Follow-up Letter to Pace Setter Readers

by Megan R. James, PT DPT, USATF-L2 (Immersion PT) and Robert Rehberger, PT DPT, OCS (Resolute Physical Therapy)

Photo courtesy of Megan James

The April issue of The Pace Setter included an article titled “Off the Road Column – the ACL” by Russ Ebbets, D.C. In this article, Dr. Ebbets presented some basic anatomy of the ACL and risk factors for injury. What this article lacked to discuss were specific action items for risk reduction, especially for the runner and female athlete; also the language used can be perceived as inappropriate from a medical professional, and demeaning toward a female athlete. As physical therapists who work with athletes, we (i.e. Megan R. James and Robert Rehberger) would like to offer further insight to our community related to this article.

First, we would like to provide recommendations for injury risk reduction, based on current available evidence:

  • Consistent sleep hygiene is essential

o   Less sleep is correlated with higher injury rates and poor sport performance in adolescents. The National Sleep Foundation recommends 7-9 hours/night for adults and 8-10 hours/night for adolescents. Additional recommendations include sleeping in a cool, dark room; avoiding use of electronics/technology in the hour before bed; and reducing or eliminating caffeine & alcohol intake in the afternoon.

o   Action item: set alarms/reminders for your final caffeine intake, end of technology use, and to go to bed.

  • Injury prevention programs should include strength, plyometrics & dynamic balance

o   Strength training reduces injury risk by up to 69% as compared to stretching (4% reduction). Programs that include plyometrics (e.g., box jumps, bounding, jump rope) have demonstrated an injury risk reduction by 55% as compared to those without plyometrics (26% reduction). Injury prevention programs that incorporate all of these aspects reduce ACL injury risk by up to 50%!

o   Action item: incorporate a comprehensive injury prevention program with the help of a qualified professional. One session can be completed in as little as 10 minutes during warm-up, prior to the start of the main training session. Plyometrics will be most effective with approximately 72 hours of rest between sessions.

  • Training under fatigue may not be beneficial

o   While this can be helpful for developing mental skills, the same cannot be said for your physical skills. Fatigue significantly affects movement quality, which may lead to a greater risk of non-contact injuries.

o   Action item: communicate with a coach / staff member about how you are feeling. Day to day “tiredness” is different from a longer term sense of feeling worn down, but both scenarios may benefit from training adaptations.

Figure of the endogenous menstrual cycle. Note that a regular cycle can range from 23-35 days, with ovulation occurring approximately 14 days before the next period, or around midway for most women. Source: and provided by Megan James.

Second, we would like to bring awareness to Dr. Ebbets’ language, particularly the phrase “the woman’s monthly cycle issue”, and deeming the menstrual cycle “problematic”. As healthcare providers, we strive to utilize the medically appropriate terminology and convey messages that are supportive of athletes in sports. We can do far more than “awareness and monitoring” for women at various points in their cycle. Below are summaries of the phases of the menstrual cycle, and how we can adapt training to optimize benefits and performance, and reduce injury risk. This does not mean that you can’t do [xyz] at another point in your menstrual cycle; this is a general framework to help determine when you can get the most out of certain types of workouts.

  • Follicular (low-hormone) phase, including menstruation: this phase is generally ideal for heavy resistance and high intensity training (with potential exceptions for painful and/or heavy periods)

o   Examples: mile-pace intervals; 2 x 4 reps of heavy-load back squat; box jumps

  • Ovulation: estrogen peaks briefly to stimulate egg release & bone growth. Roughly mid-way through a woman’s cycle – though not necessarily at day 14 – we typically see improved sleep quality, and an added “boost” of tolerance for high-intensity exercise.

o   Examples: time trial; extra day of heavy lifting and/or plyometrics

  • Early luteal phase: With estrogen and progesterone both on the rise, this phase is more suitable for aerobic and moderate intensity training

o   Examples: long run with marathon pace segments; 3 x 6-8 reps of moderately heavy-load deadlifts

  • Late luteal (high-hormone) phase: With primary hormones at their highest (other than the ovulatory estrogen peak), this is a good time to focus on drills, mobility & functional movements, all at a generally low intensity. Added focus on recovery strategies is recommended.

o   Examples: agility ladder drills; vinyasa yoga; extra day of cross-training

Ideally, a stiffer ligament is better suited for controlling joint mobility. Strength training is beneficial for increasing ligamentous stiffness, particularly plyometrics. Estrogen, however, tends to increase the ligamentous laxity; therefore, it is plausible that the highest risk of a ligament injury would be during and after the times of highest estrogen, including right after ovulation and in the late luteal phase, with a potential extension into the beginning of menstruation as estrogen may still be present. Mitigating injury risk by way of training adaptations requires: (a) female athletes to track their menstrual cycle & know their body, (b) female athletes to feel comfortable communicating about their cycle with a coach, and (c) a coach to be willing and able to adapt training plans according to an athlete’s needs.

Finally, we encourage all readers to pay attention to how you speak about a woman’s physiology. It is normal and healthy for a woman to have a regular menstrual cycle, and she should feel comfortable discussing it with her training partners, coach(es) and healthcare providers, with the appropriate terminology.  Women are not different from men; rather, women and men are different – it may be a seemingly small matter of semantics, but it has a profound impact.  

Megan R. James, PT DPT, USATF-L2 (Immersion PT)
Robert Rehberger, PT DPT, OCS (Resolute Physical Therapy)

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