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Vitamin D and Musculoskeletal Health

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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 Sep 202617 citations
A sun shining over a bone.
Vitamin D, the 'sunshine vitamin', is essential for bone strength and muscle function. Kieran Hirpara 4.0

What it is

Vitamin D is a nutrient your body needs to build and maintain bone. Your skin makes it from sunlight, and you also get it from some foods and supplements. When your levels are low, it is called vitamin D deficiency.

Low vitamin D matters to bones and joints. It has been linked to a higher chance of some ligament tears in the knee, and to a higher chance that a reconstructed ligament fails [1]. It has also been linked to stress fractures, which is why levels are often checked in people at higher risk of these injuries [2]. In older adults, low vitamin D matters for bone health after a fracture from a simple fall [3].

Your doctor may check your vitamin D around the time of surgery. Low levels before an operation have been linked to slower wound healing and to some complications after joint replacement [4] [5]. Checking beforehand means deficiency can be found and treated, rather than missed [6].

How it helps is still being worked out. Vitamin D plays a role in how bone heals and how the immune system behaves. It may also support tendon healing, although the research so far is small and limited to one tendon group [7]. Not every question has a clear answer yet. For example, the evidence does not currently support routine vitamin D supplementation for every patient having a knee replacement [8], and routine testing for every rotator cuff repair is not justified by current reviews [9].

In short, vitamin D is something your body needs, and low levels are a risk factor that can be found with a simple blood test and treated. Whether it matters for you depends on your health, your planned treatment, and your levels.

Does it work?

The honest answer is that it depends on what you are hoping vitamin D will do.

For bones, the picture is clearest. In postmenopausal women with osteoporosis, taking calcium and vitamin D together improved bone density in the pelvis and corrected low blood levels [1]. But the same research found it did not reduce the chance of breaking a bone [1]. So it helps the bone look better on a scan, yet that has not translated into fewer fractures in the trials done so far.

Around surgery, the results are mixed. Low vitamin D before an operation has been linked to complications after shoulder replacement, and it is something that can be treated beforehand [2]. But giving a single large dose of vitamin D on the day of knee replacement surgery did not change how well patients recovered, how quickly they got moving, or their complication rates compared with a placebo [3]. And for rotator cuff repair, a review concluded there is not enough evidence to justify testing and supplementing every patient [4].

There are real gaps in the research. Much of it is small, and some findings come from animal studies rather than trials in people [5]. Researchers are still working out who benefits from testing, who benefits from treatment, and how much vitamin D actually matters for healing after surgery.

What this means for you is simple. Vitamin D matters for bone health, and low levels are worth finding and fixing. But it is not a proven way to make surgery go better or wounds heal faster, and the evidence does not support giving it to everyone automatically. Your doctor will use your own health, your planned treatment, and your blood test results to decide whether it is relevant for you.

What are the risks?

Vitamin D treatment is not risk free, and the honest picture is that some things work and some do not.

The most common problem is that treatment does not work as well as hoped. In one study of knee replacement patients, only 33.7% of those with low levels reached a normal level, even with medium-to-high dose supplementation [1]. Giving a single large dose on the day of knee replacement surgery did not change recovery, how quickly patients got moving, or complication rates compared with a placebo [2]. And for rotator cuff repair, a review found the evidence does not justify testing and supplementing every patient [3].

There are also limits on what vitamin D can do. In postmenopausal women with osteoporosis, calcium and vitamin D together improved bone density in the pelvis but did not reduce the chance of breaking a bone [4]. Vitamin D status alone may not change your immediate recovery after surgery, although keeping levels adequate may help longer term survival after hip fracture surgery [5].

Some findings come from animal studies rather than trials in people, so they cannot be applied directly to you [6]. Evidence on tendon healing is limited to a single tendon group and the studies are low quality [7]. There is also no good safety and efficacy data for peptide supplements, so they are not recommended as a replacement or addition to standard orthopaedic care [8].

What this means for you is that vitamin D is worth checking and treating when levels are low, but it is not a guaranteed fix. Your doctor will weigh the evidence against your own situation before recommending it.

Is it right for you?

