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Esteroides anabólicos, testosterona y riesgo de ruptura tendinosa

Anabolic steroids and testosterone are linked to a higher risk of tendon rupture, including the rotator cuff, biceps and quadriceps. How steroids and TRT affect tendons, joints, bone and recovery from surgery.

Updated Sep 2026
Una estructura molecular junto a un frasco pequeño.
La testosterona influye en los músculos y los huesos; sus niveles y la suplementación con este hormona tienen implicaciones musculoesqueléticas que merecen ser comprendidas. Kieran Hirpara 4.0

Esta página se tradujo automáticamente y todavía no la ha revisado un médico. La versión en inglés es la versión oficial.

¿Qué son?

Los esteroides anabólicos son versiones sintéticas de la testosterona, la hormona que ayuda a desarrollar músculo y hueso. La terapia de reemplazo de testosterona (TRT) es un medicamento recetado que corrige los niveles bajos de testosterona en hombres cuyos cuerpos ya no producen suficiente. Un grupo más reciente de fármacos llamados SARMs (moduladores selectivos de los receptores androgénicos) actúan sobre el mismo sistema hormonal y a veces se utilizan para desarrollar músculo.

Algunas personas usan estos fármacos para tratar una verdadera deficiencia hormonal; otras los emplean para ganar masa muscular o fuerza, a menudo sin receta médica. Ambos grupos deben saber que estas hormonas afectan no solo al músculo, sino también a los tendones—las estructuras resistentes que unen el músculo al hueso—y a las articulaciones.

La investigación ha vinculado la testosterona recetada con lesiones en varios tendones. Las personas que recibieron receta de testosterona tuvieron mayor probabilidad de sufrir lesiones en el tendón del cuádriceps, en la parte frontal de la rodilla, durante el año siguiente [1]. También presentaron tasas más altas de lesiones en el tendón distal del bíceps, en el codo, y de desgarros del manguito rotador, en el hombro [2] [3]. Los usuarios de testosterona tuvieron un riesgo 2,9 veces mayor de ruptura tendinosa en comparación con quienes no la usaban [4]. El uso de esteroides anabólicos también se ha relacionado con la ruptura del músculo pectoral mayor en culturistas, es decir, el desgarro de dicho músculo a nivel del tendón [5].

Parece que estas hormonas modifican el comportamiento de los tendones. Algunos estudios indican que la testosterona los vuelve más rígidos o más débiles, lo que incrementa el riesgo de lesiones; sin embargo, otro estudio no halló cambios estructurales en el propio colágeno tendinoso [6]. Los niveles bajos de testosterona también son relevantes: al parecer perjudican igualmente el sistema musculoesquelético [7]. Esta página explica lo que demuestran las investigaciones, para que pueda conversar sobre su caso particular con su médico.

¿Funciona?

No existe una respuesta sencilla, ya que estas hormonas desempeñan funciones distintas en distintas partes del cuerpo.

En cuanto a los tendones, el panorama es preocupante. Las personas que recibieron recetas de testosterona tuvieron mucha mayor probabilidad de sufrir lesiones en el tendón cuádriceps, situado en la parte frontal de la rodilla, dentro de un año; además, fueron más propensas a necesitar cirugía para repararlo [1]. Aquellas a quienes se recetó testosterona durante al menos 3 meses presentaron una tasa más alta de lesiones del ligamento cruzado anterior en la rodilla durante un período de 2 años [2]. Quienes usaron testosterona inyectable dentro del año posterior a una reconstrucción del ligamento cruzado anterior requirieron con mayor frecuencia una nueva intervención quirúrgica [3]. Los usuarios de testosterona también tuvieron un riesgo mayor de complicaciones tras una reparación del tendón bíceps distal en el codo [4].

En relación con las articulaciones, un estudio determinó que niveles más altos de testosterona disponible en la sangre se asocian con artritis por desgaste [5]. En cuanto a la salud general, tanto los niveles bajos de testosterona como el uso de esteroides anabólicos parecen perjudicar al sistema musculoesquelético, es decir, a los músculos, tendones, huesos y articulaciones en conjunto [6].

No todo es negativo, sin embargo. Cuatro ensayos aleatorizados —el tipo de estudio más fiable— demostraron que la administración de testosterona alrededor del momento de la cirugía mejora los indicadores de recuperación, la composición corporal y la densidad ósea en cirugías ortopédicas [7]. En lo referente a la reparación del manguito rotador en el hombro, un estudio no halló aumento de complicaciones a corto plazo en pacientes que recibían reemplazo de testosterona [8]; otro estudio concluyó que la decisión de suspenderlo previamente a la cirugía debe tomarse caso por caso [9]. En el caso de la ruptura del músculo pectoral mayor, continuar con el uso de esteroides durante la recuperación no pareció afectar negativamente la recuperación muscular [10].

