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Testosterona, esteroides anabolizantes y salud 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
Una estructura molecular junto a un pequeño vial.
La testosterona influye en los músculos y los huesos; sus niveles y su uso como suplemento tienen implicaciones musculoesqueléticas que conviene conocer. Kieran Hirpara 4.0

Esta página se tradujo automáticamente y todavía no la ha revisado un médico. La versión en inglés es la versión oficial.

¿Qué es?

Los esteroides anabolizantes son versiones sintéticas de la testosterona, la hormona que impulsa la fuerza de los músculos y los huesos en los hombres. La terapia de reemplazo de testosterona (TRT) es una forma de testosterona recetada a personas cuyos propios niveles son bajos. Un grupo más reciente de fármacos llamados SARM (moduladores selectivos del receptor de andrógenos) actúa de forma parecida y aumenta la masa muscular sin usar la propia testosterona.

Algunas personas usan estos fármacos para tratar una enfermedad. Otras los usan para ganar músculo con fines deportivos o estéticos. Ambos grupos deben saber que estos fármacos afectan a los tendones, los cordones resistentes que unen el músculo al hueso. La investigación ha relacionado el uso de testosterona con un mayor riesgo de roturas del manguito rotador [1], lesiones del tendón del bíceps [2] y lesiones del tendón del cuádriceps en el plazo de 1 año desde que se retira la receta en la farmacia [3]. Un estudio encontró que los usuarios de testosterona tenían un riesgo de rotura de tendón 2,9 veces mayor que quienes no la usaban [4]. El uso de SARM también se asocia con daño en los tendones [5].

La relación parece funcionar en ambos sentidos. El exceso de testosterona parece sobrecargar los tendones y las articulaciones. La falta también causa problemas, porque el hipogonadismo (testosterona muy baja) parece tener un efecto perjudicial sobre el sistema musculoesquelético [6]. Los estudios también han relacionado los niveles de testosterona con la artrosis, el tipo de artritis por desgaste [7].

Si usted toma testosterona recetada y va a someterse a una cirugía, dígaselo a su médico. Esto modifica algunos cálculos de riesgo en operaciones como la prótesis de hombro y la reparación del manguito rotador.

¿Funciona?

No hay una respuesta sencilla, porque estos fármacos tienen efectos distintos en distintas partes del cuerpo.

La testosterona puede aumentar la fuerza de los músculos y los huesos. Cuatro ensayos controlados aleatorizados (estudios en los que se asigna al azar a las personas a recibir o no un tratamiento) encontraron que la testosterona administrada en torno al momento de la cirugía mejoró los resultados clínicos, la composición corporal y la densidad mineral ósea en cirugías ortopédicas [8]. La investigación también ha señalado una posible forma de mejorar la consolidación de las fracturas actuando sobre el eje andrógenos/receptor de andrógenos en el periostio (la fina capa de tejido que recubre el hueso) [9].

Pero las mismas hormonas pueden sobrecargar los tendones y las articulaciones. Los pacientes que retiraron una receta de terapia de reemplazo de testosterona tuvieron muchas más probabilidades de sufrir una lesión del músculo o del tendón del cuádriceps en el plazo de 1 año desde que la retiraron, y tenían un mayor riesgo de necesitar una reparación quirúrgica del tendón del cuádriceps [3]. Los pacientes a los que se recetaron al menos 3 meses de terapia de reemplazo de testosterona tuvieron una incidencia significativamente mayor de lesiones del ligamento cruzado anterior (LCA) que los controles durante un seguimiento de 2 años [10]. El uso de terapia de reemplazo de testosterona inyectable en el plazo de 1 año tras una primera reconstrucción del LCA se asocia con un aumento de 3,3 veces en las tasas de revisión de la reconstrucción del LCA con 2 años de seguimiento [11]. Un estudio de aleatorización mendeliana bidireccional (un estudio genético que analiza la relación de causa y efecto) respaldó una relación causal entre los niveles de testosterona biodisponible y la artrosis, e identificó los niveles de testosterona biodisponible como un factor de riesgo de artrosis [7].

Los resultados de la cirugía son variados. Los pacientes a los que se recetó testosterona como suplemento tuvieron un mayor riesgo de reintervención por cualquier causa y de reintervención por infección después de una artroplastia total de hombro (prótesis de hombro) [12]. El uso de terapia de reemplazo de testosterona antes de la operación no se relacionó con un aumento de las complicaciones a corto plazo después de la reparación artroscópica del manguito rotador (cirugía del tendón del hombro por pequeñas incisiones) [13]. A los pacientes en tratamiento con testosterona se les debe informar de su mayor riesgo de complicaciones después de la reparación del tendón distal del bíceps, y se debe hacer tanto una estratificación del riesgo como una optimización antes de la operación para reducir al mínimo el riesgo en torno a la cirugía [14]. La suspensión de la terapia de reemplazo de testosterona antes de la reparación del manguito rotador debe valorarse de forma individual para cada paciente [15]. El uso de esteroides anabolizantes puede contribuir a la rotura del pectoral mayor (un desgarro del gran músculo del pecho), pero seguir tomándolos durante la recuperación no parece tener un efecto negativo sobre la recuperación funcional [16].

