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Vitamin D and Musculoskeletal Health

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

Overview

Vitamin D status is a critical determinant of musculoskeletal health across diverse populations, yet significant gaps in evidence remain regarding its specific impact on elite athletic performance and injury prevention [1]. Current data indicate that educational initiatives and revised guidelines have improved prescription rates following fragility fractures, but broader awareness of vitamin D’s role in bone health for older adults requires further emphasis [2]. Consequently, assessment of vitamin D status is recommended for high-risk groups, including athletes and military personnel, to guide preventive strategies aimed at maintaining optimal levels [3].

Deficiency is highly prevalent in several clinical contexts and is associated with distinct pathological outcomes. In orthopaedic populations, deficiency is common among arthroplasty patients, particularly those presenting in winter, and regular supplementation significantly reduces this likelihood [6]. It is also highly prevalent in knee osteoarthritis, where severity correlates with bilateral disease and polyarthralgia rather than inflammatory markers [10]. In adolescents, deficiency is independently linked to unfavorable body composition, modulated by demographic factors [5]. Furthermore, diagnosis of vitamin D deficiency is associated with increased odds of anterior cruciate ligament tears and reconstruction failure [4].

The role of vitamin D extends to diagnostic prediction and surgical outcomes. In school-aged children, hand grip strength, vitamin D status, and diet serve as non-invasive predictors of bone health suitable for epidemiological use [11]. However, 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 [13].

Background & Causes

Vitamin D deficiency is a prevalent condition across diverse orthopaedic populations, including adolescents [5], patients with knee osteoarthritis [10], and arthroplasty patients presenting in winter [6]. In adolescents, deficiency is independently associated with unfavorable body composition, modulated by demographic factors [5]. Among knee osteoarthritis patients, deficiency severity correlates with bilateral disease and polyarthralgia, though it is not associated with inflammatory markers [10]. Preoperative screening reveals that deficiency is highly prevalent in hip fracture surgery candidates under general anesthesia [7] and is linked to adverse medical outcomes following total shoulder arthroplasty [8].

Deficiency serves as a potential modifiable risk factor for postoperative complications, including reconstruction failure and anterior cruciate ligament tears [4]. In the context of rotator cuff pathology, deficiency is associated with increased proinflammatory cytokine expression in medium tears, but it is not associated with the expression of myogenesis-related or muscle atrophy–related genes in the supraspinatus muscle [20]. The direct role of vitamin D in rotator cuff tear pathogenesis and its impact on clinical outcomes after rotator cuff surgery and total shoulder arthroplasty require further elucidation [13].

Preventive strategies should include assessment in high-risk groups such as athletes and military personnel to guide stress fracture prevention [3]. Regular supplementation significantly reduces the likelihood of deficiency [6] and is indicated for hip fracture patients with levels below 20 ng/mL [7]. For open carpal tunnel release surgery, preoperative determination of vitamin D levels and subsequent supplementation may prevent delayed wound healing [12]. Active vitamin D3 treatment promotes fracture healing in osteoporotic patients by affecting immune factor levels [22].

Despite these associations, educational initiatives and revised guidelines have not fully resolved insufficient awareness regarding vitamin D’s importance for bone health in older adults [2]. In pediatric populations, hand grip strength, vitamin D status, and diet are predictive of bone health in 6–12-year-old school children and may serve as non-invasive diagnostic predictors in epidemiological contexts [11]. However, the effects of supplementation on bone health and injury risk in elite athletes require further research [1]. Future prospective cohort studies and randomized controlled trials are necessary to establish causality regarding vitamin D’s role in postoperative tendon healing, assess its effects across various tendons, and determine optimal supplementation strategies [14].

Symptoms & Presentation

Vitamin D deficiency is highly prevalent in specific orthopaedic populations, including adolescents [5], patients with knee osteoarthritis [10], and arthroplasty patients presenting in winter [6]. In adolescents, deficiency is independently associated with unfavorable body composition, a relationship modulated by demographic factors [5]. Among knee osteoarthritis patients, the severity of deficiency correlates with bilateral disease and polyarthralgia, but not with inflammatory markers [10].

Clinically, deficiency is linked to adverse outcomes in ligamentous and arthroplasty contexts. It is associated with increased rates of anterior cruciate ligament tears and increased odds of reconstruction failure [4]. Furthermore, vitamin D deficiency is associated with adverse medical outcomes following total shoulder arthroplasty [8].

