Anabolic Steroids, Testosterone and Tendon Rupture Risk Info Evidence
Reviewed by Dr Kieran Hirpara, Specialist Orthopaedic Surgeon Last reviewed
What you're feeling
You may notice a sudden, sharp pain in your shoulder or upper arm. This often happens when you lift something heavy or make a quick movement. The pain can be intense and immediate. You might hear or feel a pop at the moment of injury. After the initial shock, the area can become swollen and bruised. You may find it difficult to raise your arm or move it away from your body. Simple tasks like reaching for a cup on a high shelf or putting on a jacket can become very hard.
If you have a tear in the tendon at the front of your upper arm, you might feel pain in the crease of your elbow. This area can look deformed or feel weak. You may struggle to bend your elbow or turn your palm upward. Everyday actions like opening a jar or using a screwdriver can feel impossible. The weakness can be significant enough that you cannot support the weight of your own arm.
In some cases, you might experience pain in the chest muscle near the armpit. This can happen after heavy lifting or intense exercise. The pain may worsen when you press on the area or move your arm across your chest. You might notice swelling or bruising on the front of your shoulder or upper arm. Night pain is common, making it difficult to sleep on the affected side. You may wake up feeling stiff and in discomfort.
Your doctor will assess these symptoms to determine the extent of the injury. Testosterone levels can influence tendon health and rupture risk. Low testosterone is linked to higher risks of joint issues and tendon injuries. If you are taking testosterone or anabolic steroids, this history is important for your care. We need to understand your full medical background to plan your treatment safely. Your doctor will discuss these factors with you during your consultation.
What's actually happening
Testosterone plays a complex role in how your tendons and joints hold up under stress. Think of your tendons as thick ropes made of collagen fibres. These fibres need the right hormonal balance to stay strong and flexible. When testosterone levels are too low, your body struggles to maintain this structural integrity. This creates a non-linear risk for wear-and-tear arthritis, where the protective cartilage in your joints breaks down faster than normal.
Conversely, high levels of testosterone or the use of anabolic steroids can make these tendon 'ropes' brittle. They lose their natural elasticity and become prone to snapping under load. This is why users of testosterone or anabolic steroids face a significantly higher risk of tendon ruptures. In fact, data shows that testosterone users have a 2.9-fold increased risk of tendon rupture compared to nonusers. This includes common injuries like rotator cuff tears in the shoulder or distal biceps injuries in the arm.
Your doctor will consider your hormonal history when assessing these risks. Hormonal status is a key part of understanding why certain injuries happen. For example, anabolic steroid use has been linked to pectoralis major ruptures in bodybuilders. While continuing steroids during recovery from such a rupture does not seem to negatively affect functional healing, the initial injury risk remains high.
There is also a link between testosterone use and the need for further surgery. Patients prescribed testosterone have higher rates of rotator cuff repairs and subsequent re-repairs. In shoulder joint replacement, testosterone use is associated with a higher risk of infection-related and all-cause reoperations in male patients. This suggests that testosterone may interfere with the body’s ability to heal cleanly after major orthopaedic procedures.
We advise discussing your endocrinologic history openly. This helps us counsel you on the risks for injury or re-injury. It is not just about the hormone level itself, but how it interacts with your unique risk profile. Maintaining optimal testosterone levels may be important for long-term joint health, but this must be balanced against the potential for tissue damage.
What we can do about it
We start with self-care and physical therapy. Your doctor may suggest rest, ice, and gentle exercises to strengthen the muscles around the injured area. This helps support the tendon and reduce strain. Physiotherapy aims to restore your range of motion and build strength safely. Give this approach time to work. Most people see improvement over several weeks of consistent effort.
If pain persists, your doctor may discuss medication. Over-the-counter pain relievers or anti-inflammatories can help manage discomfort. Regarding hormone therapy, the evidence shows a complex picture. Testosterone replacement therapy is associated with an increased risk of surgically treated tendon rupture. Users had a 2.9-fold increased risk of tendon rupture compared to nonusers. Patients with prior prescription testosterone exposure have an increased rate of distal biceps tendon injury and biceps tendon repair. There is also an increased risk of quadriceps muscle or tendon injury within 1 year of filling a prescription for testosterone replacement therapy. Because of these risks, clinicians should prescribe testosterone judiciously with a thorough assessment of your unique risk profile. Hormonal status should be considered in your musculoskeletal risk assessment.
