Acute Rotator Cuff Tear with Long-Term Testosterone Replacement Therapy: A Case Report

The use of exogenous anabolic androgenic steroids (AAS) results in significantly increased skeletal muscle mass and improves athletic performance [1, 2]. Testosterone replacement therapy (TRT) is frequently prescribed to aging male patients to combat symptomatic hypogonadism, and in those recovering from prior AAS use [3]. Testosterone therapy can improve mood, increase energy and libido, and increase muscle mass, but its long-term impact on tendon structure and the healing process remains poorly understood [4, 5]. Younger patients with these types of injuries often present to either a primary clinic or to the ED with acute shoulder injury but no fracture or dislocation, traditionally they are treated with a sling and NSAIDS without any further evaluation.

Rotator cuff tears are often associated with older adults, but traumatic tears in younger patients are becoming increasingly common [6, 7]. Disproportionate muscle-tendon loading and altered collagen architecture may occur in younger patients with any history of exogenous androgen exposure, leading to acute, nondegenerative types of tearing [4, 5, 8, 9]. Since these injuries have a unique pattern and lack the classic degenerative findings seen in older populations, these patients often experience later diagnosis and under-treatment [10]. Additionally, because of the altered tendon structure with TRT and AAS, tendon related injuries should undergo advanced imaging earlier given the high risk for tendon related rupture/injury [11]. Given their high functional demands and greater tendon healing potential, early surgical intervention should be strongly considered in young patients, especially those with a history of AAS or TRT exposure.

Most reports in orthopaedic literature linking exogenous androgens to tendon injuries occur in men taking supraphysiologic doses of AAS, which are associated with increased risk of rupture from impaired collagen synthesis and decreased tendon elasticity, but this should not diminish the significance of the potential impact TRT can have on tendon health [4, 12]. There is some evidence indicating that the rate of tendon tearing is higher in patients taking TRT, with studies showing that men undergoing testosterone replacement therapy experience a higher rate of Achilles tendon injuries-approximately 378 versus 246 per 100,000 person-years in treated versus untreated individuals over two years [8]. Another large analysis found that TRT recipients were about 2.9 times more likely to suffer any tendon rupture (3.2% vs. 1.1%) and roughly 0.35% experienced an anterior cruciate ligament (ACL) injury within two years, compared to 0.10% in controls [13]. Given this data, one can assume that TRT although beneficial in some aspects of health and medicine also has significant negative consequences that need to be considered when starting these medications.

The question becomes, do physiologic doses of exogenous testosterone such as those prescribed in TRT also alter tendon homeostasis and contribute to decreased strength and a higher risk for rupture. Although human data is limited, animal studies have suggested that testosterone can change tendon gene expression and may also lead to disproportionate muscle hypertrophy contributing to a mismatch in strength relative to tendon adaptation [12]. If true, this discrepancy would predispose patients taking TRT to tendonrelated injuries.

This case presents a 41-year-old male patient with a history of AAS use who was on TRT at the time of injury. He sustained a transtendinous full-thickness supraspinatus and infraspinatus tear following a single traumatic event, and this combined with a previous distal biceps’ tendon rupture and exogenous androgen exposure offers insight into the possible cumulative effect chronic testosterone exposure has on tendon health and resilience, even in the absence of supraphysiologic doses. This case highlights the clinical importance of recognizing patients who are prescribed exogenous androgens of any kind and demonstrates the need for further research into the effects of TRT on musculoskeletal health, particularly with previous steroid use or tendon pathology.

A 41-year-old right hand dominant male patient presented to clinic with persistent left shoulder pain and weakness on abduction following a traumatic injury sustained while cutting logs in October 2024. He reports that a large branch fell off the platform he was on, and he grabbed it to keep it from falling on his car. It forcefully jerked his arm downward, and he experienced immediate pain. He sought care after several weeks from the injury as he continued to have pain and weakness that was causing functional limitations and failed to improve with rest.

His past medical history included a distal biceps tendon that ruptured while lifting weights. This required surgical intervention and healed without any complications. He also reported a history of anabolic steroid use in his early 30s while he was bodybuilding. The patient denied any current AAS use at the time of presentation but was receiving testosterone replacement therapy for hypogonadism managed by his primary care physician. He denied any previous shoulder pain or weakness prior to the injury in question and appeared to be physically fit and in excellent overall health.

He was initially seen by another provider at an outlying facility, and treatment consisted of a subacromial corticosteroid injection and a course of physical therapy, neither of which provided any meaningful relief or improvement. He was referred to us after failing conservative management. He reported significant pain with any overhead movement, and he noted weakness with difficulty lifting away from his body. He endorsed general impediments to his activities of daily living. The physical exam of the left shoulder showed anterolateral tenderness, no tenderness was elicited in the bicipital groove, and there were no signs of instability. His motion testing revealed active forward flexion to 120°, external rotation to 60°, and internal rotation to T10. The patient had full passive range of motion. There was some pain with resisted forward elevation and external rotation, with notable weakness in both his supraspinatus and infraspinatus.