En resumen: estas hormonas se relacionan con tasas más altas de ciertas lesiones tendinosas y complicaciones quirúrgicas. No obstante, existen evidencias de beneficios en situaciones quirúrgicas específicas. Gran parte de esta investigación es de tipo observacional, es decir, sigue a los pacientes a lo largo del tiempo en lugar de probar directamente un tratamiento; por ello, no puede establecer una relación causal. Lo que sí puede hacer es ayudarle a usted y a su médico a evaluar sus propios riesgos antes de la cirugía.

¿Cuáles son los riesgos?

Los riesgos dependen de qué fármacos se utilicen y del motivo de su uso. Si se toma testosterona recetada, la investigación ha asociado su uso con lesiones en varios tendones: el tendón del cuádriceps en la parte frontal de la rodilla, el tendón del bíceps en el codo y el manguito rotador del hombro [1] [2] [3]. Los hombres en tratamiento con testosterona presentan un riesgo mayor de ruptura tendinosa que las mujeres que reciben el mismo tratamiento [4]. Quienes toman SARMs suelen ingerir dosis mucho superiores a las bajas utilizadas en los estudios, lo que incrementa la probabilidad de daño tendinoso, lesión hepática y problemas cardíacos o vasculares [5] [6].

También existen riesgos relacionados con la cirugía. En pacientes que reciben testosterona y necesitan una prótesis de hombro, los estudios muestran una tasa más alta de intervenciones quirúrgicas repetidas, incluso por infección [7] [8]. Tras una reparación del tendón distal del bíceps, quienes siguen terapia con testosterona presentan mayor número de complicaciones [9]. En la reconstrucción del LCA de la rodilla, el uso de testosterona inyectable durante el año previo a la cirugía se asoció con un aumento de 3,3 veces en la necesidad de repetir dicha intervención [10]. La decisión de suspender o no la testosterona antes de una reparación del manguito rotador debe tomarse caso por caso [11].

No obstante, hay hallazgos que indican lo contrario. Un estudio no encontró aumento alguno en las complicaciones a corto plazo tras una reparación artroscópica del manguito rotador en pacientes en tratamiento con testosterona [12]. Continuar usando esteroides anabólicos durante la recuperación tras una ruptura del músculo pectoral mayor no pareció afectar negativamente la recuperación muscular [13]. Además, cuatro ensayos aleatorizados demostraron que la administración de testosterona alrededor del momento de la cirugía mejora los indicadores de recuperación, la composición corporal y la densidad ósea [14].

Quedan dos aspectos poco estudiados. La investigación sobre si la terapia con testosterona incrementa el riesgo de accidente cerebrovascular en adultos jóvenes es limitada y poco explorada [15]. En cuanto a la salud articular, la relación entre los niveles de testosterona y la artrosis no es lineal; por ello, tanto niveles excesivos como insuficientes podrían ser perjudiciales [16] [17]. Si utiliza cualquiera de estas hormonas, informe a su médico antes de la intervención quirúrgica. Su historial hormonal influye en la evaluación de los riesgos.

¿Es adecuado para usted?

Que estas hormonas sean apropiadas para usted depende del motivo por el cual desee tomarlas. Si su cuerpo ya no produce suficiente testosterona, una terapia prescrita puede ser de ayuda. Cuatro ensayos aleatorizados, que son el tipo de estudio más riguroso, demostraron que la administración de testosterona alrededor del momento de la cirugía mejora los indicadores de recuperación, la composición corporal y la densidad ósea [1]. No obstante, este mismo tratamiento está asociado a ciertas lesiones tendinosas y complicaciones quirúrgicas, tal como se explica en las secciones anteriores. Por lo tanto, la decisión no es sencilla ni unidireccional.

Si ya cuenta con niveles saludables de testosterona y desea tomar estos fármacos para desarrollar masa muscular, la evidencia apunta en sentido contrario. Las personas que consumen SARMs suelen tomar dosis mucho mayores que las bajas empleadas en los estudios, lo cual incrementa el riesgo de daño tendinoso, lesiones hepáticas y problemas cardíacos o vasculares [2]. Tanto el uso de esteroides anabólicos como los niveles bajos de testosterona parecen perjudicar a los músculos, tendones, huesos y articulaciones en conjunto [3]. Existe, además, una vía intermedia: un estudio reveló que tanto niveles excesivos como insuficientes de testosterona pueden afectar las articulaciones; por ello, mantener los niveles dentro de un rango saludable parece ser importante [4].

