Performance-Enhancing Drugs (Anabolic Steroids / Stimulants) in Sport

An unexpected pectoralis major rupture with little provocation in a notably muscular athlete should make me suspect anabolic-androgenic steroid use. Anabolic steroids increase muscle mass and strength, but they strengthen the muscle disproportionately to the tendon and alter tendon properties, predisposing to tendon rupture - classically of the pectoralis major, and also the Achilles, quadriceps or patellar and biceps tendons - so the rupture may be the presenting sign of doping. Beyond the injury, I would be concerned about the wider health consequences of anabolic steroids, which can be severe and sometimes permanent: cardiovascular disease, including cardiomyopathy, hypertension, dyslipidaemia and thrombosis; hepatic disease, including cholestasis and tumours, especially with oral 17-alpha-alkylated agents; renal disease; endocrine effects such as testicular atrophy and hypogonadism, gynaecomastia and, in women, virilisation; and psychiatric effects such as aggression, mood disturbance and dependence, with premature physeal closure and stunted growth in adolescents. If stimulants are also being used, there are additional cardiovascular and heat-illness risks. So I would repair the tendon as indicated but also recognise and address the doping: counsel the athlete honestly about the health risks, screen for and treat the consequences, and work within the anti-doping framework and education/prevention to foster an anti-doping culture - rather than treating the tendon rupture in isolation.