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Testosterone, Anabolic Steroids and Musculoskeletal Health

How testosterone, testosterone replacement therapy and anabolic steroids affect tendons, joints, bone and surgical outcomes — including the risks of TRT and the effects of anabolic-androgenic steroid use.

Overview

Testosterone levels exhibit a threshold-dependent relationship with shoulder pathology [1], and hormonal status should be considered in musculoskeletal risk assessment [1]. There is a non-linear relationship between low testosterone levels and the risk of osteoarthritis (OA) [4], with bioavailable testosterone levels serving as a risk factor that supports a causal relationship between bioavailable testosterone levels and OA [10]. Maintaining optimal testosterone levels may be important for joint health [4].

Clinicians should prescribe testosterone replacement therapy (TRT) judiciously with a thorough assessment of each patient's unique risk profile [2]. It is premature to imply causation between testosterone replacement therapy (TRT) and anterior cruciate ligament (ACL) injuries based on existing results due to confounding variables [2]. Surgeons should discuss endocrinologic history with patients and counsel those with testosterone deficiency on the risks for injury or re-injury [5]. Data regarding the safety and association of testosterone supplementation with stroke in young adults remains limited and underexplored [7].

Testosterone use is associated with an increased risk of rotator cuff tears (RCTs) [8], an increased risk of rotator cuff repairs (RCRs) [8], and an increased risk of subsequent rotator cuff repairs (RCRs) [8]. Testosterone use is associated with a higher risk of infection-related reoperations after primary total shoulder arthroplasty in male patients [17] and a higher risk of all-cause reoperations after primary total shoulder arthroplasty in male patients [17]. Further research is needed to understand the mechanism by which testosterone increases the risk of reoperation after total shoulder arthroplasty (TSA) [9].

Four randomized controlled trials found that perioperative testosterone supplementation improved clinical outcomes in orthopaedic surgeries [3]. Perioperative testosterone supplementation improved body composition in orthopaedic surgeries [3] and improved bone mineral density (BMD) in orthopaedic surgeries [3]. Anabolic steroid use may contribute to pectoralis major rupture in body builders [6], yet continuation of anabolic steroids during recovery from pectoralis major rupture does not seem to have a negative effect on functional recovery [6].

Background & Causes

Hormonal Status and Pathology Risk: Testosterone levels exhibit a threshold-dependent relationship with shoulder pathology [1], and bioavailable testosterone levels are a risk factor for osteoarthritis (OA), supporting a causal relationship between bioavailable testosterone levels and OA [10]. A non-linear relationship exists between low testosterone levels and the risk of OA [4], suggesting that maintaining optimal testosterone levels may be important for joint health [4]. Hormonal status should be considered in musculoskeletal risk assessment [1].

Tendon and Ligament Integrity: Testosterone users had a 2.9-fold increased risk of tendon rupture compared to nonusers [13]. Testosterone replacement therapy is associated with increased odds of surgically treated tendon rupture [11]. 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 [12]. There is an increased risk of rotator cuff tears (RCTs), rotator cuff repairs (RCRs), and subsequent RCRs in patients prescribed testosterone [8]. Anabolic steroid use may contribute to pectoralis major rupture [6], though continuation of anabolic steroids during recovery from pectoralis major rupture does not seem to have a negative effect on functional recovery [6].

Surgical Outcomes and Reoperation: Testosterone deficiency is associated with poorer postoperative outcomes in total joint arthroplasty, with distinct patterns observed in total hip arthroplasty (THA) and total knee arthroplasty (TKA) [15]. Prescription testosterone is associated with a higher risk of both infection-related and all-cause reoperations after primary total shoulder arthroplasty in male patients [17]. Further research is needed to understand the mechanism by which testosterone increases the risk of reoperation after total shoulder arthroplasty (TSA) [9].

Therapeutic Considerations and Safety: Testosterone supplementation improves clinical outcomes, body composition, and bone mineral density (BMD) in orthopaedic surgeries [3], although evidence regarding orthopaedic perioperative use of TRT is heterogeneous [3]. It is premature to imply causation between testosterone replacement therapy (TRT) and anterior cruciate ligament (ACL) injuries based on existing results due to confounding variables [2]. Clinicians should remain vigilant and prescribe TRT judiciously with a thorough assessment of each patient's unique risk profile [2]. Surgeons should discuss endocrinologic history with patients and counsel those with testosterone deficiency on the risks for injury or re-injury [5]. Data regarding the safety and association of testosterone supplementation with stroke in young adults remains limited and underexplored [7]. Selective androgen receptor modulator (SARM) use is associated with increased muscle mass, hepatotoxicity, cardiotoxicity, tendon damage, and androgenic side effects throughout the body [16].

