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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.

18 citationsUpdated Aug 2026

For patients: a plain-language version of this topic is available. See the patient guide.

Overview

Testosterone levels exhibit a threshold-dependent relationship with shoulder pathology [1], and low testosterone levels correlate with an increased risk of osteoarthritis [7]. Consequently, hormonal status should be considered in musculoskeletal risk assessment [1], as maintaining optimal testosterone levels may be important for joint health [7]. However, clinical implications are complex. Patients prescribed supplemental testosterone have a higher risk of all-cause reoperation after total shoulder arthroplasty [2], including a higher risk of reoperation for infection [2]. There is also an increased risk of rotator cuff tears, rotator cuff repairs, and subsequent rotator cuff repairs in patients prescribed testosterone [8]. Furthermore, testosterone therapy is associated with increased odds of quadriceps tendon injury [6] and surgically treated tendon rupture [9], with users facing a 2.9-fold increased risk of tendon rupture compared to nonusers [10].

Testosterone supplementation improves clinical outcomes, body composition, and bone mineral density in orthopaedic surgeries [5], yet evidence regarding orthopaedic perioperative use of testosterone replacement therapy is heterogeneous [5]. In specific contexts, such as pectoralis major rupture in bodybuilders, anabolic steroid use may contribute to the injury [3], but continuation of anabolic steroids during recovery does not seem to have a negative effect on functional recovery [3]. Conversely, selective androgen receptor modulator use is associated with increased muscle mass but also with hepatotoxicity, cardiotoxicity, tendon damage, and androgenic side effects throughout the body [14].

Given these divergent signals, it is premature to imply causation between testosterone replacement therapy and anterior cruciate ligament injuries based solely on existing results due to confounding variables [4]. Clinicians should remain vigilant and prescribe testosterone replacement therapy judiciously with a thorough assessment of each patient's unique risk profile [4]. Surgeons should be more intentional about discussing endocrinologic history with patients regarding testosterone therapy [6] and counsel patients with testosterone deficiency on the risks for injury or re-injury [6].

How It Works

Surgical Outcomes and Infection Risk: Supplemental testosterone increases the risk of all-cause reoperation after total shoulder arthroplasty [2]. This supplementation also increases the risk of reoperation for infection following the same procedure [2].

Tendon and Muscle Injury: Prescription testosterone is associated with an increased likelihood of distal biceps tendon injury [12]. It is also associated with an increased rate of requiring surgical repair for distal biceps tendon injury [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 [13]. These patients were at increased risk of undergoing surgical repair of the quadriceps tendon [13].

Selective Androgen Receptor Modulators (SARMs): Abuse of selective androgen receptor modulators is associated with tendon damage [14]. This abuse is associated with increased muscle mass [14]. It is also associated with hepatotoxicity [14], cardiotoxicity [14], and androgenic side effects throughout the body [14].

Osteoarthritis Pathophysiology: Low testosterone levels correlate with the risk of osteoarthritis [7]. Bioavailable testosterone levels have a causal relationship with osteoarthritis [15]. Bioavailable testosterone levels are a risk factor for osteoarthritis [15].

Clinical Considerations and Safety Data: Surgeons should be more intentional about discussing endocrinologic history with patients [6]. Data regarding the safety and association of testosterone supplementation with stroke in young adults remains limited and underexplored [11].

What the Evidence Shows

Reoperation and Infection Risk: Supplemental testosterone increases the risk of all-cause reoperation after total shoulder arthroplasty (TSA) [2]. This includes a specific increase in reoperation for infection [2]. In male patients, testosterone use is associated with a higher risk of infection-related reoperations after primary TSA [18] and a higher risk of all-cause reoperations after primary TSA [18].

Soft Tissue and Tendon Integrity: Anabolic steroid use may contribute to pectoralis major rupture in body builders [3]. Patients prescribed testosterone face an increased risk of rotator cuff tears (RCTs) [8], rotator cuff repairs (RCRs) [8], and subsequent RCRs [8]. Testosterone users had a 2.9-fold increased risk of tendon rupture compared to nonusers [10]. Patients who filled a prescription for testosterone replacement therapy (TRT) were much more likely to experience a quadriceps muscle or tendon injury within 1 year of filling their prescription [13]. These patients were also at increased risk of undergoing surgical repair of the quadriceps tendon [13]. Selective androgen receptor modulator (SARM) use is associated with tendon damage [14].

