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Pagkumpuni ng Tendon ng Distal Biceps

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Isang protektadang plano ng paggaling na may maagang paggalaw pagkatapos ng operasyong pagkumpuni ng naputol na distal biceps tendon, na nagbibigay-daan sa komportableng paggalaw mula sa unang araw habang pinoprotektahan ang pagkumpuni laban sa resisted lifting hanggang sa mabuo ang lakas nang hakbang-hakbang.

Illustrasyon ng distal biceps tendon na nakabalik-taas sa radial tuberosity sa siko gamit ang cortical button.
Ang distal na tendon ng biceps ay muling nakadikit sa kanyang bonyong footprint sa radius sa siko. Kieran Hirpara 4.0

Ang pahinang ito ay isinalin ng makina at hindi pa nasusuri ng isang doktor. Ang bersyong Ingles ang siyang opisyal.

Ang protokol na ito ay gabay sa iyong paggaling pagkatapos ng operasyong pagkumpuni ng putol na distal biceps tendon kay Dr. Kieran Hirpara sa Mater Private Hospital Rockhampton. Nagsisimula ito sa iyong home exercise program, sinundan ng istrukturadong klinikal na protokol na isinulat para sa iyong physiotherapist o hand therapist. Dalhin ang pahinang ito o ang PDF nito sa iyong unang bisita sa therapy upang manatiling koordinado ang iyong rehabilitasyon. Maaaring baguhin ng iyong therapist ang plano depende sa pag-unlad ng iyong paggaling.

Kung mayroon kang anumang alalahanin tungkol sa iyong sugat pagkatapos ng operasyon, makipag-ugnayan sa mga kwarto. Karaniwang makakatulong na kumuha ng litrato ng sugat at ipadala ito sa pamamagitan ng email para sa pagsusuri.

Ano ang inaasahan

Ang distal biceps tendon ay ang kordilya na nag-aanchor ng iyong biceps muscle sa radius bone sa ilalim ng harap ng siko. Kapag ito ay naputol, ito ay muling ididikit sa kanyang bony footprint sa radius. Si Dr. Hirpara ay aayusin ito gamit ang cortical button, isang maliit at matibay na fixation na nagpapanatili ng tendon nang mahigpit laban sa buto habang ito ay gumagaling.

Dahil ito ay isang matibay na repair, ang recovery ay nakabatay sa komportableng maagang paggalaw imbes na mahigpit na immobilisation. Magdudulot ka ng simpleng sling ng humigit-kumulang 6 linggo (hindi hinged elbow brace) at inirerekomenda na gumalaw ang siko sa buong komportableng range mula sa unang araw, kasama ang pagwawasto nito. Ang maagang paggalaw ay nagpapanatili ng siko mula sa pagiging matigas, na isa sa mga pangunahing problema pagkatapos ng operasyong ito.

Ang lakas ng repair ay disenyong gamitin upang payagan ang maagang paggalaw. Ito ay hindi pahintulot na mag-angat nang maaga. Ang tendon ay kailangan pa ring mag-ugat biolohikal na sa buto, at ang paggaling na iyon ang nagpoprotekta sa iyo mula sa muling pagputol. Dahil dito, ang pagbebenta ng braso (pag-angat, mahigpit na paghawak at resisted strengthening) ay pinipigilan hanggang sa humigit-kumulang 4 buwan, pagkatapos ay dahan-dahang ipinakilala at binubuo nang unti-unti. Ang sling ay pangunahing para sa komportableng paggamit at bilang paalala na huwag gamitin ang braso nang mabigat; ito ay tinatanggal para sa iyong mga ehersisyo at paghuhugas.

Para sa wound, swelling at scar management, tingnan ang wound care guidance ng practice.

Mga Precaution at Limitasyon

Gawin

  • Galawin ang iyong siko, forearms, pulso, at kamay sa buong komportableng range of motion mula sa unang araw: pagbaluktot, pagwasto, at pag-ikot ng forearms.
  • Alisin ang sling para sa iyong mga ehersisyo at para sa kalinisan; isuot ito para sa komportableng proteksyon sa natitirang oras sa loob ng humigit-kumulang 6 linggo.
  • Gamitin ang braso para sa napakagaan na mga pang-araw-araw na gawain (pagkain, magaan na self-care) hangga't komportable.