Vitamin D treatment tends to suit people whose levels are low and who are having surgery or recovering from a fracture. Regular supplementation reduces the chance of deficiency in joint replacement patients presenting in winter [1]. If your levels are already sufficient, low-dose supplementation can help you maintain them, while low levels usually need medium-to-high doses to correct [2]. Keeping your levels adequate may also improve longer term survival after hip fracture surgery, even if it does not change your immediate recovery [3].

Vitamin D is probably not for you if your levels are already normal and you have no planned treatment, or if you were hoping for a guaranteed boost to healing. It is not a replacement for standard orthopaedic care, and peptide supplements should not be used instead of or alongside it, because there is no good safety and efficacy data for them yet [4]. Researchers are also still building better ways to track injuries and health problems in female athletes, which should improve prevention advice in future [5].

The choice is one you make together with your doctor. They will look at your levels, your planned treatment, and your overall health, then discuss whether testing or supplementation makes sense for you. The possible downsides are covered in the risks section above.

The bottom line

Vitamin D is worth checking if you are having surgery or recovering from a fracture, because low levels can be found with a blood test and treated. Regular supplementation reduces the chance of deficiency in joint replacement patients presenting in winter [1]. If your levels are already sufficient, a low dose can keep them there, while low levels usually need medium-to-high doses to correct [2]. Keep your expectations realistic: treatment may not change your immediate recovery, although keeping levels adequate may help longer term after hip fracture surgery [3]. The main caveat is that vitamin D is not a guaranteed fix, and it works alongside standard care rather than replacing it.

Reviewed by Kieran Hirpara · 13 June 2026.

Want the clinical detail? Read the clinician version.

Talk to your treating clinician for advice specific to you.

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

References
  1. A Diagnosis of Vitamin D Deficiency Is Associated With Increased Rates of Anterior Cruciate Ligament Tears and Reconstruction Failure. *Arthroscopy*. 2023. 10.1016/j.arthro.2023.04.011
  2. 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. 10.1177/03635465261441254
  3. 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. 10.5435/jaaos-d-23-00932
  4. 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. 10.5435/jaaos-d-25-00410
  5. Vitamin D deficiency is associated with adverse medical outcomes following total shoulder arthroplasty. *JSES International*. 2025. 10.1016/j.jseint.2025.01.010
  6. 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. 10.1016/j.arth.2025.04.080
  7. The Role of Vitamin D in Postoperative Tendon Healing: A Scoping Review. *Orthopaedic Journal of Sports Medicine*. 2025. 10.1177/23259671251371300
  8. Effect of Vitamin D Supplementation on Total Knee Arthroplasty Outcomes: A Systematic Review. *Orthopaedic Journal of Sports Medicine*. 2026. 10.1177/23259671261432670
  9. Preoperative serum vitamin D deficiency is associated with increased rotator cuff fatty degeneration but is unlikely to influence post repair outcomes: a systematic review and meta-analysis of correlation coefficients. *JSES Reviews, Reports, and Techniques*. 2025. 10.1016/j.xrrt.2025.02.006
  10. The effects of combined calcium and vitamin D supplementation on bone mineral density and fracture risk in postmenopausal women with osteoporosis: a systematic review and meta-analysis of randomized controlled trials. *BMC Musculoskeletal Disorders*. 2025. 10.1186/s12891-025-09089-7
  11. Vitamin D3 Supplementation Prior to Total Knee Arthroplasty: A Randomized Controlled Trial. *The Journal of Arthroplasty*. 2023. 10.1016/j.arth.2022.08.020
  12. 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. 10.1016/j.jse.2023.02.077
  13. 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. 10.5435/jaaos-d-24-00005
  14. 25-Hydroxyvitamin D Levels, Free Serum Calcium, Glomerular Filtration Rate, Albumin, and Femoral Fracture Elderly Patient Mortality. *JAAOS: Global Research and Reviews*. 2026. 10.5435/jaaosglobal-d-25-00108
  15. Peptide Supplements and Their Therapeutic Applications in Sports Medicine. *The American Journal of Sports Medicine*. 2026. 10.1177/03635465261464420
  16. Higher prevalence of vitamin D deficiency among arthroplasty patients presenting in winter. *Journal of Orthopaedic Surgery and Research*. 2025. 10.1186/s13018-025-06482-9
  17. Female athlete health domains: a supplement to the International Olympic Committee consensus statement on methods for recording and reporting epidemiological data on injury and illness in sport. *British Journal of Sports Medicine*. 2023. 10.1136/bjsports-2022-106620
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