Esta decisión debe tomarse en conjunto con su médico. Lleve a la consulta todo su historial hormonal, incluyendo cualquier tratamiento con testosterona, uso de esteroides o SARMs, tanto en el pasado como en el presente. Su médico podrá evaluar su perfil de riesgo y sopesar los beneficios frente a los riesgos en su caso particular [5]. Si tiene programada una cirugía, informe a su equipo quirúrgico acerca de su uso de hormonas con anticipación, pues esto influye en la evaluación y manejo de sus riesgos [6].

Conclusión

Si su cuerpo necesita testosterona según lo prescrito, puede ser beneficioso tomarla; cuatro ensayos aleatorizados demostraron que mejora los indicadores de recuperación, la composición corporal y la densidad ósea tras la cirugía [1]. No obstante, es fundamental conversar primero sobre los tendones, ya que esta misma terapia se asocia con lesiones en la rodilla, el codo y el hombro, así como con tasas de complicaciones más altas tras ciertas reparaciones tendinosas [2] [3]. La advertencia más importante: si utiliza testosterona, esteroides anabólicos o SARM, informe a su médico antes de cualquier intervención quirúrgica, pues su historial hormonal influye en la evaluación y gestión de los riesgos [3]. En caso de no padecer deficiencia hormonal y desear usar estos fármacos para desarrollar masa muscular, la evidencia científica no respalda su uso [4] [5].

Referencias

[1] La terapia con testosterona se asocia con un mayor riesgo de lesión del tendón cuadríceps. Clinical Orthopaedics & Related Research. 2023. DOI: 10.1097/corr.0000000000002744

[2] Relación entre la terapia con testosterona y los desgarros del manguito rotador, así como sus reparaciones y revisiones. Journal of the American Academy of Orthopaedic Surgeons. 2023. DOI: 10.5435/jaaos-d-22-00554

[3] El uso de testosterona recetada se asocia con una mayor probabilidad de sufrir una lesión del tendón distal del bíceps y, posteriormente, requerir reparación quirúrgica. Journal of Shoulder and Elbow Surgery. 2023. DOI: 10.1016/j.jse.2023.02.122

[4] Póster 374: Desgarros tendinosos en pacientes tratados con esteroides anabólicos terapéuticos exógenos: análisis retrospectivo de ocho años en una sola institución. Orthopaedic Journal of Sports Medicine. 2024. DOI: 10.1177/2325967124s00339

[5] Ruptura del músculo pectoral mayor en culturistas: serie de casos que incluye el uso de esteroides anabólicos. BMC Musculoskeletal Disorders. 2023. DOI: 10.1186/s12891-023-06382-1

[6] Análisis ultraestructural de tendones rotos en usuarios de esteroides anabólicos. Injury. 1998. DOI: 10.1016/s0020-1383(98)00183-1

[7] Testosterona. JBJS Reviews. 2024. DOI: 10.2106/jbjs.rvw.24.00061

[8] La testosterona recetada se asocia con un mayor riesgo de lesión del ligamento cruzado anterior. Arthroscopy. 2024. DOI: 10.1016/j.arthro.2024.10.032

[9] La terapia de reemplazo con testosterona inyectable en el año previo a la reconstrucción del ligamento cruzado anterior se asocia con tasas más altas de revisiones quirúrgicas. Orthopaedic Journal of Sports Medicine. 2026. DOI: 10.1177/23259671251399845

[10] Artículo 30: Resultados comparativos de la reparación del tendón distal del bíceps en pacientes con y sin terapia con testosterona. Orthopaedic Journal of Sports Medicine. 2026. DOI: 10.1177/2325967126s00288

[11] Efecto causal de los niveles de testosterona biodisponible sobre la artrosis: estudio aleatorizado mendeliano bidireccional. BMC Musculoskeletal Disorders. 2025. DOI: 10.1186/s12891-025-08626-8

[12] La suplementación con testosterona perioperatoria mejora los resultados de las cirugías ortopédicas: revisión sistemática de estudios heterogéneos. Arthroscopy. 2024. DOI: 10.1016/j.arthro.2024.12.026

[13] Asociación entre la terapia de reemplazo con testosterona preoperatoria y las complicaciones postoperatorias tras la reparación del manguito rotador. Journal of Shoulder and Elbow Surgery. 2026. DOI: 10.1016/j.jse.2025.12.013

[14] Terapia de reemplazo con testosterona preoperatoria: posible factor de riesgo para complicaciones y reoperaciones tras la reparación del manguito rotador. JSES International. 2026. DOI: 10.1016/j.jseint.2025.10.002

[15] Terapia con testosterona y tasas asociadas de desgarro tendinoso y reparación quirúrgica: análisis retrospectivo. Orthopaedic Journal of Sports Medicine. 2026. DOI: 10.1177/23259671261430731

[16] Póster 390: Revisión sistemática del abuso de moduladores selectivos de los receptores androgénicos en atletas. Orthopaedic Journal of Sports Medicine. 2023. DOI: 10.1177/2325967123s00352