Symptoms & Presentation

Hormonal Status and Joint Pathology: Testosterone levels exhibit a threshold-dependent relationship with shoulder pathology [1]. Low testosterone levels are correlated with an increased risk of osteoarthritis [4], and bioavailable testosterone levels have a causal relationship with osteoarthritis, acting as a risk factor for the condition [10]. Testosterone deficiency is associated with poorer postoperative outcomes in total joint arthroplasty, with distinct patterns observed in total hip arthroplasty and total knee arthroplasty [15].

Tendon Rupture Risk: Testosterone replacement therapy is associated with an increased risk of anterior cruciate ligament injuries [2]. Testosterone therapy is associated with an increased risk of rotator cuff tears, rotator cuff repairs, and subsequent revision rotator cuff repairs [8]. Supplemental testosterone increases the risk of reoperation after total shoulder arthroplasty [9]. Testosterone replacement therapy is associated with increased odds of surgically treated tendon rupture [11], and testosterone users have a 2.9-fold increased risk of tendon rupture compared to nonusers [13]. This increased tendon rupture risk applies to men but not women [18]. 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 [12]. Testosterone therapy is associated with increased odds of quadriceps tendon injury [5]. Patients who filled a prescription for testosterone replacement therapy were 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 [14].

Other Soft Tissue Injuries: Anabolic steroid use may contribute to pectoralis major rupture [6]. Selective androgen receptor modulator (SARM) use is associated with tendon damage [16].

Management

Risk Assessment and Counseling: Testosterone levels exhibit a threshold-dependent relationship with shoulder pathology [1]. Hormonal status should be considered in musculoskeletal risk assessment [1]. Surgeons should discuss endocrinologic history with patients and counsel those with testosterone deficiency on the risks for injury or re-injury [5].

Tendon and Ligament Injury Risk: There is an increased risk of rotator cuff tears (RCTs), rotator cuff repairs (RCRs), and subsequent RCRs in patients prescribed testosterone [8]. Testosterone users had a 2.9-fold increased risk of tendon rupture compared to nonusers [13]. Testosterone replacement therapy is associated with increased odds of surgically treated tendon rupture [11]. Patients with prior prescription testosterone exposure have an increased rate of distal biceps tendon injury compared with patients without such exposure [12]. Patients with prior prescription testosterone exposure have an increased rate of biceps tendon repair compared with patients without such exposure [12]. 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 [14]. Patients who filled a prescription for testosterone replacement therapy were at increased risk of undergoing surgical repair of the quadriceps tendon [14].

Osteoarthritis and Bone Health: There is a non-linear relationship between low testosterone levels and the risk of osteoarthritis (OA) [4]. Bioavailable testosterone levels are a risk factor for OA, supporting a causal relationship between bioavailable testosterone levels and OA [10]. Maintaining optimal testosterone levels may be important for joint health [4].

Perioperative Supplementation: Four randomized controlled trials found that perioperative testosterone supplementation improved clinical outcomes in orthopaedic surgeries [3]. Perioperative testosterone supplementation improved body composition in orthopaedic surgeries [3]. Perioperative testosterone supplementation improved bone mineral density (BMD) in orthopaedic surgeries [3].

Anabolic Steroid Use and Specific Injuries: Anabolic steroid use may contribute to pectoralis major rupture [6]. Continuation of anabolic steroids during recovery from pectoralis major rupture does not seem to have a negative effect on functional recovery [6]. Further research is needed to understand the mechanism by which testosterone increases the risk of reoperation after total shoulder arthroplasty (TSA) [9].

Prescribing Considerations: It is premature to imply causation between testosterone replacement therapy (TRT) and anterior cruciate ligament (ACL) injuries based on existing results due to confounding variables [2]. Clinicians should prescribe TRT judiciously with a thorough assessment of each patient's unique risk profile [2]. Data regarding the safety and association of testosterone supplementation with stroke in young adults remains limited and underexplored [7].

Key Considerations

Hormonal Status and Risk Assessment: Testosterone levels exhibit a threshold-dependent relationship with shoulder pathology [1]. Low testosterone levels correlate with an increased risk of osteoarthritis, suggesting that maintaining optimal testosterone levels may be important for joint health [4]. Consequently, hormonal status should be considered in musculoskeletal risk assessment [1]. Surgeons should discuss endocrinologic history with patients and counsel those with testosterone deficiency on the risks for injury or re-injury [5].