  • A diagnosis of vitamin D deficiency is associated with increased rates of anterior cruciate ligament tears and reconstruction failure [2].
  • Vitamin D status should be assessed in high-risk populations to guide preventive strategies focused on maintaining optimal levels regarding the risk of stress fractures in athletes and military personnel [3].
  • Educational initiatives and revised guidelines may have improved vitamin D prescription rates after fragility fracture, but there is a need to raise awareness about the importance of vitamin D for bone health, particularly in older adults [4].
  • Vitamin D represents a potentially modifiable risk factor that could be optimized during both surgical and nonsurgical management of patients with Charcot arthropathy [5].
  • Regular vitamin D supplementation significantly reduces the likelihood of deficiency among arthroplasty patients presenting in winter [6].
  • Evidence suggests vitamin D may support tendon healing, particularly in rotator cuff repair, although studies remain low quality and limited to a single tendon group [7].
  • Preoperative vitamin D screening and potential supplementation strategies are important for patients who have vitamin D levels below 20 ng/mL undergoing hip fracture surgery under general anesthesia [8].
  • Hand grip strength, vitamin D status, and diets might be considered diagnostic non-invasive predictors of bone health for clinical use in epidemiological contexts in 6–12 years old school children [25].

How It Works

Bone Health and Fracture Risk

  • Vitamin D deficiency is associated with increased rates of anterior cruciate ligament tears and reconstruction failure [2].
  • Vitamin D status should be assessed in high-risk populations to guide preventive strategies focused on maintaining optimal levels for stress fracture risk [3].
  • Educational initiatives and revised guidelines may have improved vitamin D prescription rates after fragility fracture, but awareness of its importance for bone health in older adults needs to be raised [4].
  • Preoperative vitamin D screening and potential supplementation strategies are important for patients who have vitamin D levels below 20 ng/mL to address short- and long-term mortality risks after hip fracture surgery [8].
  • Active vitamin D3 treatment promoted fracture healing by affecting the levels of immune factors in osteoporotic fracture patients [17].

Tendon and Soft Tissue Healing

  • Evidence suggests vitamin D may support tendon healing, particularly in rotator cuff repair, though studies remain low quality and limited to a single tendon group [7].
  • Preoperative nonselective 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].
  • 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].
  • 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 [20].

Wound Healing and Infection

  • 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 [10].
  • 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 [12].

Immune Modulation and Other

  • 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 [15].
  • Targeted interventions are needed to optimize musculoskeletal and metabolic health in adolescents with vitamin D deficiency and adverse body composition [13].

What the Evidence Shows

Fracture and Bone Health

  • 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 vitamin D consumption or high-intensity interval training alone [16].
  • Maintaining adequate vitamin D levels may improve longer-term survival after proximal femoral fracture surgery, although vitamin D status alone may not influence immediate recovery [22].

Arthroplasty and Joint Surgery

  • Preoperative vitamin D screening and potential supplementation strategies are important for patients with vitamin D levels below 20 ng/mL undergoing hip fracture surgery under general anesthesia [8].
  • Low-dose vitamin D supplementation was beneficial for vitamin D–sufficient total knee arthroplasty patients to achieve higher levels and maintain sufficiency [21].
  • Deficient total knee arthroplasty patients benefited from medium-to-high dose vitamin D supplementation, though only 33.7% achieved repletion [21].
  • Perioperative vitamin D supplementation may enhance early recovery and lower complication rates after total knee arthroplasty [23].
  • Supplementation with 50,000 international units of 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 in total knee arthroplasty patients [24].

Tendon and Soft Tissue Healing

  • Nonselective vitamin D supplementation appears to be more cost-effective than selective supplementation for arthroscopic rotator cuff repair, likely due to the lower cost of 25(OH)D supplementation compared to serum assays [9].