[17] Abuso de moduladores selectivos de los receptores androgénicos en atletas: revisión sistemática. The American Journal of Sports Medicine. 2025. DOI: 10.1177/03635465241252435

[18] Póster 149: La suplementación con testosterona aumenta el riesgo de reoperación tras la artroplastia total de hombro. Orthopaedic Journal of Sports Medicine. 2024. DOI: 10.1177/2325967124s00118

[19] La testosterona recetada se asocia con mayor riesgo de reoperaciones por infecciones y por cualquier causa tras la artroplastia total de hombro primaria en pacientes masculinos. JSES International. 2026. DOI: 10.1016/j.jseint.2026.101634

[20] Suplementación con testosterona y accidente cerebrovascular en adultos jóvenes: revisión de la literatura. Frontiers in Neurology. 2024. DOI: 10.3389/fneur.2024.1422931

[21] Correlación entre niveles bajos de testosterona y riesgo de artrosis: análisis transversal de datos de NHANES (2011–2016). BMC Musculoskeletal Disorders. 2025. DOI: 10.1186/s12891-024-08272-6

[22] Comentario editorial:


Evidence & references

This is the clinical evidence summary written for health professionals. It is technical, and it lists the research this page was built from. You do not need to read it to understand your treatment or to make a decision about it.

Overview

  • Testosterone replacement therapy is associated with increased odds of surgically treated tendon rupture [1].
  • Anabolic steroids did not induce ultrastructural collagen changes that might predispose to tendon rupture in humans [2].
  • Testosterone users had a 2.9-fold increased risk of tendon rupture compared to nonusers [3].
  • It is premature to imply causation between testosterone replacement therapy and ACL injuries based solely on existing results due to confounding variables [4].
  • Exogenous testosterone is a risk factor for increased postoperative complications following distal biceps tendon repair [5].
  • There is a threshold-dependent relationship between testosterone and shoulder pathology [6].
  • Patients with prior prescription testosterone exposure have an increased rate of distal biceps tendon injury and biceps tendon repair compared with patients without such exposure [7].
  • Surgeons should be more intentional about discussing endocrinologic history with patients and counseling those with testosterone deficiency on the risks for injury or re-injury [8].
  • TRT is associated with increased tendon rupture risk in men but not women, potentially due to sex-specific differences in dosing [9].
  • Patients who filled a prescription for testosterone replacement therapy were much more likely to experience a quadriceps muscle or tendon injury within 1 year of filling their prescription and were at increased risk of undergoing surgical repair of the quadriceps tendon [10].
  • SARM use is associated with tendon damage [11].
  • Cessation of TRT prior to rotator cuff repair should be considered on a patient-specific basis [12].

How It Works

  • Further research is needed to understand the mechanism by how testosterone increases the risk of reoperation after TSA [13].
  • Anabolic steroids use may contribute to pectoralis major injury [14].
  • Continuation of anabolic steroids during recovery does not seem to have a negative effect on functional recovery after pectoralis major injury [14].
  • Testosterone use is associated with a higher risk of both infection-related and all-cause reoperations after total shoulder arthroplasty [15].

What the Evidence Shows

Tendon Rupture Risk and Injury Association

  • Patients who filled a prescription for testosterone replacement therapy were much more likely to experience a quadriceps muscle or tendon injury within 1 year of filling their prescription [10].
  • Patients who filled a prescription for testosterone replacement therapy were at increased risk of undergoing surgical repair of the quadriceps tendon [10].
  • There is increased risk of rotator cuff tears in patients prescribed testosterone [16].
  • There is increased risk of rotator cuff repairs in patients prescribed testosterone [16].
  • There is increased risk of subsequent rotator cuff repairs in patients prescribed testosterone [16].
  • TRT is associated with increased tendon rupture risk in men but not women [9].
  • The association between TRT and increased tendon rupture risk in men but not women is potentially due to sex-specific differences in dosing [9].

Postoperative Complications and Reoperation

  • Testosterone use is associated with a higher risk of infection-related reoperations after total shoulder arthroplasty [15].
  • Testosterone use is associated with a higher risk of all-cause reoperations after total shoulder arthroplasty [15].
  • Supplemental testosterone increases the risk of reoperation after total shoulder arthroplasty [13].
  • Preoperative testosterone replacement therapy is a potential risk factor for complications after rotator cuff repair [12].
  • Preoperative testosterone replacement therapy is a potential risk factor for reoperation after rotator cuff repair [12].

Mechanisms and Ultrastructure

Clinical Considerations and Causation

  • Clinicians should remain vigilant and prescribe TRT judiciously with a thorough assessment of each patient's unique risk profile [4].
  • Surgeons should be more intentional about discussing endocrinologic history with patients [8].
  • Surgeons should counsel patients with testosterone deficiency on the risks for injury or re-injury [8].
  • Further research is needed to understand the mechanism by which testosterone increases the risk of reoperation after total shoulder arthroplasty [13].
  • Hormonal status should be considered in musculoskeletal risk assessment [6].

