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Vitamin D at Kalusugan ng Musculoskeletal

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How vitamin D affects bone, muscle strength, falls, fracture and tendon healing, and surgical outcomes — including who benefits from supplementation.

Updated Jul 2026
Isang araw na nagniningning sa ibabaw ng isang buto.
Ang bitamina D, na tinatawag na 'bitamina ng araw', ay mahalaga para sa lakas ng buto at pag-andar ng kalamnan. Kieran Hirpara 4.0

Ang pahinang ito ay isinalin ng makina at hindi pa nasusuri ng isang doktor. Ang bersyong Ingles ang siyang opisyal.

Ano ang nararamdaman mo

Maaaring mapansin mo na iba ang pakiramdam ng iyong katawan kapag mababa ang antas ng vitamin D. Ang nutrient na ito ay tumutulong upang panatilihing malakas ang iyong mga buto at kalamnan. Kung kulang dito, maaaring mas pagod ka kaysa karaniwan. Maaaring mas mahina o mas madaling masaktan ang iyong mga kalamnan. Maaari ring mapansin mo na mas maputik ang pakiramdam ng iyong mga buto. Lalo itong totoo kung ikaw ay isang atleta o nagsisilbi sa militar. Ang mga grupong ito ay may mas mataas na panganib para sa stress fractures, na mga maliit na bitak sa buto.

Kung mayroon kang pinsala sa tuhod, maaaring gawing mas mahirap ng mababang vitamin D ang sitwasyon. Ito ay nauugnay sa mas mataas na tsansang masira ang ligament sa harap ng iyong tuhod. Maaari rin nitong gawing mas mahirap para sa ligament na gumaling kung kailangan mo ng operasyon. Maaaring mararamdaman mo ang kawalan ng katatagan o sakit kapag gumagalaw ang iyong tuhod. Ito ay dahil ang vitamin D ay may papel sa kung gaano kagaling ang iyong katawan na mag-ayos pagkatapos ng pinsala.

Para sa mga matatanda, ang pagkamaligaw sa vitamin D ay mahalaga. Maaaring magkaroon ka ng fragility fracture, na isang pagkabasag dahil sa maliit na pagkabagsak. Susuriin ng iyong doktor ang iyong mga antas upang gabayan ang iyong paggamot. Kung ikaw ay may operasyon para sa hip fracture, karaniwan ang mga antas na mas mababa sa 20 ng/mL. Maaaring irekomenda ng iyong doktor ang mga supplement bago ang iyong operasyon upang tulungan kang gumaling nang mas mabuti. Ito ay isang simpleng hakbang na maaaring magdulot ng malaking pagkakaiba sa iyong paggaling.

Kung ikaw ay may operasyon sa balikat, tulad ng pagkukumpuni ng rotator cuff, mahalaga rin ang vitamin D. Maaari nitong tulungan ang iyong tendon na gumaling, bagaman patuloy pa lamang ang ebidensya. Ilang pag-aaral ang nagpapakita na ang pag-check ng iyong mga antas at pag-inom ng mga supplement ay worth ang gastusin. Tumutulong ito upang matiyak na mayroon ang iyong katawan ng kailangan nito upang ayusin ang naputol na tendon.

Para sa mga bata at kabataan, ang vitamin D ay nakakaapekto sa higit pa sa mga buto lamang. Ang mga mababang antas ay nauugnay sa mas hindi malusog na komposisyon ng katawan. Maaaring mapansin mo ang mga pagbabago sa lakas o paglago. Ang lakas ng hawak ng kamay at diyeta ay mga senyales din ng kalusugan ng buto sa mga kabataan. Ang pagpapanatili ng iyong mga antas ng vitamin D ay sumusuporta sa kanilang pangkalahatang kalusugan ng muskuloskeletal. Tumutulong ito upang manatili silang aktibo at malakas habang lumalaki.

