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Anabolic Steroids, Testosterone and Tendon Rupture Risk Info Evidence

Reviewed by Dr Kieran Hirpara, Specialist Orthopaedic Surgeon Last reviewed

What it is

Testosterone is a hormone that helps build muscle and maintain bone strength. You might hear it discussed in the context of hormone replacement therapy for low levels, or as anabolic steroids used by some athletes to boost performance. While these substances can increase muscle mass, they also change how your body handles stress and repair.

Your doctor will look at your hormonal history when assessing your risk for injury. Research shows that taking supplemental testosterone is linked to a higher chance of tendon ruptures. In fact, users face a 2.9-fold increased risk of tendon rupture compared to non-users. This includes injuries to the rotator cuff, quadriceps, and distal biceps tendons. There is also a higher risk of needing surgery for these tears, or for infection after shoulder replacement.

These changes happen because testosterone affects the balance between muscle growth and tendon strength. Your tendons may not strengthen at the same rate as your muscles. This mismatch can put extra strain on the connective tissue. Additionally, low testosterone levels are linked to a higher risk of wear-and-tear arthritis. Maintaining optimal levels is important for joint health, but adding extra hormones requires careful consideration of these risks.

Does it work?

The evidence on testosterone and tendon health is mixed. It depends heavily on why you are taking it and your personal health profile.

For some patients, short-term use around surgery may help. Four studies found that testosterone given before or after orthopaedic surgery improved body composition and bone density. These changes can support recovery in the short term.

However, long-term or supplemental use carries significant risks for your tendons and joints. Research shows that people prescribed testosterone face a 2.9-fold higher risk of tendon rupture compared to those who do not use it. You are also more likely to suffer a quadriceps muscle or tendon injury within one year of filling a prescription. This can lead to needing surgical repair.

There is also a link between testosterone and joint issues. Low testosterone levels are associated with a higher risk of osteoarthritis, which is wear-and-tear arthritis. Bioavailable testosterone levels have been identified as a direct risk factor for this condition. Additionally, patients prescribed testosterone have an increased risk of rotator cuff tears and subsequent repairs.

Infection and reoperation risks are also higher. Supplemental testosterone increases the risk of all-cause reoperation after total shoulder replacement. It also raises the risk of reoperation for infection in these cases. Male patients using testosterone face a higher risk of infection-related reoperations after primary shoulder surgery.

Conversely, testosterone deficiency is linked to poorer outcomes after total joint replacements, such as hip and knee replacements. This suggests that maintaining balanced levels is important, but adding more may not always be beneficial.

We must remain cautious. It is premature to claim that testosterone replacement therapy directly causes anterior cruciate ligament injuries due to other confounding factors. However, clinicians should assess your unique risk profile carefully. Selective androgen receptor modulators, often used for muscle building, are also associated with tendon damage and other serious side effects.

Your doctor will discuss your endocrinologic history to weigh these benefits against the risks. The goal is to support your healing without increasing your chance of injury.

What are the risks?

You may notice changes in your body composition and bone density. Some studies show that short-term testosterone use can improve these areas after orthopaedic surgery. However, other evidence suggests that low testosterone levels are linked to a higher risk of wear-and-tear arthritis in your joints. The relationship between hormone levels and joint health is complex and not always straightforward.

There is a clear link between testosterone use and tendon injuries. You are at a higher risk of tearing tendons, particularly in your biceps, rotator cuff, or quadriceps. Data shows that testosterone users have a 2.9-fold increased risk of tendon rupture compared to non-users. If you do suffer an injury, you are also more likely to need surgical repair. This risk applies to both prescription therapy and the misuse of related substances like selective androgen receptor modulators.

Infection and the need for further surgery are also concerns. If you undergo shoulder replacement, supplemental testosterone increases your risk of reoperation for infection and other complications. For men having primary shoulder surgery, testosterone use is associated with a higher risk of infection-related reoperations. You should be aware that these risks are specific to certain procedures and patient profiles.