Practical Considerations

Risk Assessment and Counseling

  • A threshold-dependent relationship exists between testosterone and shoulder pathology, highlighting the need to consider hormonal status in musculoskeletal risk assessment [6].

Operative Considerations

Anabolic Steroids and SARMs

  • SARM use is associated with increased muscle mass, hepatotoxicity, cardiotoxicity, tendon damage, and androgenic side effects throughout the body [11].
  • Anabolic steroids use may contribute to pectoralis major injury in body builders [14].
  • Continuation of anabolic steroids during recovery from pectoralis major injury does not seem to have a negative effect on functional recovery [14].

Key Evidence

  • [L3] Testosterone replacement therapy is associated with increased odds of surgically treated tendon rupture. [1] (10.1177/2325967125s00009)
  • [L4] The authors conclude that anabolic steroids did not induce ultrastructural collagen changes that might predispose to tendon rupture in humans. [2] (10.1016/s0020-1383(98)00183-1)
  • [L3] Testosterone users had a 2.9-fold increased risk of tendon rupture compared to nonusers. [3] (10.1177/2325967124s00339)
  • [L5] It is premature to imply causation between testosterone replacement therapy and ACL injuries based solely on existing results due to confounding variables; clinicians should remain vigilant and prescribe TRT judiciously with a thorough assessment of each patient's unique risk profile. [4] (10.1016/j.arthro.2024.11.086)
  • [L3] These findings suggest that exogenous testosterone is a risk factor for increased postoperative complications following distal biceps tendon repair. [5] (10.1177/2325967126s00288)
  • [L3] These findings suggest a threshold-dependent relationship between testosterone and shoulder pathology and highlight the need to consider hormonal status in musculoskeletal risk assessment. [6] (10.1016/j.jse.2026.01.012)
  • [L3] Patients with prior prescription testosterone exposure have an increased rate of distal biceps tendon injury and biceps tendon repair compared with patients without such exposure. [7] (10.1016/j.jse.2023.02.122)
  • [L5] The author advises surgeons to be more intentional about discussing endocrinologic history with patients and counseling those with testosterone deficiency on the risks for injury or re-injury. [8] (10.1097/corr.0000000000002835)
  • [L3] TRT is associated with increased tendon rupture risk in men but not women, potentially due to sex-specific differences in dosing. [9] (10.1177/23259671261430731)
  • [L3] Patients who filled a prescription for testosterone replacement therapy were much more likely to experience a quadriceps muscle or tendon injury within 1 year of filling their prescription and were at increased risk of undergoing surgical repair of the quadriceps tendon. [10] (10.1097/corr.0000000000002744)
  • [L4] SARM use is associated with increased muscle mass, hepatotoxicity, cardiotoxicity, tendon damage, and androgenic side effects throughout the body. [11] (10.1177/03635465241252435)
  • [L3] Cessation of TRT prior to rotator cuff repair should be considered on a patient-specific basis. [12] (10.1016/j.jseint.2025.10.002)
  • [L3] Further research is needed to understand the mechanism by how testosterone increases the risk of reoperation after TSA. [13] (10.1177/2325967124s00118)
  • [L4] Anabolic steroids use may contribute to the injury, but continuation during recovery does not seem to have a negative effect on functional recovery. [14] (10.1186/s12891-023-06382-1)
  • [L2] Testosterone use is associated with a higher risk of both infection-related and all-cause reoperations after total shoulder arthroplasty. [15] (10.1016/j.jseint.2026.101634)
  • [L3] There is increased risk of RCTs, RCRs, and subsequent RCRs in patients prescribed testosterone. [16] (10.5435/jaaos-d-22-00554)

References

[1] Testosterone Replacement Therapy Increases Odds of Tendon Ruptures Treated Surgically. Orthopaedic Journal of Sports Medicine. 2025. DOI: 10.1177/2325967125s00009

[2] Ultrastructural analysis of ruptured tendon from anabolic steroid users. Injury. 1998. DOI: 10.1016/s0020-1383(98)00183-1

[3] Poster 374: Tendon Tears Among Patients Treated with Exogenous Therapeutic Anabolic Steroids: An Eight Year Retrospective Analysis in a Single Institution. Orthopaedic Journal of Sports Medicine. 2024. DOI: 10.1177/2325967124s00339

[4] Editorial Commentary: Testosterone Replacement Therapy and Anterior Cruciate Ligament Injury Risk: Insights and Cautions for Clinical Application. Arthroscopy. 2024. DOI: 10.1016/j.arthro.2024.11.086