Huwag Gawin

  • Huwag magbitbit, magdala, mahigpit na hawakan, o gumawa ng anumang resisted strengthening gamit ang operadong braso hangga't hindi pa inilalabas sa 4 na buwan. Ito ang pinakamahalagang precaution.
  • Huwag pilitin ang biglaang matulis na pagwasto ng siko laban sa load, at iwasan ang pilit o jerky na mga galaw.
  • Huwag i-stretch ang iyong balikat pabalik sa hyperextension nang maaga, dahil ito ay humihigpit sa healing wound sa harap ng siko.

Ang iyong mga ehersisyo

Ito ang mga ehersisyo mula sa iyong handout para panatilihin ang galaw ng iyong siko, forearm, at kamay sa mga unang linggo. Alisin ang sling bago gawin ang mga ito. Gumalaw lamang hanggang sa kumportable ka, at simulan ang mga ito ayon sa gabay ni Dr. Hirpara at ng iyong terapeuta. Ang dalawang ehersisyo para sa pagpapalakas ay ipinakilala nang higit pa: lamang pagkatapos mong makatanggap ng pahintulot na magsimula ng pag-load sa humigit-kumulang 4 na buwan.

Ang iyong klinikal na protokol

Ang natitirang bahagi ng pahinang ito ay ang klinikal na protokol para sa rehabilitasyon pagkatapos ng cortical-button distal biceps tendon repair. Ang seksyong ito ay dapat ibigay sa iyong physiotherapist o hand therapist, at ang bawat yugto sa ibaba ay nagsisimula sa simpleng paliwanag sa wikang Ingles tungkol sa nangyayari.

Ang gabay na prinsipyo ay maagang komportableng galaw na may pinagkaantala na pag-load: ang cortical-button construct ay sapat na matibay upang pahintulutan ang walang limitasyong paggalaw mula sa unang araw, kaya walang hinged brace at walang extension block. Ang tibay ng construct ay ginagamit upang pigilan ang stiffness, hindi upang maging dahilan ng maagang pag-load; ang resisted strengthening at pag-angat ng mabigat ay disenyadong ipinagbabawal upang protektahan ang paggaling ng tendon-to-bone at bawasan ang re-rupture.

Yugto I — Protektadong komportableng galaw (Linggo 0 → 6)

Isang simpleng sling ang isusuot para sa komportableng suporta at bilang paalala laban sa mabigat na paggamit; ito ay tatanggalin para sa mga ehersisyo at paglilinis. Layunin nitong mapanatili ang komportableng halos buong saklaw ng galaw habang pinoprotektahan ang pagkaka-repair mula sa anumang bigat o load.

Para sa iyong pisioterapeuta:

  • Pag-i immobilize: Simpleng sling sa loob ng 6 linggo, tinatanggal para sa mga ehersisyo at paglilinis. Walang hinged brace; walang extension block.
  • Saklaw ng galaw (Range of motion): Lahat ng galaw ay gagawin ayon sa komportableng limitasyon mula araw 1: aktibo at pasibong elbow flexion, extension, at forearm rotation. Walang restriction sa arc at walang extension block.
  • Mga layunin: Mapanatili ang komportableng buong saklaw ng galaw; protektahan ang pagkaka-repair mula sa load; panatilihing mobile ang kamay, pulso, at balikat.
  • Mga ehersisyo: Aktibong elbow flexion/extension hanggang sa komportableng limitasyon; tinutulungan (pasibo) na elbow flexion; aktibong saklaw ng forearm pronation/supination habang nakadikit ang siko sa gilid; galaw ng kamay, pulso, at grip; saklaw ng galaw ng scapula at balikat. Walang resisted biceps o supination loading.
  • Mga paalala (Precautions): Walang pag-angat, pagkupot, o resisted strengthening; iwasan ang biglaang pinilit na eccentric extension laban sa load; iwasan ang hyperextension ng balikat.
  • Mga pamantayan para magpatuloy (Criteria to progress): Nabalot na ang sugat, komportableng halos buong saklaw ng galaw, at wala nang sling sa 6 na linggo.

