Testosterone, Anabolic Steroids and Musculoskeletal Health Info Evidence

What it is

Anabolic steroids are man-made versions of testosterone, the hormone that drives muscle and bone strength in men. Testosterone replacement therapy (TRT) is a prescribed form of testosterone for people whose own levels are low. A newer group of drugs called SARMs (selective androgen receptor modulators) act in a similar way, building muscle without using testosterone itself.

Some people use these drugs to treat a medical condition. Others use them to build muscle for sport or appearance. Both groups should know the drugs affect tendons, the strong cords that join muscle to bone. Research has linked testosterone use with a higher risk of rotator cuff tears [1], biceps tendon injuries [2], and quadriceps tendon injuries within 1 year of filling a prescription [3]. One study found testosterone users had a 2.9-fold increased risk of tendon rupture compared to nonusers [4]. SARM use is also associated with tendon damage [5].

The link seems to work both ways. Too much testosterone appears to strain tendons and joints. Too little causes problems too, because hypogonadism (very low testosterone) seems to have a detrimental effect on the musculoskeletal system [6]. Studies have also connected testosterone levels with osteoarthritis, the wear-and-tear kind of arthritis [7].

If you are on prescribed testosterone and facing surgery, tell your doctor. It changes some risk calculations around operations such as shoulder replacement and rotator cuff repair.

Does it work?

There is no simple answer here, because these drugs do different things in different parts of your body.

Testosterone can build muscle and bone strength. Four randomised controlled trials (studies where people are randomly given a treatment or not) found that testosterone given around the time of surgery improved clinical outcomes, body composition, and bone mineral density in orthopaedic surgeries [8]. Research has also pointed to a possible way to improve fracture healing by targeting the androgen/androgen receptor axis in the periosteum (the thin layer of tissue covering bone) [9].

But the same hormones can strain tendons and joints. 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 needing surgical repair of the quadriceps tendon [3]. Patients prescribed at least 3 months of testosterone replacement therapy had a significantly higher incidence of ACL injuries compared to controls within a 2-year follow-up period [10]. Injectable testosterone replacement therapy use within 1 year of primary ACL reconstruction is associated with a 3.3-fold increase in ACL reconstruction revision rates with 2 years of follow-up [11]. A bidirectional Mendelian randomised study (a genetic study that tests cause and effect) supported a causal relationship between bioavailable testosterone levels and osteoarthritis, identifying bioavailable testosterone levels as a risk factor for osteoarthritis [7].

Surgery outcomes are mixed. Patients prescribed supplemental testosterone had a higher risk of all-cause reoperation and reoperation for infection after total shoulder arthroplasty (shoulder replacement) [12]. Preoperative testosterone replacement therapy use was not linked to increased short-term complications after arthroscopic rotator cuff repair (keyhole shoulder tendon surgery) [13]. Patients on testosterone therapy should be counselled about their increased risk for complications following distal biceps tendon repair, and both preoperative risk stratification and optimisation should be employed to minimise perioperative risk [14]. Cessation of testosterone replacement therapy prior to rotator cuff repair should be considered on a patient-specific basis [15]. Anabolic steroids use may contribute to pectoralis major rupture (a tear of the large chest muscle), but continuation during recovery does not seem to have a negative effect on functional recovery [16].

Both too much and too little testosterone seem to have a detrimental effect on the musculoskeletal system (your muscles, tendons, bones and joints) [6].

What are the risks?

The clearest risks sit in your tendons. Research links testosterone use with a higher chance of quadriceps tendon injury [17]. SARM users often take far more than the doses studied, and case reports tie that to tendon damage [18]. Anabolic steroids and very low testosterone can both harm your muscles, tendons, bones and joints [6].

Your joints can be affected too. A genetic study found a causal link between bioavailable testosterone levels and osteoarthritis [7]. The relationship is not a straight line, so keeping testosterone in a healthy range may matter for joint health [19].

If you take testosterone and need surgery, the risks change. Testosterone use is linked with a higher risk of reoperations after shoulder replacement, both for infection and for any reason [20]. It is also a possible risk factor for complications and reoperation after rotator cuff repair, though one study found no link with short-term problems after keyhole rotator cuff surgery [15] [13]. Stopping testosterone before rotator cuff repair is a decision made case by case [15]. Patients on testosterone face a higher risk of complications after distal biceps tendon repair, so doctors assess and prepare you carefully beforehand to lower that risk [14].

Some findings cut the other way. Four randomised controlled trials found testosterone given around the time of surgery improved clinical outcomes, body composition, and bone mineral density in orthopaedic surgeries [8]. Anabolic steroid use may contribute to a pectoralis major rupture, a tear of the large chest muscle, but continuing the drugs during recovery does not seem to harm how well you recover [16].

Some questions remain open. Evidence on whether testosterone supplementation is linked with stroke in young adults is limited and underexplored [21]. And testosterone raises tendon rupture risk in men but not women, possibly because men and women are given different doses [22].

Is it right for you?

These drugs suit different people for different reasons. Prescribed testosterone can help if your own levels are low, and it can build muscle and bone strength. Four randomised controlled trials found testosterone given around the time of surgery improved clinical outcomes, body composition, and bone mineral density in orthopaedic surgeries [8]. But the same hormones can strain tendons and joints, and research links testosterone use with a higher chance of quadriceps tendon injury [17]. A genetic study also found a causal link between bioavailable testosterone levels and osteoarthritis [7]. The relationship is not a straight line, so keeping testosterone in a healthy range may matter for joint health [19].

SARMs are a harder call. They can increase lean body mass at low doses, but case reports suggest users take far more than the doses studied, raising the risk of tendon damage, liver injury and cardiovascular events [18]. SARM use is also associated with liver and heart harm and androgenic side effects throughout the body [5]. There are no good trials showing they are safe, and public health bodies have called for regulation of these grey-market compounds [23].

If you are on testosterone and facing surgery, your doctor should assess your individual risk profile before deciding together [14]. Hormonal status belongs in any assessment of your muscle, tendon and joint risks [24]. This is a shared decision, made with your doctor, based on your own health and goals.

The bottom line

If your testosterone levels are low, prescribed testosterone can help your muscles and bones. But these hormones can strain tendons and joints, and the risks rise with higher doses. If you are facing surgery, tell your doctor about any testosterone or SARM use, because it changes how your risks are assessed. The single most important caveat: both too much and too little testosterone can harm your body, so any decision should be made case by case with your doctor.

Testosterone, Anabolic Steroids and Musculoskeletal Health Info Evidence

What it is

Does it work?

What are the risks?

Is it right for you?

The bottom line

Overview

How It Works

What the Evidence Shows

Tendon Rupture Risk and Injury Association

Postoperative Complications and Reoperation

Mechanisms and Ultrastructure

Clinical Considerations and Causation

Practical Considerations

Risk Assessment and Counseling

Operative Considerations

Anabolic Steroids and SARMs

Key Evidence

References