere between 25 and 35 days, you know, typically people will say like 28 to 30 days is a menstrual cycle. And so I want to talk about that too, because. You know, I remember, well, first of all, full disclaimer, I just learned about this.
I read Laura Bryden's book, The Period Repair Manual, back in like maybe 2020, and I was, when I, when I recorded this podcast last week, and I was putting the links in, which I will link that book in the show notes, so, well, Joe will link that book in the show notes. Um, when I, um, I was trying to remember when I read the book and, and I, I saw when it was published and I think it was only published in like 2019 or 2018.
And so I'm like, well, I guess that answers my question when I read it because, um, I was thinking it was longer than that, but yeah, it was 2020, 2021 when I read it. And I remember reading it and looking at my sister and being like, oh my gosh, like I think every, Everyone should, this should be required reading for everyone.
Because basically, you know, she explains what the menstrual cycle is, what the different phases of it is, and what the symptoms of a dysregulated menstrual cycle are. And it talks a lot about how in society most women are put on oral contraceptives really early on, sometimes more to control dysregulated menstrual cycle.
versus actually for contraceptive needs. And so what happens is you have women who have dysfunctional menstrual cycles, put them on medicine, which makes them, which is a hormone replacement therapy basically. And it, it mimics a monthly bleed. So it mimics a healthy or functional cycle. And then they go for years on that and then they come off of it.
And what they're left with is the still dysregulated menstrual cycle that they had in the beginning or even worse off, right? And so, and understanding that, like, there's a lot of things nutritionally, mineral wise, that we can do to sort of make our, cycle healthier before we jump to oral contraceptives, if at all need to jump to oral contraceptives from a standpoint of making our symptoms better versus using them for actual birth control.
That's a whole nother conversation. But, um, It was a really interesting read and, and when I, when I read that book and I started talking to my sister and my friends about it, I was actually shocked but not shocked to find that when I was using words of the phases of the mental cycle, which I mean arguably I learned in school, it's not like we didn't learn this in school, but it wasn't As many things in classes in college and in high school, when they're not actually practically applied to real life, we don't place value on really truly learning them and it goes in one ear and out the other.
Right? And so when I started using words like, um, follicular phase and luteal or luteal phase, like People are like, what, what are you talking about? And so that's why I feel like, like, let's start there. Like, let's talk about the menstrual cycle, the cycle of our sex hormones. As we go through that month, we'll call it a month just for lack of, uh, you know, ease of talking, but basically the cycle begins on the first day of your bleed and then.
Um, that also is the follicular phase. And the follicular, um, the, the follicular phase is the phase at which we're getting ready to let go of the follicle or the egg, right? And so the follicular phase leads up to ovulation or the ovulatory phase, if you want to call it its own phase. So ovulation happens around the middle of the cycle.
It can be, you know, shifted either direction, right? A little bit more on one end or the other. But for sake of conversation, we'll just say it's like mid cycle. So if it's a 28 day cycle, ovulation usually happens on day 14. So at the beginning of our cycle, while we're menstruating, or we're bleeding, during the follicular phase.
the hormones, the sex hormones, all of them are at their lowest levels. This symptom wise is why oftentimes when you are on your period, you have a higher libido because while the estrogen, progesterone, luteinizing hormone, and follicular stimulating hormone are low, they are not countering testosterone.
So testosterone sort of stays relatively, I think relatively. the same for a female. So, but as these drop out, we get the feelings from the testosterone a lot more, which often are equated with a higher libido. So, um, as we progress towards ovulation, our hormones start to rise, our estrogen starts to rise, our progesterone starts to rise, FSH follicular stimulating hormone starts to rise.
That's what stimulates the release of the egg from the ovary into the fallopian tube. And then that moment when that happens, that's ovulation. And then that begins the beginning of the next phase of the menstrual cycle, which is the luteal phase. The luteal phase is when the progesterone gets really high.
And then the estrogen and the luteinizing hormone and the FSH all start to slowly decline. And then if we don't fertilize the egg, then the progesterone drops out as well to meet us back at that beginning of the cycle, the lowest hormones. And so, um, the interesting pieces of this, I'd say if you asked a lot of people when they thought estrogen was a highest, they'd probably say during the actual bleed or the period itself.