If symptoms remain severe despite self-management and medication, your doctor may refer you for specialist assessment. In some cases, a procedure may be considered to repair the damaged tissue. This decision depends on the specific injury and your overall health. Your doctor will discuss whether this step is necessary for your recovery.
What to expect
Your outlook depends heavily on your hormonal health and whether you use testosterone or anabolic steroids. Evidence shows a clear link between these substances and tendon injuries. If you take testosterone replacement therapy, you are 2.9 times more likely to suffer a tendon rupture than someone who does not. This increased risk applies to tendons in your shoulder, elbow, and thigh. You may also face a higher chance of needing surgery to repair these tears.
For some patients, low testosterone levels are linked to a higher risk of wear-and-tear arthritis in the joints. Keeping your hormone levels in a healthy range may support better joint health. However, if you are prescribed testosterone, your doctor will discuss your specific risks with you. This includes the potential for injury or re-injury. It is important to understand that while testosterone can improve bone density and body composition after surgery, it also carries specific risks for tendon strength.
If you have already suffered a rupture, such as a tear to your pectoralis major muscle, continuing anabolic steroids during recovery does not appear to negatively affect your functional results. This means your ability to regain strength and movement may remain stable even if you continue the medication. However, this does not mean the risk of new injuries disappears. You should remain vigilant about your body’s signals.
Your doctor will assess your unique risk profile before making any decisions about treatment. This includes reviewing your endocrinologic history. If you have testosterone deficiency, you will be counseled on the specific dangers of injury. The goal is to manage your health safely while addressing the underlying hormonal issues. Recovery is a gradual process. You should expect to work closely with your medical team to balance hormone therapy with tendon protection. There are no guarantees, but understanding these risks helps you make informed choices about your care and activity levels.
When to see someone
See your GP if you have persistent pain, weakness, or instability that does not improve with rest. Ask for a specialist review if your shoulder locks, gives way, or if symptoms interfere with sleep or work. Testosterone levels affect tendon health. Low levels increase osteoarthritis risk. Therapy may raise rupture risk for rotator cuff, biceps, or quadriceps tendons. Users face a 2.9-fold higher rupture risk. Sudden worsening of symptoms needs prompt attention. Your doctor will assess your hormonal status and tendon integrity to guide safe recovery and prevent further injury.
Evidence & references
Overview
- Testosterone replacement therapy is associated with increased odds of surgically treated tendon rupture [1].
- Testosterone users had a 2.9-fold increased risk of tendon rupture compared to nonusers [2].
- It is premature to imply causation between testosterone replacement therapy and anterior cruciate ligament injuries based solely on existing results due to confounding variables [3].
- Clinicians should remain vigilant and prescribe testosterone replacement therapy judiciously with a thorough assessment of each patient's unique risk profile regarding anterior cruciate ligament injury risk [3].
- There is a threshold-dependent relationship between testosterone levels and shoulder pathology [4].
- Hormonal status should be considered in musculoskeletal risk assessment [4].
- The use of prescription testosterone is associated with an increased likelihood of experiencing a distal biceps tendon injury [5].
- The use of prescription testosterone is associated with an increased likelihood of subsequently requiring surgical repair for distal biceps tendon injury [5].
- Patients with prior prescription testosterone exposure have an increased rate of distal biceps tendon injury compared with patients without such exposure [5].
- Patients with prior prescription testosterone exposure have an increased rate of biceps tendon repair compared with patients without such exposure [5].
- Surgeons should be more intentional about discussing endocrinologic history with patients regarding quadriceps tendon injury risk [6].
- Surgeons should counsel patients with testosterone deficiency on the risks for injury or re-injury [6].
- 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 [7].
- Patients who filled a prescription for testosterone replacement therapy were at increased risk of undergoing surgical repair of the quadriceps tendon [7].
- Testosterone replacement therapy is associated with increased tendon rupture risk in men [8].
- Testosterone replacement therapy is not associated with increased tendon rupture risk in women [8].
- The association between testosterone replacement therapy and increased tendon rupture risk may be due to sex-specific differences in dosing [8].
- Anabolic steroid use may contribute to pectoralis major rupture [9].
- Continuation of anabolic steroids during recovery from pectoralis major rupture does not seem to have a negative effect on functional recovery [9].