Plain film x-rays were negative and are seen in Figure 1. The MRI of the left shoulder showed a full-thickness transtendinous tear involving the infraspinatus and supraspinatus, and low-grade articular fraying of the subscapularis. These images are shown in Figure 2. There was no evidence to indicate any rotator cuff muscular atrophy or glenohumeral degenerative changes. The biceps tendon was intact with some increased fluid around the sheath, indicating mild tendinopathy.

After discussion of both conservative and operative treatment options, the patient elected to undergo arthroscopic repair of his supraspinatus and infraspinatus with subacromial depression. Upon arthroscopic evaluation, the labrum was determined to be in good condition, as was the articular cartilage on the glenoid and the humerus. The subscapularis tendon was intact, and the biceps tendon was normal in appearance with no evidence of partial tearing or synovitis. The patient had a full-thickness transtendinous defect within the rotator cuff at the junction of the supraspinatus and infraspinatus tendons. The split extended from near the footprint laterally to the muscle tendon junction medially. The edges of the tear were cleaned up to healthy tissue with a shaver. Five permanent sutures were passed across the tear, working from medial to lateral. These sutures were tied, and the rotator cuff was brought back together anatomically. These images can be seen in Figure 3. The quality of the tissue was excellent. Biceps tenodesis was initially planned but not performed as there were no signs of pathology of the biceps tendon intraoperatively. The patient tolerated the procedure well and went home the same day with no complications and instructions for standard post-operative rehabilitation. The patient is presently doing well four months after surgery. He has full range of motion, he does not have pain, and his strength is slowly improving. So far, the patient is happy with his surgery and the recovery process.

In this case report we explore a clinically significant rotator cuff tear in a 41-year-old otherwise healthy male patient with history of AAS use and currently on TRT. The injury occurred when the patient attempted to prevent a tree branch from falling on his car. The patient was originally seen by non-operative sports medicine and was treated conservatively with corticosteroid injection and physical therapy which did not improve his pain or weakness. He was later referred to orthopaedic surgery, and it was discovered that the injury had resulted in a full-thickness tear of the supraspinatus and infraspinatus with low-grade fraying of the subscapularis. Given his additional relevant history of a prior biceps tendon rupture, AAS exposure, and current use of TRT, the index of suspicion for decreased tendon integrity should be high. For patients like this, early diagnosis and treatment of tendon injuries may contribute to a more successful outcome.

While the connection between AAS use and tendon rupture is well-documented in orthopedic and endocrinology literature, we have limited data on the role played by physiologic-dose testosterone therapy [4, 5, 9]. Whether chronic exposure to exogenous testosterone negatively impacts tendon integrity remains unclear [4, 14]. Animal studies suggest that testosterone potentially decreases the content of type 1 collagen in extracellular tendon matrices, and some data indicates that even low therapeutic levels of exogenous testosterone can cause enough skeletal muscle hypertrophy to result in a biomechanical mismatch and cause the tendons to become mechanically overloaded [5, 12]. Despite no clinical evidence or imaging to suggest chronic tendinopathy or significant retraction, this patient’s history of multiple traumatic tendon ruptures and the unique transtendinous tear pattern could reflect an underlying compromise in his tendon tissue.

It is important to note that this patient was not actively using AAS at the time of his injury, but the cumulative effects of previous supraphysiologic steroid exposure followed later by chronic TRT may have contributed over time to a biomechanically weakened tendon [4, 5, 14]. Additionally, his pattern of injury including the absence of footprint retraction and the split nature of the tear also suggests a non-degenerative pattern of injury. This mechanism is consistent with acute traumatic overload in a tendon that may have underlying structural compromise and impaired resilience.

TRT is a frequently prescribed and sometimes misused therapy for a variety of pathologies [1-3]. In the world of orthopaedics, its impact on tendon health and integrity is often overlooked [4, 5]. These concerns are amplified in the setting of past anabolic steroid use. This case highlights the importance of understanding and considering the potential impact TRT and steroid use have on the musculoskeletal system. The patient’s unusual transtendinous tear pattern and repeat tendon rupture suggests that even at therapeutic doses, exogenous testosterone may compromise tendon structure [12,14]. Orthopaedic and primary care providers should maintain a high level of suspicion for tendon injury in any patients currently taking or with a history of either TRT or AAS and consider early imaging and surgical referral where appropriate.

We would like to acknowledge all the authors and their contributions to this paper.

No conflict of interest.

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