Testosterone Replacement Therapy and Tendinopathies

Recently, more men have started using Testosterone Replacement Therapy (TRT). Once rarely discussed, TRT is now common, and many medical offices and telehealth providers offer it. While this article won’t focus on who should consider this treatment or its efficacy, this article will discuss one of the common side effects seen clinically: Testosterone Replacement Therapy and Tendinopathies.

Many recreational athletes notice lower energy levels and reduced performance as they age. To counter this, some begin TRT. As a physical therapist, I see these athletes dealing with more tendon injuries. This article will share my thoughts on why that happens and how to reduce the risk.

 

Performance Enhancing Benefits of TRT

First, let’s talk about the performance benefits seen in men on TRT. A study placed men on various doses of TRT for six months. They had experience with weightlifting but were asked not to lift during the study.

The graphs below show gains in fat-free mass (kg) and leg press strength. Participants on a 125mg weekly dose gained 3.4kg in lean mass. Higher doses led to even bigger gains.

It’s worth noting that doses of 300+ mg are much higher than typical TRT dosages, resembling a steroid cycle. However, doses between 100-200mg per week are common in “Sports TRT.”

The study also found that participants (at 50, 300, and 600mg/week) saw significant increases in leg press strength. These gains would likely be even greater if the men had been training during the study.

 

Strength & Muscle Mass Gains—But at What Cost?

Though the muscle and strength gains are impressive, there are risks. A 2023 study found that men on TRT were twice as likely to suffer distal biceps tendon injuries compared to those not on TRT (PMID: 36918119). Another study found a 3.6 times greater risk of rotator cuff tears for men on TRT (PMID: 36745691).

This doesn’t mean all men on TRT will rupture tendons, but it suggests this risk should be considered. Strategies to reduce this risk are essential.

 

Why the Increase in Tendon Injuries?

In my practice, I see more tendinopathy cases in men on TRT than in others. While there’s no study showing an increase in tendinopathies specifically, the research on increased tendon tears suggests some level of tendon disrepair in men on TRT.

Why does this happen? I believe TRT restores energy in hypogonadal men, leading to more physical activity and big increases in muscle mass and strength. Tendons, however, don’t adapt as fast as muscles. This can create a mismatch between training intensity and tendon capacity, resulting in pain and injury.

 

Testosterone Replacement Therapy and Tendinopathies – Reducing the Risk

First, and most important, is to monitor your training load. Tendons don’t respond well to large spikes in training volume. So if you’ve been working out twice a week, don’t immediately jump up to 5 or 6 days per week. Increase that to 3x/week along with some long walks or Zone 2 cardio. Every 4-6 weeks, increase a bit more.

Next, I’d make two modifications to weight training. The first would be to perform some of your heavy lifts with a slow tempo. Heavy, slow resistance training is a staple of tendon rehab, helping to improve collagen synthesis and mechanical stiffness of tendons. I am not aware of any studies showing that this prevents tendon injuries, but I feel confident that if it helps rehab tendons, it likely has a positive effect on healthy tendons as well.

Related Article: Lifter’s Guide to Tendinopathy

This does not have to apply to all of your lifts, but I think each month choosing 1-2 movement patterns and performing one exercise with a slower tempo is a great move for tendon health.

Example:

• Month 1: Squats and Chin Ups performed at tempo
• Month 2: RDLs and Overhead Press
• Month 3: Calf Raises and Bench Press

This also doesn’t have to be your main lift. Consider making an accessory exercise, such as a goblet squat, your tempo move.

 

The second training modification I would make would be to incorporate some high-rep band finishers. For years, powerlifters have used fast-tempo, high-rep band work in their training. Their goal is to improve the tendon’s energy storage and release. Similar to the above, I’d rotate through different band finishers each month, targeting different areas of the body. Aim for 100-200 reps at a fast speed.

Example:

• Month 1: Tricep Pushdowns and Leg Curls
• Month 2: Leg Extensions and Band Hammer Curls

 

 

Finally, I would consider collagen supplementation. Collagen is the primary building block of your connective tissues. While the research is still in its early stages, collagen supplementation is showing some promise in tendon rehab.

A 2021 systematic review concluded that “Collagen seems to be beneficial in the treatment of tendinopathy, but conclusions about optimal dosage, timing, duration, and type of collagen supplementation cannot be drawn yet.” Hijlkema et. al., 2021

Similar to heavy, slow resistance training, I am not aware of research showing that collagen supplements reduce tendon injury risk. But if it helps with tendon rehab, it seems likely that it will also benefit healthy tendons.

My recommended collagen supplement is Bubs Naturals. While (at the time of writing this) I am not on TRT, I take this daily for my own recovery from training.

 

Conclusion – Testosterone Replacement Therapy and Tendinopathies

This article is not medical advice or a promotion of TRT. It’s important to do your own research and discuss TRT with your doctor. If you are dealing with tendon pain and want a fitness-focused approach to rehab, find an Onward Physical Therapy location near you. Our team understands tendon rehab and will help you stay active while working toward your fitness goals.