Yugto II — Buong galaw, walang bigat (Linggo 6 → ~4 buwan)

Itinatigil ang sling. Ang braso ay gagamitin nang malaya para sa magaan na pang-araw-araw na gawain, ngunit walang resisted loading o pag-angat: ang tendon ay patuloy pa ring nagninibago sa buto, at ito ang panahon kung saan ang pag-iingat laban sa load ay pinakamahalaga kahit ligtas na ang paggalaw.

Para sa iyong physiotherapist:

  • Mga layunin: Buong simetrikong range of motion na walang sakit; normal na magaan na functional na paggamit ng kamay at braso.
  • Range of motion / paggamit: Buong galaw ayon sa kagustuhan; pang-araw-araw na magaan na paggamit nang walang resisted loading o pag-angat.
  • Mga ehersisyo: Patuloy na trabaho sa range of motion; kamay, pulso, at grip; kondisyon ng scapula at balikat. Walang resisted biceps o supination loading pa.
  • Mga pamantayan para mag-proceed: Buong range of motion na walang sakit; ang sugat at repair ay nakaayos na → magsimula ng graded loading sa humigit-kumulang 4 na buwan.

Yugto III — Pagpapalakas at unti-unting pagdadagdag ng bigat (~4 → 6 buwan)

Magsisimula ang pagdadagdag ng bigat. Ang magaan na resisted strengthening para sa elbow flexion at forearm supination ay ipinakilala at unti-unting pinapalalim hanggang sa mga pangangailangan na functional, at partikular sa trabaho o isport.

Para sa iyong physiotherapist:

  • Mga Layunin: Muling pagbuo ng lakas sa flexion at supination; pagbabalik sa trabaho at isport.
  • Mga ehersisyo: Magsimula ng magaan na resisted strengthening at pag-angat ng mga bagay sa humigit-kumulang 4 na buwan; unti-unting pag-usapan (isotonic curls at resisted supination → functional patterns → pagdadagdag ng bigat na partikular sa trabaho at isport).
  • Mga pamantayan upang makapagpatuloy: Walang sakit na resisted flexion at supination; lakas na humahapit na sa kabilang bahagi.

Pagbabalik sa trabaho at gawain

Sa unang 6 linggo, inaasahan na gagamitin ang braso lamang para sa magaan at komportableng pang-araw-araw na mga gawain habang nakasuot ng sling para sa proteksyon. Madalas na posible ang magaan na gawain sa opisina o isang kamay nang maagang; ang mas mabigat o dalawang-kamay na pisikal na trabaho ay inaantay hanggang sa magsimula at lumakas ang pag-load.

Ang mga pangunahing milestone ay:

  • Walang pag-angat at walang resisted loading sa mga unang buwan: ito ay disenyado upang hayaang gumaling ang tendon sa buto.
  • Magaan na pag-angat at pagpapalakas mula sa humigit-kumulang 4 na buwan, nagsisimula nang dahan-dahan at unti-unting pag-unlad linggo-linggo.
  • Walang limitasyong gawain at pagbabalik sa sports sa humigit-kumulang 6 na buwan, kapag natupad ang mga pamantayan: buong painless na range of motion, lakas na hindi bababa sa 90–100% ng kabilang bahagi, at kakayahang tumugon sa partikular na mga pangangailangan ng iyong trabaho o sports.

Hindi dapat magmaneho habang nakasuot ng sling. Magbabalik ang pagmamaneho kapag wala nang sling at kayang kontrolin nang komportable at ligtas ang sasakyan, ayon sa pagpapatunay sa iyong review. Laging sundin ang tiyak na payo ni Dr. Hirpara, dahil maaaring mag-iba ang mga oras depende sa mga pangangailangan ng iyong trabaho at sports.

Pagkatapos ng iyong protocol

Ang protocol na ito ay kasabay ng pangkalahatang payo para sa paggaling ng klinika; tingnan ang pamamahala ng post-operative na sakit at pag-aalaga sa sugat. Ang phased na plano sa itaas ay naaayon sa publikadong ebidensya tungkol sa rehabilitasyon pagkatapos ng distal biceps tendon repair, at ang iyong patuloy na paggaling ay indibidwal na pinamumunuan ng iyong physiotherapist o hand therapist ayon sa kung paano ang pag-unlad ng iyong siko.