Management

Assessment and Screening: Vitamin D status should be assessed in high-risk populations, such as athletes and military personnel, to guide preventive strategies for stress fractures [3]. A diagnosis of vitamin D deficiency is associated with increased odds of anterior cruciate ligament tears and reconstruction failure [4]. Deficiency is prevalent among adolescents and is independently associated with unfavorable body composition, modulated by demographic factors [5]. Among arthroplasty patients, deficiency has a higher prevalence among those presenting in winter [6]. Preoperative vitamin D screening and potential supplementation strategies are important for hip fracture surgery patients with vitamin D levels below 20 ng/mL [7].

Supplementation Strategies: Regular vitamin D supplementation significantly reduces the likelihood of vitamin D deficiency in arthroplasty patients [6]. Administering an oral 300,000 U single-dose vitamin D regimen to correct deficiency can positively impact outcomes following primary total joint arthroplasty [9]. Determining preoperative vitamin D levels and providing supplementation if deficiency is present may be beneficial for preventing delayed wound healing after open carpal tunnel release surgery [12]. Nonselective preoperative vitamin D supplementation appears 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 [15].

Joint Arthroplasty Outcomes: Vitamin D deficiency is associated with adverse medical outcomes following total shoulder arthroplasty [8]. Orthopedic surgeons should recognize vitamin D deficiency as a potential modifiable risk factor for postoperative complications in total shoulder arthroplasty [8]. Low-dose vitamin D supplementation was beneficial for vitamin D–sufficient total knee arthroplasty patients to achieve higher levels and maintain sufficiency [17]. Deficient total knee arthroplasty patients benefited from medium-to-high dose vitamin D supplementation, though only 33.7% achieved repletion [17].

Special Populations and Adjuncts: 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 raising [2]. Vitamin D supplementation effects on bone health and injury risk in elite athletes require further research [1]. Supplementation with vitamin D 10,000 IU/day for 8 weeks can increase vitamin D levels to >50 ng/dl to optimally act as an immunomodulator in tuberculosis spondylitis patients [16]. High-intensity interval training combined with vitamin D consumption may be a strategic option to prevent bone mineral density reduction with aging or to slow demineralization in women with osteoporosis [18]. Combining systemic and localized vitamin D delivery via 3D-printed nanofiber sheets significantly enhanced tendon-to-bone healing, muscle regeneration, and biomechanical strength in a rabbit rotator cuff tear model [19]. Regular sling core stabilization training based on calcium and vitamin D supplementation can improve bone mineral density and prevent low back pain in a patient with primary osteoporosis over a 6-year period [21].

Key Considerations

Assessment and Demographics: Vitamin D status requires assessment in high-risk populations, including athletes and military personnel, to guide preventive strategies [3]. Deficiency is prevalent among adolescents and is independently associated with unfavorable body composition, modulated by demographic factors [5]. A higher prevalence of vitamin D deficiency occurs among arthroplasty patients presenting in winter [6].

Orthopedic Injury and Deficiency: A diagnosis of vitamin D deficiency is associated with increased rates of anterior cruciate ligament tears and reconstruction failure [4]. Lower preoperative serum vitamin D levels correlate strongly with lower tissue vitamin D levels and lower serum levels at 1 year after rotator cuff repair [23].

Arthroplasty Outcomes and Management: Vitamin D deficiency is associated with adverse medical outcomes following total shoulder arthroplasty [8]. Orthopedic surgeons should recognize vitamin D deficiency as a potential modifiable risk factor for postoperative complications in this procedure [8]. Regular vitamin D supplementation significantly reduces the likelihood of deficiency in arthroplasty patients [6]. Preoperative screening and supplementation are important for hip fracture surgery patients under general anesthesia with levels below 20 ng/mL [7]. Administering an oral 300,000 U single-dose regimen to correct deficiency can positively impact outcomes following primary total joint arthroplasty [9].

Public Health and Research Gaps: Educational initiatives and revised guidelines may have improved prescription rates after fragility fracture, but awareness of vitamin D’s importance for bone health in older adults needs raising [2]. More research is needed to determine the effect of supplementation on bone health and injury risk in elite athletes [1]. Future prospective cohort studies and randomized controlled trials are required to establish causality, assess effects across various tendons, and determine optimal supplementation strategies for postoperative tendon healing [14].

