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Testosterona, esteroides anabolizantes e saúde musculoesquelética

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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
Uma estrutura molecular ao lado de um pequeno frasco.
A testosterona influencia os músculos e os ossos; os níveis do hormônio e a suplementação têm implicações musculoesqueléticas que vale a pena entender. Kieran Hirpara 4.0

Esta página foi traduzida automaticamente e ainda não foi verificada por um médico. A versão em inglês é a versão oficial.

O que é

Os esteroides anabolizantes são versões sintéticas da testosterona, o hormônio que determina a força dos músculos e dos ossos nos homens. A terapia de reposição de testosterona (TRT) é uma forma de testosterona prescrita para pessoas cujos próprios níveis estão baixos. Um grupo mais recente de medicamentos, chamados SARMs (moduladores seletivos do receptor androgênico), age de maneira semelhante, aumentando a massa muscular sem usar a própria testosterona.

Algumas pessoas usam esses medicamentos para tratar uma condição médica. Outras os usam para ganhar massa muscular para o esporte ou por estética. Os dois grupos devem saber que esses medicamentos afetam os tendões, os cordões fortes que ligam o músculo ao osso. Pesquisas associaram o uso de testosterona a um risco maior de rupturas do manguito rotador [1], lesões do tendão do bíceps [2] e lesões do tendão do quadríceps em até 1 ano após a compra do medicamento com receita [3]. Um estudo constatou que os usuários de testosterona tinham um risco 2,9 vezes maior de ruptura de tendão em comparação com os não usuários [4]. O uso de SARMs também está associado a danos nos tendões [5].

A relação parece funcionar nos dois sentidos. O excesso de testosterona parece sobrecarregar os tendões e as articulações. A falta também causa problemas, porque o hipogonadismo (testosterona muito baixa) parece ter um efeito prejudicial sobre o sistema musculoesquelético [6]. Estudos também relacionaram os níveis de testosterona à osteoartrite, o tipo de artrite causado por desgaste [7].

Se você usa testosterona prescrita e vai fazer uma cirurgia, informe o seu médico. Isso muda parte da avaliação de risco de operações como a prótese de ombro e o reparo do manguito rotador.

Funciona mesmo?

Não há uma resposta simples aqui, porque esses medicamentos fazem coisas diferentes em diferentes partes do seu corpo.

A testosterona pode aumentar a força dos músculos e dos ossos. Quatro ensaios clínicos randomizados (estudos em que as pessoas são sorteadas para receber ou não um tratamento) constataram que a testosterona administrada no período da cirurgia melhorou os resultados clínicos, a composição corporal e a densidade mineral óssea em cirurgias ortopédicas [8]. Pesquisas também apontaram uma possível forma de melhorar a consolidação de fraturas atuando sobre o eixo andrógeno/receptor androgênico no periósteo (a fina camada de tecido que recobre o osso) [9].

Mas os mesmos hormônios podem sobrecarregar os tendões e as articulações. Pacientes que compraram com receita a terapia de reposição de testosterona tiveram uma probabilidade muito maior de sofrer uma lesão no músculo ou no tendão do quadríceps em até 1 ano após a compra, e tiveram risco maior de precisar de reparo cirúrgico do tendão do quadríceps [3]. Pacientes que receberam prescrição de pelo menos 3 meses de terapia de reposição de testosterona tiveram uma incidência significativamente maior de lesões do LCA (ligamento cruzado anterior) em comparação com o grupo controle, em um período de acompanhamento de 2 anos [10]. O uso de terapia de reposição de testosterona injetável em até 1 ano após a primeira reconstrução do LCA está associado a um aumento de 3,3 vezes nas taxas de revisão da reconstrução do LCA, com 2 anos de acompanhamento [11]. Um estudo de randomização mendeliana bidirecional (um estudo genético que testa causa e efeito) confirmou uma relação causal entre os níveis de testosterona biodisponível e a osteoartrite, identificando os níveis de testosterona biodisponível como um fator de risco para a osteoartrite [7].