Reviewed by Dr Kieran Hirpara · 18 June 2026.

Want the clinical detail? Read the clinician version.

Talk to your treating clinician for advice specific to you.

For an appointment with the CQ Hand + Upper Limb team, ask your GP about a referral or visit www.cqupperlimb.com.

Evidence & references

Distal Biceps Tendon Repair — Post-operative Rehabilitation (Evidence)

Topic scope: Post-operative rehabilitation after surgical repair of a ruptured distal biceps tendon reattached to the radial tuberosity with cortical-button fixation. The protocol here reflects Dr Hirpara's practice — a sling-only, early-comfort-motion approach with deliberately delayed loading — set against the published spectrum of distal-biceps rehabilitation protocols.

Defining principle: Cortical-button fixation is the strongest available construct, and biomechanical and clinical evidence show it tolerates immediate motion safely. Dr Hirpara's stance is to spend that strength on early movement, not early loading: a simple sling for 6 weeks (no hinged brace, no extension block) with all motion to comfort from day 1 including extension, but with resisted strengthening and lifting held back until ~4 months to protect tendon-to-bone healing and minimise re-rupture, and unrestricted activity / return to sport at ~6 months on criterion-based clearance. This sits at the protective end of loading while matching the most current thinking on early motion for stiffness prevention.

Where this protocol sits in the evidence

Published distal-biceps protocols span a wide range, from rigid hinged-brace extension-block schemes to immediate unrestricted motion. Dr Hirpara's plan diverges from the "traditional" template in two deliberate ways:

  1. Immobilisation: A simple sling for comfort, not a hinged ROM brace, and no extension block. Motion is unrestricted to comfort from day 1. The mainstream BWH/MGB protocols instead use a posterior splint at 90° for 5–7 days, then a hinged brace with a 45°→30° extension block opened ~10°/week to full extension by ~6 weeks (or ~3 weeks in the accelerated variant). Dr Hirpara's approach is at the early-motion end and is justified by the strength of the cortical-button construct.
  2. Loading: Resisted strengthening and lifting are deferred to ~4 months. This is more conservative than the published loading timelines (accelerated resisted work at week 6; standard/MGB at weeks 8–10–12; light weights weeks 12–14). Crucially, this conservatism is a choice made despite having the construct that would permit earlier loading.

The endpoint — unrestricted activity / return to sport at ~6 months, criterion-based — is the single most commonly cited endpoint across protocols and matches the mainstream consensus.

Key evidence and controversies

  1. Early/immediate motion is safe with modern fixation. (Moderate) Biomechanical work supports immediate motion: Bisson et al (AJSM 2007) found aggressive rehabilitation safe after the modified 2-incision approach, and Rose et al (KSSTA 2010) showed single-incision EndoButton/FiberWire repairs survive 2,000 immediate-motion cycles. Several series report no increased re-rupture with immediate post-operative motion. This underpins the sling-only, motion-to-comfort approach.

  2. Cortical-button strength enables early motion. (Moderate) Cortical-button (± interference screw) fixation has the highest load-to-failure of the available constructs (Olsen JSES 2014; Spang JSES 2006; Lang OTSR 2018 — comparable functional outcomes across constructs but higher load-to-failure for cortical button). Spencer/Edwin (HAND 2008) argued EndoButton fixation strength may allow earlier ROM. This fixation strength is the explicit rationale for permitting immediate movement.

  3. Mobilisation timing may not change outcome. (Moderate) A retrospective comparison found no clinically significant difference in failure, complications, ROM or patient-reported outcomes for early versus delayed mobilisation after primary distal biceps repair. This undercuts the urgency of accelerating loading and supports a measured progression.

  4. Conservative rehab may lower re-rupture. (Consensus / survey) Rosenthal/Ting/Sher (JSES 2023), a survey of fellowship-trained elbow surgeons, suggests more conservative post-operative rehab may be associated with lower re-rupture risk — a direct counterweight to the accelerated-loading trend and the rationale for deferring loading to ~4 months. Phelps et al (JSES Int 2025, Level IV systematic review) found no consensus on the optimal return-to-sport protocol, with protocols ranging from immobilisation to immediate motion.