- Selective androgen receptor modulator (SARM) use is associated with tendon damage [10].
- Prescription testosterone is associated with a higher risk of infection-related reoperations after primary total shoulder arthroplasty in male patients [13].
- Prescription testosterone is associated with a higher risk of all-cause reoperations after primary total shoulder arthroplasty in male patients [13].
Background & Causes
- Testosterone replacement therapy is associated with increased odds of surgically treated tendon rupture [1].
- Testosterone users had a 2.9-fold increased risk of tendon rupture compared to nonusers [2].
- It is premature to imply causation between testosterone replacement therapy and anterior cruciate ligament injuries based solely on existing results due to confounding variables [3].
- There is a threshold-dependent relationship between testosterone levels and shoulder pathology [4].
- Prescription testosterone use is associated with an increased likelihood of experiencing a distal biceps tendon injury [5].
- Patients with prior prescription testosterone exposure have an increased rate of biceps tendon repair compared with patients without such exposure [5].
- Testosterone therapy is associated with increased odds of quadriceps tendon injury [6].
- 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 [7].
- Patients who filled a prescription for testosterone replacement therapy were at increased risk of undergoing surgical repair of the quadriceps tendon [7].
- Testosterone replacement therapy is associated with increased tendon rupture risk in men but not women [8].
- The association between testosterone replacement therapy and increased tendon rupture risk in men but not women may be due to sex-specific differences in dosing [8].
- Anabolic steroid use may contribute to pectoralis major rupture [9].
- Continuation of anabolic steroids during recovery from pectoralis major rupture does not seem to have a negative effect on functional recovery [9].
- Selective androgen receptor modulator (SARM) use is associated with tendon damage [10].
- Testosterone replacement therapy within 1 year of rotator cuff repair appears to be a risk factor for multiple postoperative complications [11].
- Testosterone replacement therapy within 1 year of rotator cuff repair appears to be a risk factor for subsequent shoulder surgery [11].
- Further research is needed to understand the mechanism by which testosterone increases the risk of reoperation after total shoulder arthroplasty [12].
- Prescription testosterone is associated with an increased risk of infection-related reoperations after primary total shoulder arthroplasty in male patients [13].
- Prescription testosterone is associated with an increased risk of all-cause reoperations after primary total shoulder arthroplasty in male patients [13].
- Bioavailable testosterone levels are a risk factor for osteoarthritis [17].
- There is a causal relationship between bioavailable testosterone levels and osteoarthritis [17].
- Low testosterone levels are independently associated with an increased risk of osteoarthritis in the U.S. population [18].
Symptoms & Presentation
- Testosterone replacement therapy is associated with increased odds of surgically treated tendon rupture [1].
- Testosterone users had a 2.9-fold increased risk of tendon rupture compared to nonusers [2].
- It is premature to imply causation between testosterone replacement therapy and anterior cruciate ligament injuries based solely on existing results due to confounding variables [3].
- There is a threshold-dependent relationship between testosterone levels and shoulder pathology [4].
- Prescription testosterone use is associated with an increased likelihood of experiencing a distal biceps tendon injury [5].
- Patients with prior prescription testosterone exposure have an increased rate of biceps tendon repair compared with patients without such exposure [5].
- Testosterone therapy is associated with increased odds of quadriceps tendon injury [6].
- 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 [7].
- Patients who filled a prescription for testosterone replacement therapy were at increased risk of undergoing surgical repair of the quadriceps tendon [7].
- Testosterone replacement therapy is associated with increased tendon rupture risk in men but not women [8].
- Anabolic steroid use may contribute to pectoralis major rupture [9].
- Selective androgen receptor modulator (SARM) use is associated with tendon damage [10].
- Testosterone replacement therapy within 1 year of rotator cuff repair appears to be a risk factor for multiple postoperative complications [11].
- Testosterone replacement therapy within 1 year of rotator cuff repair appears to be a risk factor for subsequent shoulder surgery [11].
- Supplemental testosterone increases the risk of reoperation after total shoulder arthroplasty [12].
- Prescription testosterone is associated with an increased risk of infection-related reoperations after primary total shoulder arthroplasty in male patients [13].
- Prescription testosterone is associated with an increased risk of all-cause reoperations after primary total shoulder arthroplasty in male patients [13].
- Testosterone therapy is associated with rotator cuff tears, repairs, and revision repairs [15].