[5] Paper 30. Comparative Outcomes of Distal Biceps Tendon Repair in Patients With and Without Testosterone Therapy. Orthopaedic Journal of Sports Medicine. 2026. DOI: 10.1177/2325967126s00288

[6] Testosterone levels and risk of adhesive capsulitis: a 1:1 propensity matched analysis. Journal of Shoulder and Elbow Surgery. 2026. DOI: 10.1016/j.jse.2026.01.012

[7] The use of prescription testosterone is associated with an increased likelihood of experiencing a distal biceps tendon injury and subsequently requiring surgical repair. Journal of Shoulder and Elbow Surgery. 2023. DOI: 10.1016/j.jse.2023.02.122

[8] CORR Insights®: Testosterone Therapy Is Associated With Increased Odds of Quadriceps Tendon Injury. Clinical Orthopaedics & Related Research. 2023. DOI: 10.1097/corr.0000000000002835

[9] Testosterone Therapy and Associated Rates of Tendon Tear and Surgical Repair: A Retrospective Analysis. Orthopaedic Journal of Sports Medicine. 2026. DOI: 10.1177/23259671261430731

[10] Testosterone Therapy Is Associated With Increased Odds of Quadriceps Tendon Injury. Clinical Orthopaedics & Related Research. 2023. DOI: 10.1097/corr.0000000000002744

[11] Athlete Selective Androgen Receptor Modulators Abuse: A Systematic Review. The American Journal of Sports Medicine. 2025. DOI: 10.1177/03635465241252435

[12] Preoperative testosterone replacement therapy: a potential risk-factor for complications and reoperation after rotator cuff repair. JSES International. 2026. DOI: 10.1016/j.jseint.2025.10.002

[13] Poster 149: Supplemental Testosterone Increases Risk of Reoperation after Total Shoulder Arthroplasty. Orthopaedic Journal of Sports Medicine. 2024. DOI: 10.1177/2325967124s00118

[14] Pectoralis major rupture in body builders: a case series including anabolic steroid use. BMC Musculoskeletal Disorders. 2023. DOI: 10.1186/s12891-023-06382-1

[15] Prescription testosterone is associated with increased risk of infection-related and all-cause reoperations after primary total shoulder arthroplasty in male patients. JSES International. 2026. DOI: 10.1016/j.jseint.2026.101634

[16] The Relationship Between Testosterone Therapy and Rotator Cuff Tears, Repairs, and Revision Repairs. Journal of the American Academy of Orthopaedic Surgeons. 2023. DOI: 10.5435/jaaos-d-22-00554

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By exercising the Licensed Rights (defined below), You accept and agree to be bound by the terms and conditions of this Creative Commons Attribution-NonCommercial 4.0 International Public License ("Public License"). To the extent this Public License may be interpreted as a contract, You are granted the Licensed Rights in consideration of Your acceptance of these terms and conditions, and the Licensor grants You such rights in consideration of benefits the Licensor receives from making the Licensed Material available under these terms and conditions.

Section 1 -- Definitions.

a. Adapted Material means material subject to Copyright and Similar Rights that is derived from or based upon the Licensed Material and in which the Licensed Material is translated, altered, arranged, transformed, or otherwise modified in a manner requiring permission under the Copyright and Similar Rights held by the Licensor. For purposes of this Public License, where the Licensed Material is a musical work, performance, or sound recording, Adapted Material is always produced where the Licensed Material is synched in timed relation with a moving image.

b. Adapter's License means the license You apply to Your Copyright and Similar Rights in Your contributions to Adapted Material in accordance with the terms and conditions of this Public License.

c. Copyright and Similar Rights means copyright and/or similar rights closely related to copyright including, without limitation, performance, broadcast, sound recording, and Sui Generis Database Rights, without regard to how the rights are labeled or categorized. For purposes of this Public License, the rights specified in Section 2(b)(1)-(2) are not Copyright and Similar Rights.

d. Effective Technological Measures means those measures that, in the absence of proper authority, may not be circumvented under laws fulfilling obligations under Article 11 of the WIPO Copyright Treaty adopted on December 20, 1996, and/or similar international agreements.

e. Exceptions and Limitations means fair use, fair dealing, and/or any other exception or limitation to Copyright and Similar Rights that applies to Your use of the Licensed Material.

f. Licensed Material means the artistic or literary work, database, or other material to which the Licensor applied this Public License.

g. Licensed Rights means the rights granted to You subject to the terms and conditions of this Public License, which are limited to all Copyright and Similar Rights that apply to Your use of the Licensed Material and that the Licensor has authority to license.

h. Licensor means the individual(s) or entity(ies) granting rights under this Public License.