Ano ang nangyayari talaga

Ang bitamina D ay mahalaga upang panatilihing matibay ang iyong mga buto at maayos ang pagganap ng iyong mga kalamnan. Isipin mo ito bilang susi na tumutulong sa iyong katawan na sumipsip ng kalsiyum. Kung kulang ang susi na ito, maaaring maging magaspang at madaling maputol ang iyong mga buto. Ito ay lalo na totoo para sa mga nakatatanda at sa mga taong nakaranas ng fragility fracture. Maaaring suriin ng iyong doktor ang iyong antas bago ang malalaking operasyon, tulad ng pag-aayos ng hip fracture, upang matiyak na mayroon ang iyong katawan ng mga kailangan nitong mapagkukunan upang gumaling nang maayos.

Ang mababang antas ng bitamina D ay may kaugnayan sa mas mataas na panganib ng seryosong pinsala. Halimbawa, ang kakulangan dito ay nagpapataas ng iyong tsansang masira ang anterior cruciate ligament sa iyong tuhod o mabigo ang operasyon ng rekonstruksyon. Pinapataas nito rin ang panganib ng stress fractures, na mga maliit na bitak sa buto na dulot ng paulit-ulit na stress. Ito ang dahilan kung bakit maaaring i-assess ng iyong doktor ang iyong kalagayan sa bitamina D kung ikaw ay isang atleta o nasa isang high-risk group tulad ng militar. Ang regular na suplementasyon ay maaaring makabawas nang malaki sa posibilidad na maging deficient, na tumutulong upang protektahan ang iyong mga kasu-kasuan at buto laban sa mga maingay na pinsalang ito.

Ang bitamina D ay may papel din sa paraan ng paggaling ng iyong mga tendon. Ang mga tendon ay ang matigas, tali-tulad na banda na nag-uugnay sa iyong mga kalamnan sa iyong mga buto. Habang limitado ang ebidensya, maaaring suportahan ng bitamina D ang paggaling pagkatapos ng mga prosedura tulad ng rotator cuff repair sa balikat. Mahalaga ito rin para sa kabuuang komposisyon ng katawan at kalusugang metaboliko, lalo na sa mga adolescent. Sa mga bata, ang mga salik tulad ng lakas ng hawak ng kamay at diyeta, kasama ang antas ng bitamina D, ay tumutulong na ma-predict ang kalusugan ng buto. Ang pagtitiyak na may sapat kang bitamina D ay hindi lamang sumusuporta sa iyong mga buto, kundi sa buong iyong musculoskeletal system, na tumutulong upang manatili kang aktibo at matibay.

Ano ang inaasahan

Ang iyong prognosis ay nakadepende sa malaking bahagi sa iyong antas ng bitamina D at sa iyong tiyak na kalagayan sa kalusugan. Kung ikaw ay may kakulangan, maaari kang harapin ang mas mataas na panganib para sa ilang sugat. Halimbawa, ang kakulangan sa bitamina D ay may kaugnayan sa mas malaking pagkakataon ng pagputol ng anterior cruciate ligament sa iyong tuhod o ng pagkabigo ng reconstructive surgery. Ito ay may kaugnayan din sa mga hindi magandang pagbabago sa komposisyon ng katawan para sa mga kabataan.

Para sa mga matatanda na nagsasagawa ng joint replacement o hip fracture surgery, maaaring suriin ng iyong doktor ang iyong antas ng bitamina D bago ang iyong pagkakagawa. Ito ay lalo na mahalaga kung ikaw ay nagsasagawa ng surgery sa taglamig, dahil mas karaniwan ang kakulangan sa mga buwang ito. Kung mababa ang iyong antas, maaaring irekomenda ng iyong doktor ang mga supplement. Ang regular na suplementasyon ay malaki ang pagbaba sa pagkakataon na manatiling kulang. Ang simpleng hakbang na ito ay makakatulong na i-optimize ang iyong kalusugan ng buto at metabolic status bago at pagkatapos ng iyong pag-aalaga.

