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 categorised into four phases using a standardised model: menstruation (phase 1; P1), remainder of follicular phase (phase 2; P2), early luteal (phase 3; P3), and pre-menstrual phase (phase 4; P4). Injury incidence rates (IRR) and ratios (IIRR) were calculated for overall injuries, injury severity, type, contact vs non-contact and game/training. Results: 593 cycles across 13,390 days were tracked during the study and 74 injuries from 26 players were eligible for analysis. When comparing IRR between phases (reference: P1), overall injury rates were highest in P4 (IIRR: 2.30 [95% CI: 0.99-5.34; p=0.05]). When examining rates by injury severity and type, IRR were also highest in P4 for ≤7 days’ time-loss (4.40 [0.93-20.76; p=0.06]), muscle-specific (6.07 [1.34-27.43; p=0.02]) and non-contact (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 days’ 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 sub-type (n=41). No anterior cruciate ligament injuries were recorded across the monitoring period. Conclusion: 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.