Anterior Cruciate Ligament (ACL) Considerations: It is premature to imply causation between TRT and anterior cruciate ligament (ACL) injuries based solely on existing results due to confounding variables [4]. Clinicians should remain vigilant and prescribe TRT judiciously with a thorough assessment of each patient's unique risk profile regarding ACL injury [4]. Surgeons should be intentional about discussing endocrinologic history with patients regarding ACL injury risk [6].

Osteoarthritis (OA) and Bone Health: Low testosterone levels correlate with an increased risk of osteoarthritis (OA) [7]. The relationship between low testosterone and OA risk is non-linear [7]. Bioavailable testosterone levels have a causal relationship with OA, identified as a risk factor for OA [15]. Perioperative testosterone supplementation improved bone mineral density (BMD) in orthopaedic surgeries [5].

Perioperative Outcomes and Body Composition: Four randomized controlled trials found that perioperative testosterone supplementation improved clinical outcomes in orthopaedic surgeries [5]. Perioperative testosterone supplementation improved body composition in orthopaedic surgeries [5]. Evidence regarding orthopaedic perioperative use of TRT is heterogeneous [5]. Testosterone deficiency is associated with poorer postoperative outcomes in total joint arthroplasty [17]. Distinct patterns of poorer postoperative outcomes associated with testosterone deficiency were observed in total hip arthroplasty (THA) and total knee arthroplasty (TKA) [17].

SARM Safety Profile: SARM use is associated with increased muscle mass [14]. However, SARM use is also associated with hepatotoxicity [14], cardiotoxicity [14], and androgenic side effects throughout the body [14].

Practical Considerations

Prior Exposure Risks: Patients with prior prescription testosterone exposure demonstrate an increased rate of distal biceps tendon injury compared with patients without such exposure [12]. This cohort also exhibits an increased rate of biceps tendon repair relative to those without prior exposure [12].

Future Directions: Future investigation is needed to provide guidance on how surgeons can mitigate adverse risks while optimizing benefits of testosterone replacement therapy in the orthopaedic patient [16].

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. [1] (10.1016/j.jse.2026.01.012)
  • [L3] Patients prescribed supplemental testosterone had a higher risk of all cause reoperation and reoperation for infection after TSA. [2] (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. [3] (10.1186/s12891-023-06382-1)
  • [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)
  • [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. [5] (10.1016/j.arthro.2024.12.026)
  • [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. [6] (10.1097/corr.0000000000002835)
  • [L3] The observed non-linear relationship suggests that maintaining optimal testosterone levels may be important for joint health. [7] (10.1186/s12891-024-08272-6)
  • [L3] There is increased risk of RCTs, RCRs, and subsequent RCRs in patients prescribed testosterone. [8] (10.5435/jaaos-d-22-00554)
  • [L3] Testosterone replacement therapy is associated with increased odds of surgically treated tendon rupture. [9] (10.1177/2325967125s00009)
  • [L3] Testosterone users had a 2.9-fold increased risk of tendon rupture compared to nonusers. [10] (10.1177/2325967124s00339)
  • [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. [11] (10.3389/fneur.2024.1422931)
  • [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. [12] (10.1016/j.jse.2023.02.122)
  • [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. [13] (10.1097/corr.0000000000002744)
  • [L4] SARM use is associated with increased muscle mass, hepatotoxicity, cardiotoxicity, tendon damage, and androgenic side effects throughout the body. [14] (10.1177/03635465241252435)
  • [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. [15] (10.1186/s12891-025-08626-8)
  • [L5] The authors suggest future areas of investigation that may provide guidance on how surgeons can mitigate adverse risks while optimizing benefits of TRT in the orthopaedic patient. [16] (10.5435/jaaos-d-23-00348)
  • [L3] Testosterone deficiency is associated with poorer postoperative outcomes in total joint arthroplasty, with distinct patterns observed in THA and TKA. [17] (10.5435/jaaos-d-25-00190)
  • [L2] Testosterone use is associated with a higher risk of both infection-related and all-cause reoperations after total shoulder arthroplasty. [18] (10.1016/j.jseint.2026.101634)

See Also

  • Osteoarthritis

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

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

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

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

[7] 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

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

[10] 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

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

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

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

[15] 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

[16] Testosterone Replacement Therapy in Orthopaedic Surgery. Journal of the American Academy of Orthopaedic Surgeons. 2024. DOI: 10.5435/jaaos-d-23-00348

[17] 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

[18] 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

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