Abstract
Objectives:
Many individuals are currently treated with exogenous testosterone for a diverse array of medical conditions. However, in some clinical studies, testosterone treatment is associated with a higher risk of tendon injuries, especially among male bodybuilders and professional athletes. In the literature to date, most tendon ruptures among anabolic steroid users were reported to be at the long head of the biceps (39%), pectoralis (29%), triceps (16%), and Achilles tendon (8%). Additionally, several basic science studies have shown an increased risk of tendon injury biomarkers associated with exogenous anabolic steroid use. Anabolic steroid use has increased since the 1990s, including use among non-athletes. However, the hazards of using testosterone in the nonathlete population has been scarcely described. This study aims to determine the risk of tendon ruptures and surgical intervention for these injuries among exogenous therapeutic testosterone users as well as the risk of recurrent injury after surgery in this setting.
Methods:
After IRB approval, patient medical records from October 2015 to July 2023 at our institution were quieried for testosterone users. The patient records were reviewed to identify a cohort of testosterone users and a cohort of all non-users in the same time period. ICD-10 diagnosis codes for tendon injury were used to search for specific tendon injuries. Exclusion criteria from both the user and nonuser groups included active tobacco smoking, type 2 diabetes, chronic inflammatory conditions, and the use of fluoroquinolone or corticosteroid medications.
Results:
A total of 1.3 million patients were identified as being evaluated at our institution during the study time frame which included 12,939 (1% of the population, 83% male) testosterone users with a total of 14,884 reported tendon ruptures. The incidence of these injuries among our non-athlete patients being treated with therapeutic exogenous testosterone was considerably lower when compared to what has been reported among the NFL player (9.1%) and bodybuilder (22%) populations.
In our study, testosterone users had a 2.9-fold increased risk of tendon rupture compared to nonusers (3.2% vs. 1.1%, [95% CI, 2.6-3.2]; p<0.0001). However, no statistical differences were reported among female users (1.4%) vs. nonusers (1.0%) with an odd ratio (OR) of 1.36 [95% CI, 0.9-1.9]; p=0.10).
Overall, a higher increase in risk of tendon ruptures was found among patients aged 35-44 years (OR: 2.9) and over 85 years (OR: 2.5). Conversely, middle-aged adults (35-44 years) had the highest risk of rotator cuff tears (OR:4.69). Only two previous studies have been conducted, with conflicting results regarding the association between testosterone use and tendon ruptures. Interestingly, no significant differences were observed in NFL players concerning tendon ruptures. However, bodybuilders were reported to have an elevated risk of tendon ruptures (OR: 4.7).
In our series, among testosterone users, rotator cuff tear was the most prevalent tendon rupture location (77%, OR: 3.28), followed by the posterior thigh compartment (8%, OR: 3.60), foot and ankle (4%, OR: 3.13), Achilles’s tendon (3%, OR: 2.76). Although the long head of the biceps tendon had a overall low rate of injury in our series (1%) it had the highest OR at 7.7. It is assumed that we did not find a pectoralis rupture in this series because it is associated with specific activities in which this population had a low degree of participation.
Conclusions:
Therapeutic testosterone use increases the risk of tendon ruptures compared to patients not using therapeutic exogenous testosterone. This risk was most prevalent in men over the age of 55 years. The most common tendon tear location was rotator cuff tendon tears, and the stratification of tendon tear locations differed significantly compared to other previously reported anabolic steroid user populations (e.g. body builders).