i. NonCommercial means not primarily intended for or directed towards commercial advantage or monetary compensation. For purposes of this Public License, the exchange of the Licensed Material for other material subject to Copyright and Similar Rights by digital file-sharing or similar means is NonCommercial provided there is no payment of monetary compensation in connection with the exchange.

j. Share means to provide material to the public by any means or process that requires permission under the Licensed Rights, such as reproduction, public display, public performance, distribution, dissemination, communication, or importation, and to make material available to the public including in ways that members of the public may access the material from a place and at a time individually chosen by them.

k. Sui Generis Database Rights means rights other than copyright resulting from Directive 96/9/EC of the European Parliament and of the Council of 11 March 1996 on the legal protection of databases, as amended and/or succeeded, as well as other essentially equivalent rights anywhere in the world.

l. You means the individual or entity exercising the Licensed Rights under this Public License. Your has a corresponding meaning.

Section 2 -- Scope.

a. License grant.

1. Subject to the terms and conditions of this Public License, the Licensor hereby grants You a worldwide, royalty-free, non-sublicensable, non-exclusive, irrevocable license to exercise the Licensed Rights in the Licensed Material to:

a. reproduce and Share the Licensed Material, in whole or in part, for NonCommercial purposes only; and

b. produce, reproduce, and Share Adapted Material for NonCommercial purposes only.

2. Exceptions and Limitations. For the avoidance of doubt, where Exceptions and Limitations apply to Your use, this Public License does not apply, and You do not need to comply with its terms and conditions.

3. Term. The term of this Public License is specified in Section 6(a).

4. Media and formats; technical modifications allowed. The Licensor authorizes You to exercise the Licensed Rights in all media and formats whether now known or hereafter created, and to make technical modifications necessary to do so. The Licensor waives and/or agrees not to assert any right or authority to forbid You from making technical modifications necessary to exercise the Licensed Rights, including technical modifications necessary to circumvent Effective Technological Measures. For purposes of this Public License, simply making modifications authorized by this Section 2(a) (4) never produces Adapted Material.

5. Downstream recipients.

a. Offer from the Licensor -- Licensed Material. Every recipient of the Licensed Material automatically receives an offer from the Licensor to exercise the Licensed Rights under the terms and conditions of this Public License.

b. No downstream restrictions. You may not offer or impose any additional or different terms or conditions on, or apply any Effective Technological Measures to, the Licensed Material if doing so restricts exercise of the Licensed Rights by any recipient of the Licensed Material.

6. No endorsement. Nothing in this Public License constitutes or may be construed as permission to assert or imply that You are, or that Your use of the Licensed Material is, connected with, or sponsored, endorsed, or granted official status by, the Licensor or others designated to receive attribution as provided in Section 3(a)(1)(A)(i).

b. Other rights.

1. Moral rights, such as the right of integrity, are not licensed under this Public License, nor are publicity, privacy, and/or other similar personality rights; however, to the extent possible, the Licensor waives and/or agrees not to assert any such rights held by the Licensor to the limited extent necessary to allow You to exercise the Licensed Rights, but not otherwise.

2. Patent and trademark rights are not licensed under this Public License.

3. To the extent possible, the Licensor waives any right to collect royalties from You for the exercise of the Licensed Rights, whether directly or through a collecting society under any voluntary or waivable statutory or compulsory licensing scheme. In all other cases the Licensor expressly reserves any right to collect such royalties, including when the Licensed Material is used other than for NonCommercial purposes.

Section 3 -- License Conditions.

Your exercise of the Licensed Rights is expressly made subject to the following conditions.

a. Attribution.

1. If You Share the Licensed Material (including in modified form), You must:

a. retain the following if it is supplied by the Licensor with the Licensed Material:

i. identification of the creator(s) of the Licensed Material and any others designated to receive attribution, in any reasonable manner requested by the Licensor (including by pseudonym if designated);

ii. a copyright notice;

iii. a notice that refers to this Public License;

iv. a notice that refers to the disclaimer of warranties;

v. a URI or hyperlink to the Licensed Material to the extent reasonably practicable;

b. indicate if You modified the Licensed Material and retain an indication of any previous modifications; and

c. indicate the Licensed Material is licensed under this Public License, and include the text of, or the URI or hyperlink to, this Public License.

2. You may satisfy the conditions in Section 3(a)(1) in any reasonable manner based on the medium, means, and context in which You Share the Licensed Material. For example, it may be reasonable to satisfy the conditions by providing a URI or hyperlink to a resource that includes the required information.

3. If requested by the Licensor, You must remove any of the information required by Section 3(a)(1)(A) to the extent reasonably practicable.

4. If You Share Adapted Material You produce, the Adapter's License You apply must not prevent recipients of the Adapted Material from complying with this Public License.

Section 4 -- Sui Generis Database Rights.