Maaaring tanungin mo kung tumutulong ang mga supplement sa paggaling ng tendon, tulad sa mga rotator cuff repairs. Ang ebidensya dito ay limitado at mababa ang kalidad. Habang maaaring suportahan ng bitamina D ang paggaling, hindi namin maaaring pangakuan ang tiyak na mga resulta batay sa kasalukuyang datos. Gayunpaman, para sa arthroscopic rotator cuff repair, ang pagbibigay ng bitamina D ay itinuturing na isang cost-effective na hakbang. Madalas na mas praktikal at murang magbigay nito sa lahat kaysa sa pagsusuri sa lahat ng antas ng dugo muna.

Para sa mga bata at kabataan, ang status ng bitamina D ay isang pangunahing predictor ng kalusugan ng buto kasama ang hand grip strength at diet. Kung ikaw ay isang magulang, ang mga targeted interventions ay makakatulong na i-optimize ang musculoskeletal at metabolic health ng iyong anak. Ang pagkamulat ay nananatiling mahalaga para sa mga matatanda rin. Kahit na may mga improved guidelines, marami pa ring kailangan ng mga paalala tungkol sa kahalagahan ng pagpapanatili ng malusog na antas ng bitamina D upang maiwasan ang fragility fractures at suportahan ang long-term bone strength.

Reviewed by Kieran Hirpara · 13 June 2026.

Want the clinical detail? Read the clinician version.

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For an appointment with the CQ Hand + Upper Limb team, ask your GP about a referral or visit www.cqupperlimb.com.

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

  • Vitamin D supplementation effects on bone health and injury risk in elite athletes require further research [1].
  • A diagnosis of vitamin D deficiency is associated with increased odds of anterior cruciate ligament tears and reconstruction failure [2].
  • Vitamin D status should be assessed in high-risk populations, such as athletes and military personnel, to guide preventive strategies for stress fractures [3].
  • Educational initiatives and revised guidelines may have improved vitamin D prescription rates after fragility fracture, but awareness remains needed for older adults [4].
  • Vitamin D deficiency prevalence is higher among arthroplasty patients presenting in winter [5].
  • Regular vitamin D supplementation significantly reduces the likelihood of deficiency in arthroplasty patients [5].
  • Evidence suggests vitamin D may support tendon healing, particularly in rotator cuff repair, but studies are low quality and limited to a single tendon group [6].
  • Vitamin D deficiency is associated with adverse body composition in adolescents [7].
  • Targeted interventions are needed to optimize musculoskeletal and metabolic health in adolescents regarding vitamin D status [7].
  • Preoperative vitamin D screening and potential supplementation strategies are important for patients receiving hip fracture surgery under general anesthesia who have vitamin D levels below 20 ng/mL [8].
  • Preoperative vitamin D supplementation is a cost-effective intervention in arthroscopic rotator cuff repair [9].
  • Nonselective vitamin D supplementation appears more cost-effective than selective supplementation in arthroscopic rotator cuff repair due to lower costs compared to serum assays [9].
  • Hand grip strength, vitamin D status, and diets are predictors of bone health in 6–12 year old school children [23].
  • Hand grip strength, vitamin D status, and diets might be considered diagnostic non-invasive predictors of bone health for clinical use in epidemiological contexts [23].

How It Works

  • Vitamin D deficiency is associated with increased odds of anterior cruciate ligament tears and reconstruction failure [2].
  • Vitamin D status assessment in high-risk populations (athletes and military personnel) guides preventive strategies for stress fractures [3].
  • Regular vitamin D supplementation significantly reduces the likelihood of deficiency in arthroplasty patients presenting in winter [5].
  • Vitamin D may support tendon healing, particularly in rotator cuff repair, though evidence is low quality and limited to a single tendon group [6].
  • Vitamin D deficiency is associated with adverse body composition in adolescents, highlighting the need for targeted interventions during development [7].
  • Preoperative vitamin D screening and potential supplementation are important for patients receiving hip fracture surgery under general anesthesia with levels below 20 ng/mL [8].
  • Nonselective preoperative vitamin D supplementation is more cost-effective than selective supplementation in arthroscopic rotator cuff repair due to lower costs compared to serum assays [9].
  • Determining preoperative vitamin D levels and providing supplementation if deficient may be beneficial for preventing delayed wound healing after open carpal tunnel release surgery [10].
  • Administering an oral 300,000 U single-dose vitamin D regimen to correct deficiency can positively impact outcomes following primary total joint arthroplasty [11].
  • Further research is necessary to elucidate the direct role of vitamin D in rotator cuff tear pathogenesis and its impact on clinical outcomes after rotator cuff surgery and total shoulder arthroplasty [12].
  • A nanofiber-based vitamin D sheet was compared to vitamin D supplementation for tendon-to-bone healing and muscle regeneration in a rabbit rotator cuff tear model [13].
  • Supplementation with vitamin D 10,000 IU/day for 8 weeks can increase vitamin D levels >50 ng/dl to optimally act as an immunomodulator in tuberculosis spondylitis patients [14].
  • Active vitamin D3 treatment promoted fracture healing by affecting immune factor levels in osteoporotic fracture patients [17].
  • Combining systemic and localized vitamin D delivery via 3D-printed nanofiber sheets significantly enhanced tendon-to-bone healing, muscle regeneration, and biomechanical strength in a rabbit rotator cuff tear model compared to other treatment groups [19].