  5. Tendon elongation in the mid window. (Moderate) Marshall et al (OJSM 2016, radiostereometric) showed the repaired tendon elongates mostly at 4–8 weeks post-op with minimal change at 8–16 weeks — a biomechanical argument for caution against aggressive loading in that mid window even when motion itself is safe.

  6. Incision and complications. (Moderate) Grewal et al RCT (JHS 2010): no overall functional difference single vs double incision (flexion strength slightly greater with two-incision, more minor complications with single-incision). Amarasooriya systematic review (AJSM 2020): synostosis occurred only with double incision; fixation technique did not significantly affect re-rupture. Incision choice mainly drives complication-avoidance precautions, not the ROM timeline. Re-rupture rates overall are low (0–5.6%; Garon & Greenberg 2016).

Phased rehabilitation timeline (this protocol)

Phase Window Sling / brace ROM / use Strengthening / loading Criteria to progress
I — Protected comfort motion Week 0 → 6 Simple sling 6 wk, off for exercises/hygiene. No hinged brace, no extension block All motion to comfort from day 1 — active + passive flexion, extension and forearm rotation. No arc restriction None. No resisted biceps/supination loading; hand/wrist/grip and scapular/shoulder ROM maintained Wound healed; comfortable near-full ROM; out of sling at 6 wk
II — Full motion, unloaded Week 6 → ~4 mo Sling off Full symmetric pain-free ROM; light everyday use None yet — light functional use without resisted loading or lifting Full painless ROM; wound/repair settled → begin loading ~4 mo
III — Strengthening & graded loading ~4 → 6 mo — Full ROM maintained Start LIGHT resisted strengthening / lifting at ~4 mo; progress gradually (isotonic curls + resisted supination → functional → job/sport-specific) Pain-free resisted flexion/supination; strength approaching the other side
Return to activity ~6 mo — Unrestricted Unrestricted activity / return to sport, criterion-based Full painless ROM; strength ≥90–100% of the other side; tolerance of job/sport-specific demands

One-line summary: simple sling 6 weeks with all motion to comfort from day 1 (no brace, no extension block) → full unloaded motion to ~4 months → light resisted loading from ~4 months → unrestricted activity / sport at ~6 months, criterion-based.

Evidence strength flags

  • MODERATE (biomechanical + cohort): safety of immediate/early motion with cortical-button fixation (Bisson 2007; Rose 2010; Olsen 2014; Spang 2006; Lang 2018); no clinically significant difference early vs delayed mobilisation; low overall re-rupture rates.
  • MODERATE (biomechanical): tendon elongation concentrated 4–8 weeks (Marshall 2016) — supports caution on mid-window loading.
  • CONSENSUS / survey-level: more conservative rehab may lower re-rupture (Rosenthal 2023); no consensus on optimal return-to-sport protocol (Phelps 2025, Level IV). The specific phase timings of this protocol are expert/consensus-derived, not trial-derived.

Overall evidence strength: Moderate. Phased timelines rest on consistent institutional protocol consensus reinforced by biomechanical studies and retrospective cohorts; few prospective RCTs of the rehabilitation progression itself, and no consensus on the optimal return-to-sport protocol.

CITATIONS

RAG corpus (180,000+ Orthopaedic articles)

