Risk and Clinical Patterns of Tendon Injury and Rupture Associated with Anabolic-Androgenic Steroids and Exogenous Testosterone: A Systematic Review
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Anabolic-androgenic steroids (AAS) and exogenous testosterone may increase muscle strength more rapidly than tendon adaptation, potentially increasing the risk of tendon injury and rupture. This systematic review evaluated the association between AAS or exogenous testosterone exposure and tendon injury or rupture, while describing injury patterns, potential mechanisms, structural findings, management approaches, and clinical outcomes. PubMed, the Cochrane Library, and ScienceDirect databases were searched through July 12, 2026, following the PRISMA guidelines. Human observational studies, case series, and case reports involving adult participants were included. The risk of bias was assessed using the Newcastle–Ottawa Scale and Joanna Briggs Institute critical appraisal tools, and the findings were synthesized narratively. Eight studies involving 1,150,337 participants were included. Long-term AAS users demonstrated a ninefold higher hazard of first tendon rupture compared with nonusers. Prescribed testosterone use was associated with increased odds of Achilles tendon injury (adjusted odds ratio = 1.24) and quadriceps tendon injury (odds ratio = 5.4), as well as subsequent surgical intervention. Among 35 case-based patients, 32 experienced pectoralis major tendon ruptures, predominantly during bench-pressing activities. Imaging and histopathological findings indicated tendinopathy, degenerative changes, and neovascularization, while most patients who underwent surgical treatment achieved favorable recovery outcomes. AAS and exogenous testosterone exposure are associated with tendon injuries across various clinical settings; however, heterogeneity in study designs and exposure definitions limits causal interpretation and quantitative pooling.
Albright, J. A., Lou, M., Rebello, E., Ge, J., Testa, E. J., Daniels, A. H., & Arcand, M. (2023). Testosterone replacement therapy is associated with increased odds of Achilles tendon injury and subsequent surgery: A matched retrospective analysis. Journal of Foot and Ankle Research, 16(1), 76. https://doi.org/10.1186/s13047-023-00678-0
Brinkman, J. C., Holle, A. M., Paul, B. R., Payne, C. S., Tummala, S. V, Haglin, J. M., & Chhabra, A. (2024). Prescription testosterone is associated with an increased risk of anterior cruciate ligament injury. Arthroscopy: The Journal of Arthroscopic & Related Surgery. https://doi.org/10.1016/j.arthro.2024.10.032
Cleri, N. A., Zhang, J., Singh, G., Mikell, C. B., & Pendleton, C. (2024). Thoracic intervertebral disc herniation associated with chronic anabolic androgenic steroid use: A case report. Cureus, 16(6), e62438. https://doi.org/10.7759/cureus.62438
De Castro Pochini, A., Ejnisman, B., Andreoli, C. V, Lara, P. H. S., Godoy, I. R. B., & Ribeiro, L. M. (2024). Anabolic steroids and the evaluation of patients with acute PM tendon rupture using microscopy and MRI. Journal of Surgical Case Reports, 2024(3), rjae126. https://doi.org/10.1093/jscr/rjae126
Fenelon, C., Dalton, D. M., Galbraith, J. G., & Masterson, E. L. (2016). Synchronous quadriceps tendon rupture and unilateral ACL tear in a weightlifter, associated with anabolic steroid use. BMJ Case Reports, 2016, bcr2015214310. https://doi.org/10.1136/bcr-2015-214310
Guzzoni, V., Selistre-de-Araújo, H. S., & De Cássia Marqueti, R. (2018). Tendon remodeling in response to resistance training, anabolic androgenic steroids and aging. Cells, 7(12), 251. https://doi.org/10.3390/cells7120251
Jones, I. A., Togashi, R., Hatch, G. F. R., Weber, A. E., & Vangsness, C. T. (2018). Anabolic steroids and tendons: A review of their mechanical, structural, and biologic effects. Journal of Orthopaedic Research, 36(11), 2830–2841. https://doi.org/10.1002/jor.24116
Kanayama, G., DeLuca, J., Meehan, W. P., Hudson, J. I., Isaacs, S., Baggish, A., Weiner, R., Micheli, L., & Pope, H. G. (2015). Ruptured tendons in anabolic-androgenic steroid users: A cross-sectional cohort study. The American Journal of Sports Medicine, 43(11), 2638–2644. https://doi.org/10.1177/0363546515602010
Kanayama, G., & Pope, H. G. (2018). History and epidemiology of anabolic androgens in athletes and non-athletes. Molecular and Cellular Endocrinology, 464, 4–13. https://doi.org/10.1016/j.mce.2017.02.039
Meghani, O., Albright, J. A., Testa, E. J., Arcand, M. A., Daniels, A. H., & Owens, B. D. (2024). Testosterone therapy is associated with increased odds of quadriceps tendon injury. Clinical Orthopaedics and Related Research, 482(1), 175–181. https://doi.org/10.1097/CORR.0000000000002744
Quinn, M., Albright, J. A., Lemme, N. J., Testa, E. J., Morrissey, P., Arcand, M., Daniels, A. H., & Fadale, P. (2024). The relationship between exogenous testosterone use and risk for primary anterior cruciate ligament rupture. Orthopaedic Journal of Sports Medicine, 12(11), 23259671241291064. https://doi.org/10.1177/23259671241291063
Rebello, E., Albright, J. A., Testa, E. J., Alsoof, D., Daniels, A. H., & Arcand, M. (2023). 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, 32(6), 1254–1261. https://doi.org/10.1016/j.jse.2023.02.122
Scarth, M., Havnes, I. A., Jørstad, M. L., & Bjørnebekk, A. (2025). Psychological traits associated with anabolic androgenic steroid use and dependence: An exploratory cross-sectional study among female athletes. BMC Women’s Health, 25(1), 214. https://doi.org/10.1186/s12905-025-03711-5
Seynnes, O. R., Kamandulis, S., Kairaitis, R., Helland, C., Campbell, E. L., Brazaitis, M., Skurvydas, A., & Narici, M. V. (2013). Effect of androgenic-anabolic steroids and heavy strength training on patellar tendon morphological and mechanical properties. Journal of Applied Physiology, 115(1), 84–89. https://doi.org/10.1152/japplphysiol.01417.2012
Stefanou, N., Karamanis, N., Bompou, E., Vasdeki, D., Mellos, T., & Dailiana, Z. H. (2023). Pectoralis major rupture in body builders: A case series including anabolic steroid use. BMC Musculoskeletal Disorders, 24(1), 264. https://doi.org/10.1186/s12891-023-06382-1
Testa, E. J., Albright, J. A., Hartnett, D., Lemme, N. J., Daniels, A. H., Owens, B. D., & Arcand, M. (2023). The relationship between testosterone therapy and rotator cuff tears, repairs, and revision repairs. Journal of the American Academy of Orthopaedic Surgeons, 31(11), 581–588. https://doi.org/10.5435/JAAOS-D-22-00554
William, & Angellee, J. (2026). Sindrom putus steroid anabolik androgenik: Tinjauan untuk praktisi kesehatan. Cermin Dunia Kedokteran, 53(1), 55. https://doi.org/10.55175/cdk.v53i01.1680
Yarnell, C. J., Thiruchelvam, D., & Redelmeier, D. A. (2021). Risks of serious injury with testosterone treatment. The American Journal of Medicine, 134(1), 84–94. https://doi.org/10.1016/j.amjmed.2020.07.037
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