Where the Licensed Rights include Sui Generis Database Rights that apply to Your use of the Licensed Material:

a. for the avoidance of doubt, Section 2(a)(1) grants You the right to extract, reuse, reproduce, and Share all or a substantial portion of the contents of the database for NonCommercial purposes only;

b. if You include all or a substantial portion of the database contents in a database in which You have Sui Generis Database Rights, then the database in which You have Sui Generis Database Rights (but not its individual contents) is Adapted Material; and

c. You must comply with the conditions in Section 3(a) if You Share all or a substantial portion of the contents of the database.

For the avoidance of doubt, this Section 4 supplements and does not replace Your obligations under this Public License where the Licensed Rights include other Copyright and Similar Rights.

Section 5 -- Disclaimer of Warranties and Limitation of Liability.

a. UNLESS OTHERWISE SEPARATELY UNDERTAKEN BY THE LICENSOR, TO THE EXTENT POSSIBLE, THE LICENSOR OFFERS THE LICENSED MATERIAL AS-IS AND AS-AVAILABLE, AND MAKES NO REPRESENTATIONS OR WARRANTIES OF ANY KIND CONCERNING THE LICENSED MATERIAL, WHETHER EXPRESS, IMPLIED, STATUTORY, OR OTHER. THIS INCLUDES, WITHOUT LIMITATION, WARRANTIES OF TITLE, MERCHANTABILITY, FITNESS FOR A PARTICULAR PURPOSE, NON-INFRINGEMENT, ABSENCE OF LATENT OR OTHER DEFECTS, ACCURACY, OR THE PRESENCE OR ABSENCE OF ERRORS, WHETHER OR NOT KNOWN OR DISCOVERABLE. WHERE DISCLAIMERS OF WARRANTIES ARE NOT ALLOWED IN FULL OR IN PART, THIS DISCLAIMER MAY NOT APPLY TO YOU.

b. TO THE EXTENT POSSIBLE, IN NO EVENT WILL THE LICENSOR BE LIABLE TO YOU ON ANY LEGAL THEORY (INCLUDING, WITHOUT LIMITATION, NEGLIGENCE) OR OTHERWISE FOR ANY DIRECT, SPECIAL, INDIRECT, INCIDENTAL, CONSEQUENTIAL, PUNITIVE, EXEMPLARY, OR OTHER LOSSES, COSTS, EXPENSES, OR DAMAGES ARISING OUT OF THIS PUBLIC LICENSE OR USE OF THE LICENSED MATERIAL, EVEN IF THE LICENSOR HAS BEEN ADVISED OF THE POSSIBILITY OF SUCH LOSSES, COSTS, EXPENSES, OR DAMAGES. WHERE A LIMITATION OF LIABILITY IS NOT ALLOWED IN FULL OR IN PART, THIS LIMITATION MAY NOT APPLY TO YOU.

c. The disclaimer of warranties and limitation of liability provided above shall be interpreted in a manner that, to the extent possible, most closely approximates an absolute disclaimer and waiver of all liability.

Section 6 -- Term and Termination.

a. This Public License applies for the term of the Copyright and Similar Rights licensed here. However, if You fail to comply with this Public License, then Your rights under this Public License terminate automatically.

b. Where Your right to use the Licensed Material has terminated under Section 6(a), it reinstates:

1. automatically as of the date the violation is cured, provided it is cured within 30 days of Your discovery of the violation; or

2. upon express reinstatement by the Licensor.

For the avoidance of doubt, this Section 6(b) does not affect any right the Licensor may have to seek remedies for Your violations of this Public License.

c. For the avoidance of doubt, the Licensor may also offer the Licensed Material under separate terms or conditions or stop distributing the Licensed Material at any time; however, doing so will not terminate this Public License.

d. Sections 1, 5, 6, 7, and 8 survive termination of this Public License.

Section 7 -- Other Terms and Conditions.

a. The Licensor shall not be bound by any additional or different terms or conditions communicated by You unless expressly agreed.

b. Any arrangements, understandings, or agreements regarding the Licensed Material not stated herein are separate from and independent of the terms and conditions of this Public License.

Section 8 -- Interpretation.

a. For the avoidance of doubt, this Public License does not, and shall not be interpreted to, reduce, limit, restrict, or impose conditions on any use of the Licensed Material that could lawfully be made without permission under this Public License.

b. To the extent possible, if any provision of this Public License is deemed unenforceable, it shall be automatically reformed to the minimum extent necessary to make it enforceable. If the provision cannot be reformed, it shall be severed from this Public License without affecting the enforceability of the remaining terms and conditions.

c. No term or condition of this Public License will be waived and no failure to comply consented to unless expressly agreed to by the Licensor.

d. Nothing in this Public License constitutes or may be interpreted as a limitation upon, or waiver of, any privileges and immunities that apply to the Licensor or You, including from the legal processes of any jurisdiction or authority.


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