  • Grewal R, Athwal GS, MacDermid JC, et al. Single vs. double incision technique for the repair of distal biceps tendon ruptures: a randomized clinical trial. J Hand Surg Am. 2010.
  • Amarasooriya M, Bain GI, Roper T, et al. Complications after distal biceps tendon repair: a systematic review. Am J Sports Med. 2020.
  • Keener JD. Controversies in the surgical treatment of distal biceps tendon ruptures: single versus double-incision repairs. J Shoulder Elbow Surg. 2011;20(2):S113–S125.
  • Dunphy TR, Hudson J, Batech M, et al. Surgical treatment of distal biceps tendon ruptures: an analysis of complications in 784 surgical repairs. Am J Sports Med. 2017;45(13):3020–3029.
  • Bisson LJ, Gurske-de Perio J, Weber AE, et al. Is it safe to perform aggressive rehabilitation after distal biceps tendon repair using the modified 2-incision approach? A biomechanical study. Am J Sports Med. 2007.
  • Rose DM, Archibald JD, Sutter EG, et al. Biomechanical analysis suggests early rehabilitation is possible after single-incision EndoButton distal biceps repair with FiberWire. Knee Surg Sports Traumatol Arthrosc. 2010;19(6).
  • Marshall NE, Keller RA, Okoroha K, et al. Radiostereometric evaluation of tendon elongation after distal biceps repair. Orthop J Sports Med. 2016.
  • Phelps BM, Birnbrich A, Singer W, et al. Postoperative rehabilitation and return to sport criteria following distal biceps tendon rupture surgery. JSES Int. 2025. (Level IV systematic review: no consensus on optimal RTS rehabilitation.)
  • Rosenthal R, Ting RS, Sher D. Management of distal biceps tendon ruptures: a survey of fellowship-trained subspecialist elbow surgeons. J Shoulder Elbow Surg. 2023;32(10).
  • Olsen JR, Shields E, Williams RB, et al. A comparison of cortical button with interference screw versus suture anchor techniques for distal biceps brachii tendon repairs. J Shoulder Elbow Surg. 2014;23(11):1607–1611.
  • Spang JT, Weinhold PS, Karas SG. A biomechanical comparison of EndoButton versus suture anchor repair of distal biceps tendon injuries. J Shoulder Elbow Surg. 2006.
  • Lang NW, Bukaty A, Sturz GD, et al. Treatment of primary total distal biceps tendon rupture using cortical button, transosseous fixation and suture anchor: a single center experience. Orthop Traumatol Surg Res. 2018.
  • Edwin ES (Spencer EE Jr), Tisdale A, Kostka K, Ivy RE. Is therapy necessary after distal biceps tendon repair? HAND. 2008;3(4).
  • Rubinger L, Solow M, Johal H, et al. Return to work following a distal biceps repair: a systematic review of the literature. J Shoulder Elbow Surg. 2020;29(5):1002–1009.
  • Ford SE, Andersen JS, Macknet DM, et al. Major complications after distal biceps tendon repairs: retrospective cohort analysis of 970 cases. J Shoulder Elbow Surg. 2018;27(10):1898–1906.
  • Cuzzolin M, Secco D, Guerra E, et al. Operative versus nonoperative management for distal biceps brachii tendon lesions: a systematic review and meta-analysis. Orthop J Sports Med. 2021.
  • Garon MT, Greenberg JA. Complications of distal biceps repair. Orthop Clin North Am. 2016. (Re-rupture 0–5.6%.)

Published rehabilitation protocols (web)

  • Brigham & Women's Hospital — Distal Biceps Tendon Repair Rehabilitation Protocol (standard). https://www.brighamandwomens.org/assets/BWH/patients-and-families/pdfs/elbow---distal-biceps-repair-protocol.pdf
  • Brigham & Women's Hospital — Distal Biceps Tendon Repair Accelerated Protocol. https://www.brighamandwomens.org/assets/BWH/patients-and-families/rehabilitation-services/pdfs/elbow-accelerated-distal-biceps-repair-protocol-bwh.pdf
  • Mass General Brigham Sports Medicine — Rehabilitation Protocol for Distal Biceps Tendon Repair (rev. 10/2021). https://www.massgeneral.org/assets/mgh/pdf/orthopaedics/sports-medicine/physical-therapy/rehabilitation-protocol-for-distal-biceps-repair.pdf

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2. Exceptions and Limitations. For the avoidance of doubt, where Exceptions and Limitations apply to Your use, this Public License does not apply, and You do not need to comply with its terms and conditions.

3. Term. The term of this Public License is specified in Section 6(a).

4. Media and formats; technical modifications allowed. The Licensor authorizes You to exercise the Licensed Rights in all media and formats whether now known or hereafter created, and to make technical modifications necessary to do so. The Licensor waives and/or agrees not to assert any right or authority to forbid You from making technical modifications necessary to exercise the Licensed Rights, including technical modifications necessary to circumvent Effective Technological Measures. For purposes of this Public License, simply making modifications authorized by this Section 2(a) (4) never produces Adapted Material.