And that's not true. It's actually when it's at the lowest. And so, um, this is, this, you know, is like part one of this podcast is when we're not understanding the function. of the organs. Um, we're misunderstanding a lot of the new research out there, as well as like extrapolating information about the research and about the hormones in the wrong way.
And the best example of this is sort of going back to this initial conversation that started this, started this, is people are understanding, because many research articles has shown that estrogen, the effects of estrogens on the tissues increases laxity. And this is something we also fundamentally know because when women are pregnant, part of what needs to happen and allow them to give birth to the baby is we get a high amount of like relaxin hormone causing more laxity of the joints, more laxity of the tissue, you know, fundamentally to get the baby out of the freaking pelvis.
And we need that to happen. And so this is, you know, understood and then shown in the research many times that they're uh, like we talked about in the beginning that there's these estrogen and progesterone, like these sex hormone, um, the relaxin, these sex hormone receptors on the tissue in females that are not there on the males that affect the stiffness of the tissue and the overall laxity or stiffness of the tissue.
And so. That is pointed to as a reason why women may be more likely to have ligamentous laxity and injuries around ligaments getting torn like an ACL tear. And so, Makes sense fundamentally, right? And so that's part of the argument of like doing these strengthening programs and working on the landing mechanics is to decrease, you know, the tendency for, um, the joints and the ligaments to be at risk because they're already, like, statically at risk because of these hormones.
And so the thought process is to strengthen things and increase myofascial stiffness to, you know, and improve motor control so that we're not in the positions that lead to such, you know, high forces on the already lax ligaments, etc. Makes sense, except for when you look at some of the research articles, and when you look at what part of the cycle That women tend to tear their ACLs in more than others, and this is where understanding the cycle is important because then it makes you think, like, wait a second, that doesn't match up.
You would assume Based on the information that the hormones create the laxity that in the time of the month where your hormones are high, you would expect more laxity, which would be around ovulation. But what we see is actually you have more ACL injuries during the first few days of the cycle.
specifically day one and day two, when the hormones are actually at its lowest. So this is where it's like, um, this, this, we have to then find another thought process to why. So then we look at, I think, an interesting thing, that comes with the research too. And a little bit of, um,
like a little bit of the interestingness to, to this too. Like, first of all, let me like go back a second and also like say, I'm not an expert. I'm not an expert in reading research. I'm not an expert in this specific like topic, but I know enough to be dangerous, if that makes sense. I think, um, Some of the other interesting things is one of the things that they did find in the research was those females who were utilizing oral contraceptives had less laxity.
in their tissues. Interesting. As well as they had less of a variation of myofascial pain throughout the cycle. They had more of a low level of myofascial pain kind of throughout the whole month, but they didn't have spikes in myofascial pain like people not taking oral contraceptives who had significant increases of myofascial pain during the cycle.
their period during the first few days of their cycle. So that's interesting because Going back to that Carla Stecco article, uh, that she found in the fascia, she talks a lot about, um, how this may, this information may be a, like, piece of the myofascial pain. But most importantly, I think the most important sentence in the whole article to, at least to me, from like a symptom and a practicality, is she basically said that hor at the end of the day, hormonal imbalances.
damage myofascial tissue. So less of a focus on what hormones and what was going on in the tissue, more of a focus on when the hormones are dysregulated. When, when our menstrual cycle hormones are all out of whack, this seems to be causing more damage in the myofascial tissue. Which may then also lead to increases in pain and like theoretically it makes sense that it would lead to more problems with motor control and stiffness and Perhaps injuries, right?
So I think that's really helpful information because part of the thing that happens in the tissue is when it has these hormonal imbalances is a shift to a different type of collagen that is just a little bit weaker and more like inflammatory driven. So that was sort of like the thought process around that.
But what I see when I look at, when I look at all this data, when I look at all this data and I think practically, and of course like the way, the only way I can really think practically in, in terms of like What else could be going on is how powerful this lens of view that the viscera is the most important thing to the body.