What the Evidence Shows

  • Educational initiatives and revised guidelines may have improved vitamin D prescription rates after fragility fracture, but awareness remains low in older adults [4].
  • Vitamin D deficiency is more prevalent among arthroplasty patients presenting in winter [5].
  • Regular vitamin D supplementation significantly reduces the likelihood of vitamin D deficiency [5].
  • Preoperative vitamin D screening and potential supplementation are important for patients with vitamin D levels below 20 ng/mL undergoing hip fracture surgery under general anesthesia [8].
  • Vitamin D deficiency is associated with increased short- and long-term mortality in patients receiving hip fracture surgery under general anesthesia [8].
  • Nonselective preoperative vitamin D supplementation is more cost-effective than selective supplementation in arthroscopic rotator cuff repair, likely due to lower costs compared to serum assays [9].
  • Determining preoperative vitamin D levels and providing supplementation if deficiency is present may be beneficial for preventing delayed wound healing after open carpal tunnel release surgery [10].
  • Vitamin D deficiency is associated with increased risk of periprosthetic joint infection and complications after primary total joint arthroplasty [11].
  • Further research is necessary to elucidate the direct role of vitamin D in the pathogenesis of rotator cuff tears and its impact on clinical outcomes after rotator cuff surgery and total shoulder arthroplasty [12].
  • Vitamin D may support tendon healing, particularly in rotator cuff repair, but current studies are low quality and limited to a single tendon group [6].
  • Supplementation with vitamin D 10,000 IU/day for 8 weeks can increase vitamin D levels to >50 ng/dl to optimally act as an immunomodulator in tuberculosis spondylitis patients [14].
  • Sixteen weeks of high-intensity interval training and vitamin D consumption showed greater benefits for bone mineral density levels in women with osteoporosis than either intervention alone [15].
  • Low-dose vitamin D supplementation was beneficial for vitamin D–sufficient total knee arthroplasty patients to achieve higher levels and maintain sufficiency [16].
  • Deficient total knee arthroplasty patients benefited from medium-to-high dose vitamin D supplementation, though only 33.7% achieved repletion [16].
  • Perioperative vitamin D supplementation may enhance early recovery and lower complication rates after total knee arthroplasty [20].
  • Supplementation with 50,000 international units vitamin D3 on the day of surgery failed to demonstrate statistically significant differences in functional Knee Society Score, Timed Up and Go Test times, or complications in the early postoperative period compared to placebo [21].
  • Regular sling core stabilization training based on calcium and vitamin D supplementation can improve bone mineral density and prevent low back pain in a patient with primary osteoporosis over a 6-year period [22].