Other Musculoskeletal Conditions

Research Gaps and Limitations

  • More research is needed to determine the effect of vitamin D supplementation on bone health and injury risk in elite athletes [1].

Practical Considerations

Screening and Assessment

  • Vitamin D status should be assessed in high-risk populations to guide preventive strategies focused on maintaining optimal levels [3].
  • Preoperative vitamin D screening is important for patients who have vitamin D levels below 20 ng/mL [8].
  • Vitamin D deficiency is associated with adverse medical outcomes following total shoulder arthroplasty [18].
  • Vitamin D deficiency is associated with increased rates of readmission and periprosthetic fractures following total shoulder arthroplasty [18].
  • Higher prevalence of vitamin D deficiency is observed among arthroplasty patients presenting in winter [6].

Supplementation and Management

  • Regular vitamin D supplementation significantly reduces the likelihood of deficiency [6].
  • Nonselective preoperative vitamin D supplementation appears to be more cost-effective than selective supplementation in arthroscopic rotator cuff repair [9].
  • The lower cost of 25(OH)D supplementation compared to serum assays likely contributes to the cost-effectiveness of nonselective preoperative supplementation in arthroscopic rotator cuff repair [9].

Evidence Limitations and Contraindications

  • 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 [7].
  • Peptide supplements should not currently be recommended as a replacement or adjunct for existing orthopaedic standard of care due to the lack of robust efficacy and safety data [11].

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)
  • [L4] Vitamin D represents a potentially modifiable risk factor that could be optimized during both surgical and nonsurgical management of patients with Charcot arthropathy. [5] (10.5435/jaaosglobal-d-22-00162)
  • [L3] Regular vitamin D supplementation significantly reduces the likelihood of deficiency. [6] (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. [7] (10.1177/23259671251371300)
  • [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] Administering an oral 300,000 U single-dose vitamin D regimen to correct vitamin D deficiency can positively impact outcomes following primary TJA. [10] (10.1016/j.arth.2024.05.012)
  • [L5] Because of the lack of robust efficacy and safety data, peptide supplements should not currently be recommended as a replacement or adjunct for existing orthopaedic standard of care. [11] (10.1177/03635465261464420)
  • [L3] Determining vitamin D levels preoperatively and providing supplementation if deficiency is present may be beneficial for preventing delayed wound healing. [12] (10.5435/jaaos-d-25-00410)
  • [L3] These findings highlight the need for targeted interventions to optimize musculoskeletal and metabolic health during this developmental window. [13] (10.1186/s13018-025-06091-6)
  • [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. [15] (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. [16] (10.1186/s12891-025-08275-x)
  • [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)
  • [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. [20] (10.5397/cise.2024.00220)
  • [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. [21] (10.5435/jaaos-d-24-00005)
  • [L2] Although vitamin D status alone may not influence immediate recovery, maintaining adequate levels may improve longer term survival after PFF surgery. [22] (10.5435/jaaosglobal-d-25-00108)
  • [L2] Our study demonstrated that perioperative vitamin D supplementation may enhance early recovery and lower complication rates after TKA. [23] (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. [24] (10.1016/j.arth.2022.08.020)
  • [L4] These parameters might be considered diagnostic non-invasive predictors of bone health for clinical use in epidemiological contexts. [25] (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] Prevalence of Vitamin D Deficiency in Patients With Charcot Arthropathy: A Single-Center Analysis. JAAOS: Global Research and Reviews. 2022. DOI: 10.5435/jaaosglobal-d-22-00162

[6] 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

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

[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] 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

[11] Peptide Supplements and Their Therapeutic Applications in Sports Medicine. The American Journal of Sports Medicine. 2026. DOI: 10.1177/03635465261464420

[12] 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

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

[15] 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

[16] 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

[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] 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

[21] 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

[22] 25-Hydroxyvitamin D Levels, Free Serum Calcium, Glomerular Filtration Rate, Albumin, and Femoral Fracture Elderly Patient Mortality. JAAOS: Global Research and Reviews. 2026. DOI: 10.5435/jaaosglobal-d-25-00108

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

[24] 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

[25] 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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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.