Dr. MELISSA BURMANMDJUL 2026
We Can’t Separate Hormones From Musculoskeletal Health Anymore
From My Clinic Notebook
One of the biggest surprises in my career hasn’t come from a new procedure or a landmark paper. It has come from listening to my patients. Over the past few years, women in their forties and fifties often tell remarkably similar stories — not because they’re thinking about hormones, but because a shoulder won’t recover after a minor injury, an Achilles is taking months, a gluteal tendinopathy isn’t responding. They’re still exercising, still eating well, yet something feels different.
Eventually almost every conversation arrives at the same place: “I don’t understand. My body just doesn’t recover the way it used to.” For a long time I treated that as a separate conversation from the tendon, the joint, or the MRI in front of us. More recently I’ve started wondering if that was the wrong way to think about it.
One unintended consequence of specialization is that we become experts in individual body parts. But our patients never stop being whole human beings. The shoulder doesn’t exist independently from sleep. The tendon doesn’t exist independently from metabolism. The muscle doesn’t exist independently from hormones. Maybe we’ve been looking at the right tissue but asking too narrow a question.
What We Know
The goal of musculoskeletal medicine has always been to understand why tissues become painful and how they recover. Increasingly, research reminds us those tissues exist within a much larger physiologic environment.
This is one of the least controversial statements in physiology, yet it receives surprisingly little attention in orthopedic conversations. Estrogen, testosterone, growth hormone, and IGF-1 all influence muscle protein synthesis, collagen turnover, bone remodeling, and recovery after exercise. As these hormonal environments change through life, the tissues we treat change with them. That doesn’t mean hormones explain every injury — but they influence the environment in which healing occurs.
One of the most significant physiologic transitions is menopause, yet we rarely discuss it in a musculoskeletal context. Declining estrogen is associated with reductions in muscle mass, changes in tendon collagen turnover, accelerated bone loss, altered body composition, and profound changes in sleep. Many women describe feeling their recovery has changed long before they identify hormones as part of the story. As Dr. Stacy Sims has emphasized, women are not simply smaller men.
The biology is compelling — hormones influence tendon biology, muscle protein synthesis, and bone metabolism, and hormonal changes contribute to sarcopenia, reduced tendon resilience, and fracture risk. Where we must be careful is assuming that identifying a hormonal change tells us how to treat it. This isn’t an argument for hormone therapy or routine endocrine testing — it’s an argument that physiology matters. Sometimes the first symptom of a physiologic change isn’t a hot flash; it’s the tendon that suddenly stops behaving.
Although women deserve greater attention because menopause has been underrepresented in sports medicine, the underlying principle is universal. Men experience age-related changes in testosterone, muscle mass, metabolism, sleep, and recovery. Chronic disease, nutritional deficiencies, metabolic health, stress, and poor sleep all influence the biology of healing regardless of sex. The common thread is simple: musculoskeletal tissues respond to physiology, not simply chronology.
Question to Consider
When a patient isn’t recovering the way we expect, should we only ask what’s happening in the tendon — or should we spend more time understanding the physiology surrounding it?
Medicine is constantly evolving. So are the questions worth asking. I’ll keep sharing what I’m learning — from research, from colleagues, and from the patients who continually remind me that good medicine begins with curiosity. If this perspective resonates with you, I’d be honored to have you join me for the next edition.