Testosterone Replacement Therapy (TRT) and Musculoskeletal Injury: There is an increased risk of rotator cuff tears (RCTs), rotator cuff repairs (RCRs), and subsequent RCRs in patients prescribed testosterone [8]. Supplemental testosterone increases the risk of reoperation after total shoulder arthroplasty (TSA), though further research is needed to understand the mechanism [9]. Testosterone replacement therapy is associated with increased odds of surgically treated tendon rupture [11]. 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 [12]. Furthermore, 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 [14].

Anabolic Steroids and Specific Injuries: Anabolic steroid use may contribute to pectoralis major rupture [6]. However, continuation of anabolic steroids during recovery from pectoralis major rupture does not seem to have a negative effect on functional recovery [6].

Clinical Management and Causality: It is premature to imply causation between testosterone replacement therapy (TRT) and anterior cruciate ligament (ACL) injuries based on existing results due to confounding variables [2]. Clinicians should remain vigilant and prescribe TRT judiciously with a thorough assessment of each patient's unique risk profile [2]. Data regarding the safety of testosterone supplementation and its association with stroke in young adults remains limited and underexplored [7].

Therapeutic Benefits: Despite injury risks, testosterone supplementation improves clinical outcomes, body composition, and bone mineral density (BMD) in orthopaedic surgeries [3].

Key Evidence

  • [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. (10.1016/j.jse.2026.01.012)
  • [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. (10.1016/j.arthro.2024.11.086)
  • [L2] Although evidence regarding orthopaedic perioperative use of testosterone replacement therapy is heterogeneous, 4 randomized controlled trials reviewed here found that testosterone supplementation improved clinical outcomes, body composition, and BMD. (10.1016/j.arthro.2024.12.026)
  • [L3] The observed non-linear relationship suggests that maintaining optimal testosterone levels may be important for joint health. (10.1186/s12891-024-08272-6)
  • [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. (10.1097/corr.0000000000002835)
  • [L4] Anabolic steroids use may contribute to the injury, but continuation during recovery does not seem to have a negative effect on functional recovery. (10.1186/s12891-023-06382-1)
  • [L4] The review highlights that while testosterone supplementation is increasing, data regarding its safety and association with stroke in young adults remains limited and underexplored. (10.3389/fneur.2024.1422931)
  • [L3] There is increased risk of RCTs, RCRs, and subsequent RCRs in patients prescribed testosterone. (10.5435/jaaos-d-22-00554)
  • [L3] Further research is needed to understand the mechanism by how testosterone increases the risk of reoperation after TSA. (10.1177/2325967124s00118)
  • [L1] The results of our study supported a causal relationship between bioavailable testosterone levels and OA, identifying bioavailable testosterone levels as a risk factor for OA. (10.1186/s12891-025-08626-8)
  • [L3] Testosterone replacement therapy is associated with increased odds of surgically treated tendon rupture. (10.1177/2325967125s00009)
  • [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. (10.1016/j.jse.2023.02.122)
  • [L3] Testosterone users had a 2.9-fold increased risk of tendon rupture compared to nonusers. (10.1177/2325967124s00339)
  • [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. (10.1097/corr.0000000000002744)
  • [L3] Testosterone deficiency is associated with poorer postoperative outcomes in total joint arthroplasty, with distinct patterns observed in THA and TKA. (10.5435/jaaos-d-25-00190)
  • [L4] SARM use is associated with increased muscle mass, hepatotoxicity, cardiotoxicity, tendon damage, and androgenic side effects throughout the body. (10.1177/03635465241252435)
  • [L2] Testosterone use is associated with a higher risk of both infection-related and all-cause reoperations after total shoulder arthroplasty. (10.1016/j.jseint.2026.101634)
  • [L3] TRT is associated with increased tendon rupture risk in men but not women, potentially due to sex-specific differences in dosing. (10.1177/23259671261430731)

References

[1] 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

[2] 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

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

[4] 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

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

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

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

[8] 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

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

[10] 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

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

[12] 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

[13] 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

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

[15] Testosterone Deficiency and Total Joint Arthroplasty Outcomes—A Large Claims Database Study. Journal of the American Academy of Orthopaedic Surgeons. 2025. DOI: 10.5435/jaaos-d-25-00190

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

[17] 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

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

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