Os resultados cirúrgicos são mistos. Pacientes com prescrição de testosterona suplementar tiveram um risco maior de nova operação por qualquer causa e de nova operação por infecção após a artroplastia total do ombro (prótese de ombro) [12]. O uso de terapia de reposição de testosterona antes da operação não foi associado a mais complicações de curto prazo após o reparo artroscópico do manguito rotador (cirurgia do tendão do ombro por vídeo) [13]. Pacientes em terapia com testosterona devem ser orientados sobre o risco maior de complicações após o reparo do tendão distal do bíceps, e tanto a estratificação de risco quanto a otimização antes da cirurgia devem ser usadas para minimizar o risco no período da cirurgia [14]. A suspensão da terapia de reposição de testosterona antes do reparo do manguito rotador deve ser considerada caso a caso [15]. O uso de esteroides anabolizantes pode contribuir para a ruptura do peitoral maior (uma ruptura do grande músculo do peito), mas continuar o uso durante a recuperação não parece ter efeito negativo sobre a recuperação funcional [16].

Tanto o excesso quanto a falta de testosterona parecem ter um efeito prejudicial sobre o sistema musculoesquelético (os seus músculos, tendões, ossos e articulações) [6].

Quais são os riscos?

Os riscos mais claros estão nos seus tendões. Pesquisas associam o uso de testosterona a uma chance maior de lesão do tendão do quadríceps [17]. Os usuários de SARMs costumam tomar doses muito maiores do que as estudadas, e relatos de casos associam isso a danos nos tendões [18]. Tanto os esteroides anabolizantes quanto a testosterona muito baixa podem prejudicar os seus músculos, tendões, ossos e articulações [6].

As suas articulações também podem ser afetadas. Um estudo genético encontrou uma relação causal entre os níveis de testosterona biodisponível e a osteoartrite [7]. A relação não é uma linha reta, portanto manter a testosterona em uma faixa saudável pode ser importante para a saúde das articulações [19].

Se você usa testosterona e precisa de cirurgia, os riscos mudam. O uso de testosterona está associado a um risco maior de novas operações após a prótese de ombro, tanto por infecção quanto por qualquer outro motivo [20]. Também é um possível fator de risco para complicações e nova operação após o reparo do manguito rotador, embora um estudo não tenha encontrado relação com problemas de curto prazo após a cirurgia do manguito rotador por vídeo [15] [13]. Suspender a testosterona antes do reparo do manguito rotador é uma decisão tomada caso a caso [15]. Pacientes em uso de testosterona têm risco maior de complicações após o reparo do tendão distal do bíceps, por isso os médicos avaliam e preparam você cuidadosamente antes da cirurgia para reduzir esse risco [14].

Alguns resultados apontam na direção contrária. Quatro ensaios clínicos randomizados constataram que a testosterona administrada no período da cirurgia melhorou os resultados clínicos, a composição corporal e a densidade mineral óssea em cirurgias ortopédicas [8]. O uso de esteroides anabolizantes pode contribuir para a ruptura do peitoral maior, uma ruptura do grande músculo do peito, mas continuar os medicamentos durante a recuperação não parece prejudicar a qualidade da sua recuperação [16].

Algumas questões continuam em aberto. As evidências sobre uma possível relação entre a suplementação de testosterona e o acidente vascular cerebral (AVC) em adultos jovens são limitadas e pouco estudadas [21]. E a testosterona aumenta o risco de ruptura de tendão nos homens, mas não nas mulheres, possivelmente porque homens e mulheres recebem doses diferentes [22].

É a opção certa para você?

Esses medicamentos servem para pessoas diferentes, por motivos diferentes. A testosterona prescrita pode ajudar se os seus próprios níveis estiverem baixos, e pode aumentar a força dos músculos e dos ossos. Quatro ensaios clínicos randomizados constataram que a testosterona administrada no período da cirurgia melhorou os resultados clínicos, a composição corporal e a densidade mineral óssea em cirurgias ortopédicas [8]. Mas os mesmos hormônios podem sobrecarregar os tendões e as articulações, e pesquisas associam o uso de testosterona a uma chance maior de lesão do tendão do quadríceps [17]. Um estudo genético também encontrou uma relação causal entre os níveis de testosterona biodisponível e a osteoartrite [7]. A relação não é uma linha reta, portanto manter a testosterona em uma faixa saudável pode ser importante para a saúde das articulações [19].