Practical Considerations

  • Educational initiatives and revised guidelines may have improved vitamin D prescription rates after fragility fracture, but awareness remains a need, particularly in older adults [4].
  • Regular vitamin D supplementation significantly reduces the likelihood of vitamin D deficiency in arthroplasty patients presenting in winter [5].
  • Evidence suggests vitamin D may support tendon healing, particularly in rotator cuff repair, but studies remain low quality and limited to a single tendon group [6].
  • Vitamin D deficiency is associated with adverse body composition in adolescents, highlighting the need for targeted interventions to optimize musculoskeletal and metabolic health during this developmental window [7].
  • Nonselective preoperative vitamin D supplementation appears to be more cost-effective than selective supplementation in arthroscopic rotator cuff repair, likely due to the lower cost of 25(OH)D supplementation compared to serum assays [9].
  • Determining vitamin D levels preoperatively and providing supplementation if deficiency is present may be beneficial for preventing delayed wound healing after open carpal tunnel release surgery [10].
  • Administering an oral 300,000 U single-dose vitamin D regimen to correct vitamin D deficiency can positively impact outcomes following primary total joint arthroplasty [11].
  • Low-dose vitamin D supplementation was beneficial for vitamin D–sufficient total knee arthroplasty patients to achieve higher levels and maintain sufficiency, while deficient patients benefitted from medium-to-high dose supplementation [16].
  • Only 33.7% of vitamin D–deficient total knee arthroplasty patients achieved repletion with medium-to-high dose supplementation [16].
  • Vitamin D deficiency is associated with adverse medical outcomes following total shoulder arthroplasty, including increased rates of readmission and periprosthetic fractures [18].

Key Evidence

  • [L1] More research is needed to determine the effect of vitamin D supplementation on bone health and injury risk in this population. [1] (10.1177/23259671231220371)
  • [L3] These results identify a population with increased odds of injury and provide valuable knowledge as we expand our understanding of the relationship between vitamin D and musculoskeletal health. [2] (10.1016/j.arthro.2023.04.011)
  • [L3] These findings suggest that vitamin D status should be assessed in high-risk populations to guide preventive strategies focused on maintaining optimal levels. [3] (10.1177/03635465261441254)
  • [L3] Educational initiatives and revised guidelines may have improved prescription rates, but there is a need to raise awareness about the importance of vitamin D for bone health, particularly in older adults. [4] (10.5435/jaaos-d-23-00932)
  • [L3] Regular vitamin D supplementation significantly reduces the likelihood of deficiency. [5] (10.1186/s13018-025-06482-9)
  • [L4] Although evidence suggests vitamin D may support tendon healing, particularly in rotator cuff repair, studies remain low quality and limited to a single tendon group. [6] (10.1177/23259671251371300)
  • [L3] These findings highlight the need for targeted interventions to optimize musculoskeletal and metabolic health during this developmental window. [7] (10.1186/s13018-025-06091-6)
  • [L2] These findings highlight the importance of preoperative vitamin D screening and potential supplementation strategies for patients who have vitamin D levels below 20 ng/mL. [8] (10.1016/j.arth.2025.04.080)
  • [L4] Nonselective supplementation appears to be more cost-effective than selective supplementation, likely due to the lower cost of 25(OH)D supplementation compared to serum assays. [9] (10.1016/j.jse.2023.05.007)
  • [L3] Determining vitamin D levels preoperatively and providing supplementation if deficiency is present may be beneficial for preventing delayed wound healing. [10] (10.5435/jaaos-d-25-00410)
  • [L3] Administering an oral 300,000 U single-dose vitamin D regimen to correct vitamin D deficiency can positively impact outcomes following primary TJA. [11] (10.1016/j.arth.2024.05.012)
  • [L4] Further research is necessary to elucidate the direct role of vitamin D in the pathogenesis of rotator cuff tears and its impact on clinical outcomes after rotator cuff surgery and total shoulder arthroplasty. [12] (10.5397/cise.2024.00220)
  • [L5] The study aimed to compare the efficacy of a nanofiber-based vitamin D sheet versus vitamin D supplementation on tendon-to-bone healing and muscle regeneration in a rabbit model, though specific conclusion statements were not fully provided in the text. [13] (10.1016/j.jse.2023.02.077)
  • [L1] Supplementation with vitamin D 10,000 IU/day for 8 weeks can increase vitamin D levels >50 ng/dl to optimally act as an immunomodulator. [14] (10.1186/s13018-023-04445-6)
  • [L1] Sixteen weeks of HIIT and vitamin D consumption showed greater benefits for BMD levels in women with osteoporosis than either vitamin D consumption or HIIT training alone. [15] (10.1186/s12891-025-08275-x)
  • [L3] Low-dose vitamin D supplementation was beneficial for vitamin D–sufficient TKA patients to achieve higher levels and maintain sufficiency, while deficient patients benefitted from medium-to-high dose supplementation, though only 33.7% achieved repletion. [16] (10.5435/jaaos-d-24-00005)
  • [L2] Active vitamin D3 treatment promoted fracture healing by affecting the levels of these immune factors. [17] (10.1186/s13018-023-03777-7)
  • [L3] The observed association between vitamin D deficiency and increased rates of readmission and periprosthetic fractures suggests that addressing vitamin D levels may be linked to reduced future healthcare utilization. [18] (10.1016/j.jseint.2025.01.010)
  • [L5] Combining systemic and localized vitamin D delivery significantly enhanced tendon-to-bone healing, muscle regeneration, and biomechanical strength in a rabbit rotator cuff tear model compared to other treatment groups. [19] (10.1016/j.jse.2025.12.003)
  • [L2] Our study demonstrated that perioperative vitamin D supplementation may enhance early recovery and lower complication rates after TKA. [20] (10.1177/23259671261432670)
  • [L1] Supplementation with 50,000 international units vitamin D3 on the day of surgery failed to demonstrate statistical significant differences in functional KSS, TUGT times, or complications in the early postoperative period compared to placebo. [21] (10.1016/j.arth.2022.08.020)
  • [L4] Regular sling core stabilization training based on calcium and vitamin D supplementation can improve bone mineral density and prevent low back pain in a patient with primary osteoporosis over a 6-year period. [22] (10.1186/s12891-023-06896-8)
  • [L4] These parameters might be considered diagnostic non-invasive predictors of bone health for clinical use in epidemiological contexts. [23] (10.1186/s12891-023-06960-3)