And then, you know, if you I'll link it, well, I'll have Joe link in in the show notes, but the podcast that I did with Nicole Cozean, and we talked about the importance of the pelvic organs, especially like being like very high importance. One, we know that because they're in a hard frame. And then two, they're linked to survival.
of the species, which is a big deal, right? Um, These are really important organs and so when, when the body is protecting a really important organ, the, the musculoskeletal system organizes itself around the organ to protect the organ. And you could imagine in the pelvis, the pelvis is like one of those things.
Yes, it's a hard frame, but it's also a fairly exposed. And you feel this if you've ever had pelvic Pain with your menstrual cycle or any other sort of pelvic pain when something doesn't feel good down there even being Constipated or even have gas when you don't feel good down there Like everything in your body sort of tightens up and restricts movement to protect it and so I actually think that probably is a big driver of Maybe these, this higher incidence of ACL tears during the first few days of the menstrual cycle?
Because, because the incidence of myofascial pain is greater during this cycle too. And also, you tend to be more bloated. like fluid congested, like things just don't feel good down there. And so more than likely, these are the days that you see that shift in landing mechanics from a hip dominant standpoint to a knee dominant standpoint, because the structures around the hip, the structures around the pelvis are organizing themselves in a protective pattern around the uterus, around the ovaries, because they don't feel very good.
And I see this over and over and when people don't feel good in their pelvis, they tuck it under, they create a lot of tension there, right, posterior pelvic floor, which doesn't allow a lot of hip flexion, which doesn't allow a lot of like absorbing of forces, changes our respiratory rate, and respiratory, not just rate, but our respiratory like function, right, because if we, if our pelvic floor can't expand, our um, Respiratory diaphragm can't fully expand either because they work in unison together and so I think this is probably a big missing piece in the research and in the consideration of a ACL prevention program is the Is being able to teach, one, teach athletes about their cycle.
Two, like, have a true discussion of like, what oral contraceptives are doing and if it's the right move or not. Um, and three, whether or not you choose to go on them. Let's Try to diet, like, let's try to figure out why you're having these hormone imbalances and treat that. Because hormone imbalances, we know, damage the myofascial tissue, increase myofascial pain, which is going to set us up for a musculoskeletal system to be more organized around protecting the visceral organs than landing well and protecting the knee joint.
And so also not only do we need to educate, we also need to understand how movement and really simple drills can help the visceral organs in that area to feel better too. And maybe instead of the Instead of the strength cycling or the competition cycling being around load management, I don't think it's a load management problem.
It's a protection pattern problem. And so having something like the LTAP or even just the first test of the LTAP, the SI joint test to see is someone's SI joint moving or not? What's their hip mobility like? What's happening at their lumbopelvic complex? is, are they protecting for the uterus or the ovaries?
And then here's all these exercises that you can do to help that, to help mobilize these organs, to help decrease the pain associated with these organs, right? Maybe we put these exercises in as a strategy before training or strategy before competition, or, you know, have some like Real more specific like measurements before we're like feel comfortable about letting somebody go out and, and go through these positions that are gonna put them at risk for tear their ACL.
You know that. And that's like again, always goes back to what the athlete wants, but the athlete can only make an informed decision with all the information. And so I think they're missing some big information pieces here, even to be an active participant in their care and understand like, you know, I think.
A lot of times too, like, athletes. Female athletes don't like talking about, well, one, like the world doesn't like talking about being on people's period. There's still like so much shame connected to it and so much like embarrassment connected to it. And then they don't want to seem like weaker, right?
For like, not wanting to participate in training or competition because they don't feel good in their pelvis. And so they just sort of shut up and like do what's asked of them, take medicine to try to mask it, but that doesn't change the protective pattern. And then these are incidences that they might be, you know, in a position where they tear their ACL.
And I think if they knew the consequences, like they'd speak up more and not only knowing the consequences, but if they knew there was solutions to help. They would speak up more and so that's another part of it is like knowing that there's movements, there's exercises we can do to help a lot of pelvic pain and a lot of, um, things like this are important.