Os SARMs são uma decisão mais difícil. Eles podem aumentar a massa magra em doses baixas, mas relatos de casos sugerem que os usuários tomam doses muito maiores do que as estudadas, o que aumenta o risco de danos nos tendões, lesão no fígado e eventos cardiovasculares [18]. O uso de SARMs também está associado a danos ao fígado e ao coração e a efeitos colaterais androgênicos em todo o corpo [5]. Não há bons ensaios clínicos mostrando que eles são seguros, e órgãos de saúde pública pediram a regulamentação desses compostos vendidos no mercado paralelo [23].

Se você usa testosterona e vai fazer uma cirurgia, o seu médico deve avaliar o seu perfil de risco individual antes que vocês decidam juntos [14]. O seu estado hormonal deve fazer parte de qualquer avaliação dos riscos para os seus músculos, tendões e articulações [24]. Esta é uma decisão compartilhada, tomada com o seu médico, com base na sua própria saúde e nos seus objetivos.

Conclusão

Se os seus níveis de testosterona estiverem baixos, a testosterona prescrita pode ajudar os seus músculos e ossos. Mas esses hormônios podem sobrecarregar os tendões e as articulações, e os riscos aumentam com doses mais altas. Se você vai fazer uma cirurgia, informe o seu médico sobre qualquer uso de testosterona ou de SARMs, porque isso muda a forma como os seus riscos são avaliados. A ressalva mais importante: tanto o excesso quanto a falta de testosterona podem prejudicar o seu corpo, portanto qualquer decisão deve ser tomada caso a caso com o seu médico.

Referências

[1] 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

[2] 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

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

[4] 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

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

[6] Testosterone. JBJS Reviews. 2024. DOI: 10.2106/jbjs.rvw.24.00061

[7] The causal impact of bioavailable testosterone levels on osteoarthritis: a bidirectional Mendelian randomized study. BMC Musculoskeletal Disorders. 2025. DOI: 10.1186/s12891-025-08626-8

[8] Perioperative Testosterone Supplementation Improves Outcomes of Orthopaedic Surgeries: A Systematic Review of Heterogeneous Studies. Arthroscopy. 2024. DOI: 10.1016/j.arthro.2024.12.026

[9] Targeted activation of androgen receptor signaling in the periosteum improves bone fracture repair. Cell Death & Disease. 2022. DOI: 10.1038/s41419-022-04595-1

[10] Prescription Testosterone Is Associated With an Increased Risk of Anterior Cruciate Ligament Injury. Arthroscopy. 2024. DOI: 10.1016/j.arthro.2024.10.032

[11] Injectable Testosterone Replacement Therapy Within 1 Year Before ACL Reconstruction Is Associated With Increased Revision Rates. Orthopaedic Journal of Sports Medicine. 2026. DOI: 10.1177/23259671251399845

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

[13] Association of preoperative testosterone replacement therapy with postoperative complications following rotator cuff repair. Journal of Shoulder and Elbow Surgery. 2026. DOI: 10.1016/j.jse.2025.12.013

[14] 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

[15] 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

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

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

[18] Poster 390: Systematic Review of SARMs Abuse in Athletes. Orthopaedic Journal of Sports Medicine. 2023. DOI: 10.1177/2325967123s00352

[19] Correlation between low testosterone levels and the risk of osteoarthritis: a cross-sectional analysis of NHANES data (2011–2016). BMC Musculoskeletal Disorders. 2025. DOI: 10.1186/s12891-024-08272-6

[20] 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

[21] Testosterone supplementation and stroke in young adults: a review of the literature. Frontiers in Neurology. 2024. DOI: 10.3389/fneur.2024.1422931

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

[23] Athlete SARMs Abuse: A Systematic Review. Journal of ISAKOS. 2023. DOI: 10.1016/j.jisako.2023.03.427

[24] 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

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.

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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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.