Other serious side effects exist but are less common in standard medical use. Misuse of anabolic steroids or related drugs can cause liver damage, heart problems, and other hormonal side effects. While some research looks at links to stroke or knee ligament injuries, the evidence is not yet strong enough to confirm a direct cause. Your doctor will assess your unique risk profile before proceeding. We recommend open discussion about your endocrinologic history to manage these risks effectively.

Is it right for you?

Testosterone replacement therapy may be suitable if you have clinically low levels and are seeking symptom relief. It is not a standalone fix for tendon health. You must weigh potential benefits against specific risks.

This treatment is likely not right for you if you have a history of tendon injury. Evidence shows that patients with prior prescription testosterone exposure have an increased rate of distal biceps tendon injury compared with patients without such exposure. This group also has an increased rate of biceps tendon repair compared with patients without such exposure. If you have already experienced these issues, this therapy may add to your risk rather than help.

Compared with other options, testosterone therapy addresses hormonal balance but does not strengthen tendons directly. It works alongside, not instead of, standard care. Your doctor will review your full medical history to decide if this approach fits your needs.

This decision should be shared with your doctor. They will consider your hormone levels, tendon health, and overall goals. There is no one-size-fits-all answer. Future investigation is needed to provide guidance on how doctor's can mitigate adverse risks while optimizing benefits of testosterone replacement therapy in the orthopaedic patient. For now, your care team will guide you based on current evidence.

Please read the dedicated risks section for details on tendon injury rates. We do not discuss costs or affordability here. Focus on whether this aligns with your health goals and medical history.

The bottom line

Testosterone therapy carries a clear risk of tendon and muscle injury. Users face a 2.9-fold increased risk of tendon rupture compared to non-users. You are also more likely to need surgical repair for biceps, rotator cuff, or quadriceps injuries. While some patients see improved bone density and body composition, these benefits must be weighed against the risk of reoperation. Your doctor will assess your unique profile to decide if the trade-off is worth it.

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.

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].
  • 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].
  • 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 [6].
  • Surgeons should counsel patients with testosterone deficiency on the risks for injury or re-injury [6].
  • Testosterone replacement therapy is associated with increased tendon rupture risk in men [7].
  • Testosterone replacement therapy is not associated with increased tendon rupture risk in women [7].
  • The lack of increased tendon rupture risk in women may be due to sex-specific differences in dosing [7].
  • 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 [8].
  • Patients who filled a prescription for testosterone replacement therapy were at increased risk of undergoing surgical repair of the quadriceps tendon [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].
  • Selective androgen receptor modulator (SARM) use is associated with tendon damage [10].
  • Preoperative testosterone replacement therapy is a potential risk factor for complications after rotator cuff repair [11].
  • Preoperative testosterone replacement therapy is a potential risk factor for reoperation after rotator cuff repair [11].
  • Cessation of testosterone replacement therapy prior to rotator cuff repair should be considered on a patient-specific basis [11].

How It Works

  • 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].
  • The use of prescription testosterone is associated with an increased likelihood of experiencing a distal biceps tendon injury and subsequently requiring surgical repair [5].
  • 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].
  • 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 [6].
  • TRT is associated with increased tendon rupture risk in men but not women [7].
  • The association between TRT and increased tendon rupture risk in men but not women may be due to sex-specific differences in dosing [7].
  • Testosterone therapy is associated with increased odds of quadriceps tendon injury [8].
  • Anabolic steroids use may contribute to pectoralis major rupture injury [9].
  • SARM use is associated with tendon damage [10].
  • Cessation of TRT prior to rotator cuff repair should be considered on a patient-specific basis [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 increased risk of infection-related and all-cause reoperations after primary total shoulder arthroplasty in male patients [13].
  • Testosterone use is associated with a higher risk of both infection-related and all-cause reoperations after total shoulder arthroplasty [13].
  • There is increased risk of rotator cuff tears (RCTs), rotator cuff repairs (RCRs), and subsequent RCRs in patients prescribed testosterone [14].
  • The observed non-linear relationship between low testosterone levels and osteoarthritis risk suggests that maintaining optimal testosterone levels may be important for joint health [15].