5. Downstream recipients.

a. Offer from the Licensor -- Licensed Material. Every recipient of the Licensed Material automatically receives an offer from the Licensor to exercise the Licensed Rights under the terms and conditions of this Public License.

b. No downstream restrictions. You may not offer or impose any additional or different terms or conditions on, or apply any Effective Technological Measures to, the Licensed Material if doing so restricts exercise of the Licensed Rights by any recipient of the Licensed Material.

6. No endorsement. Nothing in this Public License constitutes or may be construed as permission to assert or imply that You are, or that Your use of the Licensed Material is, connected with, or sponsored, endorsed, or granted official status by, the Licensor or others designated to receive attribution as provided in Section 3(a)(1)(A)(i).

b. Other rights.

1. Moral rights, such as the right of integrity, are not licensed under this Public License, nor are publicity, privacy, and/or other similar personality rights; however, to the extent possible, the Licensor waives and/or agrees not to assert any such rights held by the Licensor to the limited extent necessary to allow You to exercise the Licensed Rights, but not otherwise.

2. Patent and trademark rights are not licensed under this Public License.

3. To the extent possible, the Licensor waives any right to collect royalties from You for the exercise of the Licensed Rights, whether directly or through a collecting society under any voluntary or waivable statutory or compulsory licensing scheme. In all other cases the Licensor expressly reserves any right to collect such royalties, including when the Licensed Material is used other than for NonCommercial purposes.

Section 3 -- License Conditions.

Your exercise of the Licensed Rights is expressly made subject to the following conditions.

a. Attribution.

1. If You Share the Licensed Material (including in modified form), You must:

a. retain the following if it is supplied by the Licensor with the Licensed Material:

i. identification of the creator(s) of the Licensed Material and any others designated to receive attribution, in any reasonable manner requested by the Licensor (including by pseudonym if designated);

ii. a copyright notice;

iii. a notice that refers to this Public License;

iv. a notice that refers to the disclaimer of warranties;

v. a URI or hyperlink to the Licensed Material to the extent reasonably practicable;

b. indicate if You modified the Licensed Material and retain an indication of any previous modifications; and

c. indicate the Licensed Material is licensed under this Public License, and include the text of, or the URI or hyperlink to, this Public License.

2. You may satisfy the conditions in Section 3(a)(1) in any reasonable manner based on the medium, means, and context in which You Share the Licensed Material. For example, it may be reasonable to satisfy the conditions by providing a URI or hyperlink to a resource that includes the required information.

3. If requested by the Licensor, You must remove any of the information required by Section 3(a)(1)(A) to the extent reasonably practicable.

4. If You Share Adapted Material You produce, the Adapter's License You apply must not prevent recipients of the Adapted Material from complying with this Public License.

Section 4 -- Sui Generis Database Rights.

Where the Licensed Rights include Sui Generis Database Rights that apply to Your use of the Licensed Material:

a. for the avoidance of doubt, Section 2(a)(1) grants You the right to extract, reuse, reproduce, and Share all or a substantial portion of the contents of the database for NonCommercial purposes only;

b. if You include all or a substantial portion of the database contents in a database in which You have Sui Generis Database Rights, then the database in which You have Sui Generis Database Rights (but not its individual contents) is Adapted Material; and

c. You must comply with the conditions in Section 3(a) if You Share all or a substantial portion of the contents of the database.

For the avoidance of doubt, this Section 4 supplements and does not replace Your obligations under this Public License where the Licensed Rights include other Copyright and Similar Rights.

Section 5 -- Disclaimer of Warranties and Limitation of Liability.

a. UNLESS OTHERWISE SEPARATELY UNDERTAKEN BY THE LICENSOR, TO THE EXTENT POSSIBLE, THE LICENSOR OFFERS THE LICENSED MATERIAL AS-IS AND AS-AVAILABLE, AND MAKES NO REPRESENTATIONS OR WARRANTIES OF ANY KIND CONCERNING THE LICENSED MATERIAL, WHETHER EXPRESS, IMPLIED, STATUTORY, OR OTHER. THIS INCLUDES, WITHOUT LIMITATION, WARRANTIES OF TITLE, MERCHANTABILITY, FITNESS FOR A PARTICULAR PURPOSE, NON-INFRINGEMENT, ABSENCE OF LATENT OR OTHER DEFECTS, ACCURACY, OR THE PRESENCE OR ABSENCE OF ERRORS, WHETHER OR NOT KNOWN OR DISCOVERABLE. WHERE DISCLAIMERS OF WARRANTIES ARE NOT ALLOWED IN FULL OR IN PART, THIS DISCLAIMER MAY NOT APPLY TO YOU.