References

[1] Effects of Vitamin D Supplementation in Elite Athletes: A Systematic Review. Orthopaedic Journal of Sports Medicine. 2024. DOI: 10.1177/23259671231220371

[2] A Diagnosis of Vitamin D Deficiency Is Associated With Increased Rates of Anterior Cruciate Ligament Tears and Reconstruction Failure. Arthroscopy. 2023. DOI: 10.1016/j.arthro.2023.04.011

[3] Vitamin D and the Risk of Stress Fractures in Athletes and Military Personnel: A Systematic Review and Meta-analysis. The American Journal of Sports Medicine. 2026. DOI: 10.1177/03635465261441254

[4] Forgetting the Frail: National Trends in Vitamin D Prescription After Fragility Fracture—A Large Insurance Claims Database Study. Journal of the American Academy of Orthopaedic Surgeons. 2024. DOI: 10.5435/jaaos-d-23-00932

[5] Higher prevalence of vitamin D deficiency among arthroplasty patients presenting in winter. Journal of Orthopaedic Surgery and Research. 2025. DOI: 10.1186/s13018-025-06482-9

[6] The Role of Vitamin D in Postoperative Tendon Healing: A Scoping Review. Orthopaedic Journal of Sports Medicine. 2025. DOI: 10.1177/23259671251371300

[7] Vitamin D deficiency and adverse body composition in adolescents. Journal of Orthopaedic Surgery and Research. 2025. DOI: 10.1186/s13018-025-06091-6

[8] Impact of Vitamin D Deficiency on Short- and Long-Term Mortality in Patients Receiving Hip Fracture Surgery Under General Anesthesia: A Matched Cohort Study. The Journal of Arthroplasty. 2025. DOI: 10.1016/j.arth.2025.04.080

[9] Preoperative vitamin D supplementation is a cost-effective intervention in arthroscopic rotator cuff repair. Journal of Shoulder and Elbow Surgery. 2023. DOI: 10.1016/j.jse.2023.05.007

[10] The Effect of Serum Vitamin D Level on Wound Healing Process After Open Carpal Tunnel Release Surgery: Clinical Outcomes of 55 Cases. Journal of the American Academy of Orthopaedic Surgeons. 2025. DOI: 10.5435/jaaos-d-25-00410