And then also fundamentally like doing better at figuring out people's hormonal imbalances and how, how to support them. Like in my own body again, like this is the best way that I can tell you my practical experience of it, you know. A year and a half ago, a year ago, a little over a year ago, I reached out to my friend, Tina Hopper at Carrots and Cake.
I'll have Joe link that in the show notes too. And I got, um, a Dutch test and I got, um, a HGMA test. Um, and that the HGMA test specifically was the best information and the most helpful thing I've ever done to help regulate my menstrual cycle. I am so much more comfortable throughout my cycle now, and my symptoms have completely diminished.
Now that I've cleaned up my minerals, so the HMA test is a hair test mineral analysis, and it looks at your hair, and it looks at the balance of your minerals, and for me, my potassium was so low, and that was causing a lot of these imbalances in my hormones, thyroid hormone, and my sex hormones, and when I cleaned that up, the bloating, the congestion, the Myofascial pain, visceral pain around the points of, around menstruation, and the luteal phase of my cycle totally went away, and spotting that I was having during ovulation totally went away, and here's the kicker, within one cycle, it was that easy, and I just think that a lot of doctors, a lot of practitioners sort of just like, oh, chalk it up as like, oh, it's just one of those female things.
Like it's hard to regulate your hormones or here, just take your birth control and it will fix itself. And it doesn't. And there are nutritional things that you can do that makes a big difference. There's manual therapy and movement that you can do that makes a big difference. Visceral manipulation is a great tool for that too.
Pelvic floor physical therapy is a great tool. There's so many tools out there that can actually help this and we just don't even realize it's an issue. And so that's what, that's what this podcast really wanted. It really was my goal is like one, to talk about the research a little bit, to see how like the assumptions about how the sex hormones relate to us.
Laxity are important, but we're missing the boat when we actually look at when the ACL tears occur and like what else could be going on. And when we see the body from this lens of view that the primary role in the musculoskeletal system is to protect the visceral organs, it makes sense then why we see a change of a landing mechanic, change of a movement pattern throughout the menstrual cycle for these women.
So. Hopefully that provides some insights. I'm going to link in the show notes. I've got all the things. I, I'm going to link the episode, uh, that Nicole and Nicole Cozean and I did. I'm going to link, um, a few different research articles for you to take a look at. I'll link the book from Laura Bryden, uh, link the, um, link the info to Tina Hoppert.
And then, you know, I'm going to do two, two other links to two other podcast episodes. One was part three of my low back podcast episode. And um, the other one was the link to the episode called the peripheral heart on the soleus because from a training standpoint now, now from a training standpoint, and I'm not going to go fully in depth on this because.
I don't want the podcast to be really long because we know that women are just more lax in general because of the hormones. What are we going to do about it? We need to increase stiffness. And the best way to increase stiffness is to lift heavier, make sure you're eating enough food and protein to create more muscle.
That's a huge piece. Most athletes, especially female athletes, under eat. And then also, Not only increasing general stiffness in our body by lifting heavier and building more muscle, right? Muscles and hypertrophy Muscles when they hypertrophy innately create more stiffness, but then also Making sure we don't leave out the soleus as a really important muscle to train that checks Tibial anterior translation a really important muscle when it comes to decelerating leaning mechanics I think we do a good job and looking at the glutes and looking at like the hip stabilizers But for like let's not forget that the soleus plays a huge role in this too.
And so like It needs to come from both directions, but at the end of the day too, we're not lifting heavy enough. I think lifting heavy enough and building strength, um, sometimes is probably more valuable or more important than practicing landing mechanics, but that's just my opinion. I'm a little bit of a meathead in that sense.
sense, but when you check out the low back episode, maybe it'll make a little bit more sense to you on why. So hopefully all the information was helpful. Like I said, my goal is to open people's eyes to this. Oh, and I will have Joe link. There's a couple of YouTube videos. Um, I have on decreasing, um, pelvic pain, specifically pain on the sacrum, really good for cramps, really good for supporting the pelvic viscera, just from a general movement standpoint.
That's it. Those are my thoughts for the record. This was a much more well organized version of the podcast from last week. So thank you, universe. And uh, yeah, I'm interested to see what you think. And, uh, Have a great day. We'll see you next week.