b. TO THE EXTENT POSSIBLE, IN NO EVENT WILL THE LICENSOR BE LIABLE TO YOU ON ANY LEGAL THEORY (INCLUDING, WITHOUT LIMITATION, NEGLIGENCE) OR OTHERWISE FOR ANY DIRECT, SPECIAL, INDIRECT, INCIDENTAL, CONSEQUENTIAL, PUNITIVE, EXEMPLARY, OR OTHER LOSSES, COSTS, EXPENSES, OR DAMAGES ARISING OUT OF THIS PUBLIC LICENSE OR USE OF THE LICENSED MATERIAL, EVEN IF THE LICENSOR HAS BEEN ADVISED OF THE POSSIBILITY OF SUCH LOSSES, COSTS, EXPENSES, OR DAMAGES. WHERE A LIMITATION OF LIABILITY IS NOT ALLOWED IN FULL OR IN PART, THIS LIMITATION MAY NOT APPLY TO YOU.

c. The disclaimer of warranties and limitation of liability provided above shall be interpreted in a manner that, to the extent possible, most closely approximates an absolute disclaimer and waiver of all liability.

Section 6 -- Term and Termination.

a. This Public License applies for the term of the Copyright and Similar Rights licensed here. However, if You fail to comply with this Public License, then Your rights under this Public License terminate automatically.

b. Where Your right to use the Licensed Material has terminated under Section 6(a), it reinstates:

1. automatically as of the date the violation is cured, provided it is cured within 30 days of Your discovery of the violation; or

2. upon express reinstatement by the Licensor.

For the avoidance of doubt, this Section 6(b) does not affect any right the Licensor may have to seek remedies for Your violations of this Public License.

c. For the avoidance of doubt, the Licensor may also offer the Licensed Material under separate terms or conditions or stop distributing the Licensed Material at any time; however, doing so will not terminate this Public License.

d. Sections 1, 5, 6, 7, and 8 survive termination of this Public License.

Section 7 -- Other Terms and Conditions.

a. The Licensor shall not be bound by any additional or different terms or conditions communicated by You unless expressly agreed.

b. Any arrangements, understandings, or agreements regarding the Licensed Material not stated herein are separate from and independent of the terms and conditions of this Public License.

Section 8 -- Interpretation.

a. For the avoidance of doubt, this Public License does not, and shall not be interpreted to, reduce, limit, restrict, or impose conditions on any use of the Licensed Material that could lawfully be made without permission under this Public License.

b. To the extent possible, if any provision of this Public License is deemed unenforceable, it shall be automatically reformed to the minimum extent necessary to make it enforceable. If the provision cannot be reformed, it shall be severed from this Public License without affecting the enforceability of the remaining terms and conditions.

c. No term or condition of this Public License will be waived and no failure to comply consented to unless expressly agreed to by the Licensor.

d. Nothing in this Public License constitutes or may be interpreted as a limitation upon, or waiver of, any privileges and immunities that apply to the Licensor or You, including from the legal processes of any jurisdiction or authority.

Creative Commons is not a party to its public licenses. Notwithstanding, Creative Commons may elect to apply one of its public licenses to material it publishes and in those instances will be considered the “Licensor.” The text of the Creative Commons public licenses is dedicated to the public domain under the CC0 Public Domain Dedication. Except for the limited purpose of indicating that material is shared under a Creative Commons public license or as otherwise permitted by the Creative Commons policies published at creativecommons.org/policies, Creative Commons does not authorize the use of the trademark "Creative Commons" or any other trademark or logo of Creative Commons without its prior written consent including, without limitation, in connection with any unauthorized modifications to any of its public licenses or any other arrangements, understandings, or agreements concerning use of licensed material. For the avoidance of doubt, this paragraph does not form part of the public licenses.

Creative Commons may be contacted at creativecommons.org.