- Testosterone deficiency is associated with poorer postoperative outcomes in total joint arthroplasty [16].
Management
- Testosterone replacement therapy is associated with increased odds of surgically treated tendon rupture [1].
- Testosterone users had a 2.9-fold increased risk of tendon rupture compared to nonusers [2].
- It is premature to imply causation between testosterone replacement therapy and ACL injuries based solely on existing results due to confounding variables [3].
- Clinicians should remain vigilant and prescribe TRT judiciously with a thorough assessment of each patient's unique risk profile [3].
- Findings suggest a threshold-dependent relationship between testosterone and shoulder pathology [4].
- Hormonal status should be considered in musculoskeletal risk assessment [4].
- The use of prescription testosterone is associated with an increased likelihood of experiencing a distal biceps tendon injury [5].
- The use of prescription testosterone is associated with an increased likelihood of subsequently requiring surgical repair for distal biceps tendon injury [5].
- Patients with prior prescription testosterone exposure have an increased rate of distal biceps tendon injury compared with patients without such exposure [5].
- Patients with prior prescription testosterone exposure have an increased rate of biceps tendon repair compared with patients without such exposure [5].
- Surgeons should be more intentional about discussing endocrinologic history with patients [6].
- Surgeons should counsel patients with testosterone deficiency on the risks for injury or re-injury [6].
- 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 [7].
- Patients who filled a prescription for testosterone replacement therapy were at increased risk of undergoing surgical repair of the quadriceps tendon [7].
- TRT is associated with increased tendon rupture risk in men [8].
- TRT is not associated with increased tendon rupture risk in women [8].
- The association between TRT and tendon rupture risk in men but not women may be due to sex-specific differences in dosing [8].
- Anabolic steroids use may contribute to pectoralis major rupture injury [9].
- Continuation of anabolic steroids during recovery from pectoralis major rupture does not seem to have a negative effect on functional recovery [9].
- SARM use is associated with tendon damage [10].
- TRT within 1 year of rotator cuff repair appears to be a risk factor for multiple postoperative complications [11].
- TRT within 1 year of rotator cuff repair appears to be a risk factor for subsequent shoulder surgery [11].
- Further research is needed to understand the mechanism by which testosterone increases the risk of reoperation after total shoulder arthroplasty [12].
- Testosterone use is associated with a higher risk of infection-related reoperations after total shoulder arthroplasty in male patients [13].
- Testosterone use is associated with a higher risk of all-cause reoperations after total shoulder arthroplasty in male patients [13].
- Patients prescribed at least 3 months of TRT had a significantly higher incidence of ACL injuries compared to controls within a 2-year follow-up period [14].
Key Considerations
- Testosterone replacement therapy is associated with increased odds of surgically treated tendon rupture [1].
- Testosterone users had a 2.9-fold increased risk of tendon rupture compared to nonusers [2].
- It is premature to imply causation between testosterone replacement therapy and anterior cruciate ligament injuries based solely on existing results due to confounding variables [3].
- Clinicians should remain vigilant and prescribe testosterone replacement therapy judiciously with a thorough assessment of each patient's unique risk profile [3].
- Findings suggest a threshold-dependent relationship between testosterone and shoulder pathology [4].
- Hormonal status should be considered in musculoskeletal risk assessment [4].
- The use of prescription testosterone is associated with an increased likelihood of experiencing a distal biceps tendon injury [5].
- The use of prescription testosterone is associated with an increased likelihood of subsequently requiring surgical repair for distal biceps tendon injury [5].
- Patients with prior prescription testosterone exposure have an increased rate of distal biceps tendon injury compared with patients without such exposure [5].
- Patients with prior prescription testosterone exposure have an increased rate of biceps tendon repair compared with patients without such exposure [5].
- Surgeons should be more intentional about discussing endocrinologic history with patients [6].
- Surgeons should counsel patients with testosterone deficiency on the risks for injury or re-injury [6].
- 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 [7].
- Patients who filled a prescription for testosterone replacement therapy were at increased risk of undergoing surgical repair of the quadriceps tendon [7].
- Testosterone replacement therapy is associated with increased tendon rupture risk in men [8].
- Testosterone replacement therapy is not associated with increased tendon rupture risk in women [8].
- The association between testosterone replacement therapy and increased tendon rupture risk in men but not women may be due to sex-specific differences in dosing [8].