What the Evidence Shows

  • The use of prescription testosterone is associated with an increased likelihood of subsequently requiring surgical repair of the distal biceps tendon [5].
  • TRT is associated with increased tendon rupture risk in men [7].
  • TRT is not associated with increased tendon rupture risk in women [7].
  • The association between TRT and tendon rupture risk may be due to sex-specific differences in dosing [7].
  • Anabolic steroids use may contribute to pectoralis major rupture [9].
  • SARM use is associated with increased muscle mass [10].
  • SARM use is associated with hepatotoxicity [10].
  • SARM use is associated with cardiotoxicity [10].
  • SARM use is associated with androgenic side effects throughout the body [10].
  • Supplemental testosterone increases the risk of reoperation after total shoulder arthroplasty [12].
  • Further research is needed to understand the mechanism by which testosterone increases the risk of reoperation after TSA [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].
  • There is an increased risk of rotator cuff tears (RCTs) in patients prescribed testosterone [14].
  • There is an increased risk of rotator cuff repairs (RCRs) in patients prescribed testosterone [14].
  • There is an increased risk of subsequent rotator cuff repairs (RCRs) in patients prescribed testosterone [14].
  • Four randomized controlled trials found that testosterone supplementation improved clinical outcomes in orthopaedic surgeries [17].
  • Four randomized controlled trials found that testosterone supplementation improved body composition in orthopaedic surgeries [17].
  • Four randomized controlled trials found that testosterone supplementation improved bone mineral density (BMD) in orthopaedic surgeries [17].
  • Evidence regarding orthopaedic perioperative use of testosterone replacement therapy is heterogeneous [17].
  • 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 [18].
  • Injectable TRT use within 1 year of primary ACL reconstruction is associated with a 3.3-fold increase in ACLR revision rates with 2 years of follow-up [19].
  • Data regarding the safety of testosterone supplementation and its association with stroke in young adults remains limited and underexplored [20].

Practical Considerations

  • 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 [7].
  • Anabolic steroid use may contribute to pectoralis major rupture [9].
  • Prescription testosterone is associated with increased risk of infection-related reoperations after primary total shoulder arthroplasty in male patients [13].
  • Prescription testosterone is associated with increased risk of all-cause reoperations after primary total shoulder arthroplasty in male patients [13].
  • Authors suggest future areas of investigation that may provide guidance on how surgeons can mitigate adverse risks while optimizing benefits of testosterone replacement therapy in the orthopaedic patient [16].

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] TRT is associated with increased tendon rupture risk in men but not women, potentially due to sex-specific differences in dosing. [7] (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. [8] (10.1097/corr.0000000000002744)
  • [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] Cessation of TRT prior to rotator cuff repair should be considered on a patient-specific basis. [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] There is increased risk of RCTs, RCRs, and subsequent RCRs in patients prescribed testosterone. [14] (10.5435/jaaos-d-22-00554)
  • [L3] The observed non-linear relationship suggests that maintaining optimal testosterone levels may be important for joint health. [15] (10.1186/s12891-024-08272-6)
  • [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)
  • [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. [17] (10.1016/j.arthro.2024.12.026)
  • [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. [18] (10.1016/j.arthro.2024.10.032)
  • [L3] Injectable TRT use within 1 year of primary ACLR is associated with a 3.3-fold increase in ACLR revision rates with 2 years of follow-up. [19] (10.1177/23259671251399845)
  • [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. [20] (10.3389/fneur.2024.1422931)

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

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

[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] 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

[15] 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

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

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

[18] Prescription Testosterone Is Associated With an Increased Risk of Anterior Cruciate Ligament Injury. Arthroscopy. 2024. DOI: 10.1016/j.arthro.2024.10.032

[19] 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

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

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