[11] Effect of Vitamin D Deficiency on Periprosthetic Joint Infection and Complications After Primary Total Joint Arthroplasty. The Journal of Arthroplasty. 2024. DOI: 10.1016/j.arth.2024.05.012

[12] The role of vitamin D in shoulder health: a comprehensive review of its impact on rotator cuff tears and surgical results. Clinics in Shoulder and Elbow. 2024. DOI: 10.5397/cise.2024.00220

[13] The Effect Of Nanofiber-Based Vitamin D Sheet For Tendon-To-Bone Healing And Muscle Regeneration In A Rabbit Rotator Cuff Tear Model. Journal of Shoulder and Elbow Surgery. 2023. DOI: 10.1016/j.jse.2023.02.077

[14] Randomized controlled trial of vitamin d supplementation on toll-like receptor-2 (tlr-2) and toll-like receptor-4 (tlr-4) in tuberculosis spondylitis patients. Journal of Orthopaedic Surgery and Research. 2023. DOI: 10.1186/s13018-023-04445-6

[15] Concurrent effects of high-intensity interval training and vitamin D supplementation on bone metabolism among women diagnosed with osteoporosis: a randomized controlled trial. BMC Musculoskeletal Disorders. 2025. DOI: 10.1186/s12891-025-08275-x

[16] Vitamin D Supplementation May Prevent or Treat Deficiency After Total Knee Arthroplasty: A Retrospective Cohort Analysis. Journal of the American Academy of Orthopaedic Surgeons. 2024. DOI: 10.5435/jaaos-d-24-00005

[17] Determination of immune factor levels in serum and local hematoma samples of osteoporotic fracture patients and clinical study of the effect of active vitamin D3 treatment on immune factor levels. Journal of Orthopaedic Surgery and Research. 2023. DOI: 10.1186/s13018-023-03777-7

[18] Vitamin D deficiency is associated with adverse medical outcomes following total shoulder arthroplasty. JSES International. 2025. DOI: 10.1016/j.jseint.2025.01.010

[19] Localized vitamin D delivery via 3D-printed nanofiber sheets combined with systemic supplementation enhances tendon-to-bone healing in a rabbit rotator cuff tear model: a preclinical study. Journal of Shoulder and Elbow Surgery. 2026. DOI: 10.1016/j.jse.2025.12.003

[20] Effect of Vitamin D Supplementation on Total Knee Arthroplasty Outcomes: A Systematic Review. Orthopaedic Journal of Sports Medicine. 2026. DOI: 10.1177/23259671261432670

[21] Vitamin D3 Supplementation Prior to Total Knee Arthroplasty: A Randomized Controlled Trial. The Journal of Arthroplasty. 2023. DOI: 10.1016/j.arth.2022.08.020

[22] Regular sling core stabilization training improves bone density based on calcium and vitamin D supplementation. BMC Musculoskeletal Disorders. 2023. DOI: 10.1186/s12891-023-06896-8

[23] Hand grip strength, vitamin D status, and diets as predictors of bone health in 6–12 years old school children. BMC Musculoskeletal Disorders. 2023. DOI: 10.1186/s12891-023-06960-3

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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.

Creative Commons is not a party to its public licenses. Notwithstanding, Creative Commons may elect to apply one of its public licenses to material it publishes and in those instances will be considered the “Licensor.” The text of the Creative Commons public licenses is dedicated to the public domain under the CC0 Public Domain Dedication. Except for the limited purpose of indicating that material is shared under a Creative Commons public license or as otherwise permitted by the Creative Commons policies published at creativecommons.org/policies, Creative Commons does not authorize the use of the trademark "Creative Commons" or any other trademark or logo of Creative Commons without its prior written consent including, without limitation, in connection with any unauthorized modifications to any of its public licenses or any other arrangements, understandings, or agreements concerning use of licensed material. For the avoidance of doubt, this paragraph does not form part of the public licenses.

Creative Commons may be contacted at creativecommons.org.