- Anabolic steroid use may contribute to pectoralis major rupture in body builders [9].
- Continuation of anabolic steroids during recovery from pectoralis major rupture does not seem to have a negative effect on functional recovery [9].
- Testosterone replacement therapy within 1 year of rotator cuff repair appears to be a risk factor for multiple postoperative complications [11].
- Testosterone replacement therapy within 1 year of rotator cuff repair appears to be a risk factor for subsequent shoulder surgery [11].
- Further research is needed to understand the mechanism by which testosterone increases the risk of reoperation after total shoulder arthroplasty [12].
Key Evidence
- [L3] Testosterone replacement therapy is associated with increased odds of surgically treated tendon rupture. [1] (10.1177/2325967125s00009)
- [L3] Testosterone users had a 2.9-fold increased risk of tendon rupture compared to nonusers. [2] (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. [3] (10.1016/j.arthro.2024.11.086)
- [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. [4] (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. [5] (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. [6] (10.1097/corr.0000000000002835)
- [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. [7] (10.1097/corr.0000000000002744)
- [L3] TRT is associated with increased tendon rupture risk in men but not women, potentially due to sex-specific differences in dosing. [8] (10.1177/23259671261430731)
- [L4] Anabolic steroids use may contribute to the injury, but continuation during recovery does not seem to have a negative effect on functional recovery. [9] (10.1186/s12891-023-06382-1)
- [L4] SARM use is associated with increased muscle mass, hepatotoxicity, cardiotoxicity, tendon damage, and androgenic side effects throughout the body. [10] (10.1177/03635465241252435)
- [L3] TRT within 1 year of rotator cuff repair appears to be a risk factor for multiple postoperative complications and subsequent shoulder surgery. [11] (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. [12] (10.1177/2325967124s00118)
- [L2] Testosterone use is associated with a higher risk of both infection-related and all-cause reoperations after total shoulder arthroplasty. [13] (10.1016/j.jseint.2026.101634)
- [L3] This study found that patients prescribed at least 3 months of TRT had a significantly higher incidence of ACL injuries compared to controls within a 2-year follow-up period. [14] (10.1016/j.arthro.2024.10.032)
- [L3] This finding may represent a musculoskeletal consequence of TRT and is important for patients and clinicians to understand. [15] (10.5435/jaaos-d-22-00554)
- [L3] Testosterone deficiency is associated with poorer postoperative outcomes in total joint arthroplasty, with distinct patterns observed in THA and TKA. [16] (10.5435/jaaos-d-25-00190)
- [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. [17] (10.1186/s12891-025-08626-8)
- [L3] Low testosterone levels are independently associated with an increased risk of OA in the U.S. population. [18] (10.1186/s12891-024-08272-6)
References
[1] Testosterone Replacement Therapy Increases Odds of Tendon Ruptures Treated Surgically. Orthopaedic Journal of Sports Medicine. 2025. DOI: 10.1177/2325967125s00009 [2] 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 [3] 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 [4] 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 [5] 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 [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] Testosterone Therapy Is Associated With Increased Odds of Quadriceps Tendon Injury. Clinical Orthopaedics & Related Research. 2023. DOI: 10.1097/corr.0000000000002744 [8] Testosterone Therapy and Associated Rates of Tendon Tear and Surgical Repair: A Retrospective Analysis. Orthopaedic Journal of Sports Medicine. 2026. DOI: 10.1177/23259671261430731 [9] Pectoralis major rupture in body builders: a case series including anabolic steroid use. BMC Musculoskeletal Disorders. 2023. DOI: 10.1186/s12891-023-06382-1 [10] Athlete Selective Androgen Receptor Modulators Abuse: A Systematic Review. The American Journal of Sports Medicine. 2025. DOI: 10.1177/03635465241252435 [11] 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 [12] Poster 149: Supplemental Testosterone Increases Risk of Reoperation after Total Shoulder Arthroplasty. Orthopaedic Journal of Sports Medicine. 2024. DOI: 10.1177/2325967124s00118 [13] 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 [14] Prescription Testosterone Is Associated With an Increased Risk of Anterior Cruciate Ligament Injury. Arthroscopy. 2024. DOI: 10.1016/j.arthro.2024.10.032 [15] 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 [16] 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 [17] 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 [18] 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