Tanto el exceso como la falta de testosterona parecen tener un efecto perjudicial sobre el sistema musculoesquelético (sus músculos, tendones, huesos y articulaciones) [6].

¿Cuáles son los riesgos?

Los riesgos más claros están en los tendones. La investigación relaciona el uso de testosterona con una mayor probabilidad de lesión del tendón del cuádriceps [17]. Los usuarios de SARM suelen tomar dosis muy superiores a las estudiadas, y los informes de casos relacionan esto con daño en los tendones [18]. Tanto los esteroides anabolizantes como una testosterona muy baja pueden dañar sus músculos, tendones, huesos y articulaciones [6].

Sus articulaciones también pueden verse afectadas. Un estudio genético encontró una relación causal entre los niveles de testosterona biodisponible y la artrosis [7]. La relación no es lineal, por lo que mantener la testosterona en un rango saludable puede ser importante para la salud de las articulaciones [19].

Si usted toma testosterona y necesita una cirugía, los riesgos cambian. El uso de testosterona se relaciona con un mayor riesgo de reintervenciones después de una prótesis de hombro, tanto por infección como por cualquier otro motivo [20]. También es un posible factor de riesgo de complicaciones y de reintervención después de la reparación del manguito rotador, aunque un estudio no encontró relación con problemas a corto plazo después de la cirugía artroscópica del manguito rotador [15] [13]. Suspender la testosterona antes de la reparación del manguito rotador es una decisión que se toma caso por caso [15]. Los pacientes que toman testosterona tienen un mayor riesgo de complicaciones después de la reparación del tendón distal del bíceps, por lo que los médicos le evalúan y le preparan cuidadosamente antes de la operación para reducir ese riesgo [14].

Algunos hallazgos apuntan en sentido contrario. Cuatro ensayos controlados aleatorizados encontraron que la testosterona administrada en torno al momento de la cirugía mejoró los resultados clínicos, la composición corporal y la densidad mineral ósea en cirugías ortopédicas [8]. El uso de esteroides anabolizantes puede contribuir a la rotura del pectoral mayor, un desgarro del gran músculo del pecho, pero seguir tomando estos fármacos durante la recuperación no parece perjudicar lo bien que usted se recupera [16].

Algunas preguntas siguen abiertas. Las pruebas sobre si los suplementos de testosterona se relacionan con el ictus en adultos jóvenes son limitadas y poco estudiadas [21]. Y la testosterona aumenta el riesgo de rotura de tendón en los hombres pero no en las mujeres, posiblemente porque a hombres y mujeres se les administran dosis diferentes [22].

¿Es adecuado para usted?

Estos fármacos convienen a distintas personas por distintos motivos. La testosterona recetada puede ayudar si sus propios niveles son bajos, y puede aumentar la fuerza de los músculos y los huesos. Cuatro ensayos controlados aleatorizados encontraron que la testosterona administrada en torno al momento de la cirugía mejoró los resultados clínicos, la composición corporal y la densidad mineral ósea en cirugías ortopédicas [8]. Pero las mismas hormonas pueden sobrecargar los tendones y las articulaciones, y la investigación relaciona el uso de testosterona con una mayor probabilidad de lesión del tendón del cuádriceps [17]. Un estudio genético también encontró una relación causal entre los niveles de testosterona biodisponible y la artrosis [7]. La relación no es lineal, por lo que mantener la testosterona en un rango saludable puede ser importante para la salud de las articulaciones [19].

Los SARM son una decisión más difícil. Pueden aumentar la masa corporal magra en dosis bajas, pero los informes de casos indican que los usuarios toman dosis muy superiores a las estudiadas, lo que eleva el riesgo de daño en los tendones, lesión del hígado y problemas cardiovasculares [18]. El uso de SARM también se asocia con daños en el hígado y el corazón y con efectos secundarios androgénicos en todo el cuerpo [5]. No hay buenos ensayos que demuestren que sean seguros, y los organismos de salud pública han pedido que se regulen estas sustancias del mercado gris [23].

Si usted toma testosterona y va a someterse a una cirugía, su médico debe evaluar su perfil de riesgo individual antes de que decidan juntos [14]. El estado hormonal debe formar parte de cualquier evaluación de los riesgos para sus músculos, tendones y articulaciones [24]. Es una decisión compartida, tomada con su médico, basada en su propia salud y sus objetivos.

Conclusión

Si sus niveles de testosterona son bajos, la testosterona recetada puede ayudar a sus músculos y huesos. Pero estas hormonas pueden sobrecargar los tendones y las articulaciones, y los riesgos aumentan con dosis más altas. Si va a someterse a una cirugía, informe a su médico de cualquier uso de testosterona o de SARM, porque cambia la forma de evaluar sus riesgos. La advertencia más importante: tanto el exceso como la falta de testosterona pueden dañar su cuerpo, por lo que cualquier decisión debe tomarse caso por caso con su médico.

Referencias

[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.