Key Evidence

  • [L1] More research is needed to determine the effect of vitamin D supplementation on bone health and injury risk in this population. (10.1177/23259671231220371)
  • [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. (10.5435/jaaos-d-23-00932)
  • [L3] These findings suggest that vitamin D status should be assessed in high-risk populations to guide preventive strategies focused on maintaining optimal levels. (10.1177/03635465261441254)
  • [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. (10.1016/j.arthro.2023.04.011)
  • [L3] Vitamin D deficiency is prevalent among adolescents and independently associated with unfavorable body composition, modulated by demographic factors. (10.1186/s13018-025-06091-6)
  • [L3] Regular vitamin D supplementation significantly reduces the likelihood of deficiency. (10.1186/s13018-025-06482-9)
  • [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. (10.1016/j.arth.2025.04.080)
  • [L3] Orthopedic surgeons should recognize vitamin D deficiency as a potential modifiable risk factor for postoperative complications in TSA. (10.1016/j.jseint.2025.01.010)
  • [L3] Administering an oral 300,000 U single-dose vitamin D regimen to correct vitamin D deficiency can positively impact outcomes following primary TJA. (10.1016/j.arth.2024.05.012)
  • [L4] Vitamin D deficiency is highly prevalent in knee OA patients and its severity is associated with bilateral OA and polyarthralgia but not with inflammatory markers. (10.1186/s13018-025-05805-0)
  • [L4] These parameters might be considered diagnostic non-invasive predictors of bone health for clinical use in epidemiological contexts. (10.1186/s12891-023-06960-3)
  • [L3] Determining vitamin D levels preoperatively and providing supplementation if deficiency is present may be beneficial for preventing delayed wound healing. (10.5435/jaaos-d-25-00410)
  • [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. (10.5397/cise.2024.00220)
  • [L4] Future prospective cohort studies and randomized controlled trials are needed to establish causality, assess its effects across various tendons, and determine optimal supplementation strategies. (10.1177/23259671251371300)
  • [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. (10.1016/j.jse.2023.05.007)
  • [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. (10.1186/s13018-023-04445-6)
  • [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. (10.5435/jaaos-d-24-00005)
  • [L1] Therefore, HIIT plus vitamin D consumption may be a strategic option to prevent BMD reduction with aging or to slow demineralization. (10.1186/s12891-025-08275-x)
  • [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. (10.1016/j.jse.2025.12.003)
  • [L4] Vitamin D deficiency was not associated with the expression of myogenesis-related or muscle atrophy–related genes in the supraspinatus muscle of patients with rotator cuff tears, unlike in the deltoid muscle; rather, vitamin D deficiency was associated with increased proinflammatory cytokine expression. (10.1177/03635465231184392)
  • [L4] Regular sling core stabilization training based on calcium and vitamin D supplementation can improve bone mineral density and prevent low back pain in a patient with primary osteoporosis over a 6-year period. (10.1186/s12891-023-06896-8)
  • [L2] Active vitamin D3 treatment promoted fracture healing by affecting the levels of these immune factors. (10.1186/s13018-023-03777-7)
  • [L4] Lower preoperative serum vitamin D levels had a strong correlation with lower tissue vitamin D levels and lower serum vitamin D levels at 1 year after surgery. (10.1177/03635465221145711)

References

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

[2] 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

[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] 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

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

[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] 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

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

[9] 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

[10] Association between vitamin D deficiency, inflammatory markers, and knee osteoarthritis: a retrospective study. Journal of Orthopaedic Surgery and Research. 2025. DOI: 10.1186/s13018-025-05805-0

[11] 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

[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] 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

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

[15] 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

[16] 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

[17] 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

[18] 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

[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] Influence of Vitamin D Deficiency on the Expression of Genes and Proteins in Patients With Medium Rotator Cuff Tears. The American Journal of Sports Medicine. 2023. DOI: 10.1177/03635465231184392

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

[22] 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

[23] Serum Vitamin D Level Correlations With Tissue Vitamin D Level and Muscle Performance Before and After Rotator Cuff Repair. The American Journal of Sports Medicine. 2023. DOI: 10.1177/03635465221145711

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