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Os Acromiale

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Patient-facing topic on os acromiale — failed fusion of an acromial ossification centre that may cause shoulder pain and contribute to subacromial impingement.

Updated May 2026
Isang guhit-kamay na ilustrasyon ng isang anatomikal na guhit ng os acromiale, ang acromion na may hiwalay na hindi pa nagkakaisang fragment ng buto.
Os acromiale: ang harapang bahagi ng acromion ay hindi nag-ugnay sa natitirang bahagi ng acromion sa panahon ng paglaki ng balangkas ng katawan. Kieran Hirpara 4.0

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

Ano ang nararamdaman mo

Maaaring makaramdam ka ng sakit sa itaas ng iyong balikat. Ang kondisyong ito ay apektado ang mga 2.13% ng mga pasyente na may problema sa balikat na nangangailangan ng MRI. Ang sakit ay madalas na nagmumula sa isang sugat sa rotator cuff, na isang grupo ng mga kalamnan at tendon na gumagalaw sa iyong braso. Ang sugat na ito ay nangyayari dahil ang karagdagang piraso ng buto ay gumagalaw nang hindi normal at dumudurog sa iyong ibang mga tissue.

Ang iyong sakit ay maaaring lumala pagkatapos mong gawin ang ilang aktibidad. Maaari rin itong gisingin ka sa gabi o masakit kapag sinusubukan mong matulog sa gilid na iyon. Ang mga simpleng pang-araw-araw na gawain ay maaaring maging mahirap. Maaari kang magkaroon ng hirap na umabot sa likod ng iyong likod upang isara ang bra o itabi ang isang kamiseta. Ang mga galaw na ito ay naglalagay ng presyon sa lugar kung saan hindi ganap na nagkakaisa ang mga piraso ng buto.

Kung ikaw ay mayroon nang naging operasyon sa pagpapalit ng balikat, maaari mong mapansin ang pagkakaroon ng tenderness direkta sa itaas ng piraso ng butong ito. Ito ay nangyayari sa 1 sa 4 na mga pasyente pagkatapos ng prosedura. Ang magandang balita ay ang sakit na ito ay karaniwang nawawala nang sarili sa loob ng panahon para sa karamihan ng mga tao. Ang iyong doktor ay susuriin ang iyong mga sintomas upang desisyunin kung ang karagdagang piraso ng buto ang pangunahing sanhi ng iyong sakit.

Ano ang nangyayari

Mayroon kang maliit na piraso ng buto na tinatawag na os acromiale na hindi nakakabit sa pangunahing buto. Ito ay nangyayari sa humigit-kumulang 2.13% ng mga pasyente na may problema sa balikat na nangangailangan ng MRI. Isipin ang hindi nakakabit na bahagi na ito bilang isang maluwag na gasket sa pagitan ng dalawang bahagi ng iyong buto ng balikat. Sa halip na gumalaw bilang isang matibay na piraso, ang maluwag na fragment na ito ay maaaring magkuskos at lumipat kapag gumagalaw ka ng iyong braso.

Ang abnormal na galaw na ito ay madalas na nakaka-irita sa mga malambot na tisyu sa tabi nito. Ang rotator cuff ay isang grupo ng mga tendon na gumagana tulad ng mga lubid upang itaas at paikutin ang iyong braso. Dahil ang maluwag na buto ay gumagalaw nang hindi karaniwan, maaari nitong mahawakan ang mga tendon na ito. Ang paghawak na ito, o impingement, ay madalas na nagdudulot ng pagputol ng rotator cuff. Sa mga batang atleta, karaniwan ang partikular na pattern ng sugyang ito at nangangailangan ng maingat na pagsusuri upang kumpirmahin ang diagnosis.

Minsan, maaaring masugatan ang maluwag na buto matapos ang pagkabagsak o sugat, bagama’t bihira ito. Kung ikaw ay gagawin ang operasyon para sa ibang dahilan, tulad ng reverse total shoulder replacement, maaaring maranasan mo ang lokal na pagkapagod sa puntong ito sa 1 sa 4 na mga pasyente. Karaniwang nawawala ang pananakit na ito sa sarili nito sa paglipas ng panahon. Ang pagkakaroon ng karagdagang fragment ng buto ay hindi tila nakakaapekto sa iyong pangkalahatang resulta mula sa malaking operasyon ng pagpapalit ng balikat.

Mga maitutulong namin dito

Karamihan sa mga tao ay nagsisimula sa sariling pag-aalaga at pisikal na terapiya upang pamahalaan ang sakit. Gabay ng iyong terapeuta ang mga ehersisyo upang palakasin ang mga kalamnan ng balikat at mapabuti ang galaw. Layunin ng paraang ito na bawasan ang pagkiskis kung saan nakatira ang karagdagang piraso ng buto. Dapat mong bigyan ng patas na pagsubok ang planong hindi pampasurgical bago isaalang-alang ang ibang hakbang.

Kung mananatili ang sakit, maaaring talakayin ng iyong doktor ang gamot o mga injeksyon. Ang mga gamot na may anti-inflammatory ay makakatulong upang bawasan ang pamamaga at sakit sa paligid ng kasu-kasuan. Sa ilang kaso, ginagamit ang cortisone injection upang mabilis na paiti ang pamamaga. Habang hindi tiyak ng ebidensya ang eksaktong tagal ng mga tratamientong ito, maraming pasyente ang nakakahanap ng ginhawa habang gumagana ang gamot. Kung ikaw ay kompetitibong atleta, mabibigyang-pansin ng iyong doktor ang mga panganib nang mabuti, dahil karaniwang hindi inirerekomenda ang pampasurgical para sa mga propesyonal na manlalaro ng tennis.

Ang pampasurgical na operasyon ay karaniwang isaalang-alang lamang kung nabigo ang mga konservatibong pagsisikap na kontrolin ang iyong mga sintomas. Layunin ng operasyon na alisin ang hindi matatag na piraso ng buto o ayusin ito sa lugar upang pigilan ang nakakairit na galaw. Ang desisyong ito ay ginagawa kasama ng iyong doktor pagkatapos suriin ang iyong partikular na kaso at resulta ng imahen.

Kailan kumonsulta sa doktor

Kumonsulta sa iyong doktor kung mayroon kang patuloy na sakit sa balikat na hindi gumagaling kahit magpahinga. Humingi ng pagsusuri ng espesyalista kung napapansin mo ang kahinaan, kawalan ng katatagan, o kung nakakabit o bumabagsak ang iyong balikat. Ang mga sintomas na nakakaapekto sa pagtulog o sa trabaho ay nangangailangan din ng pansin. Humingi ng tulong kung mararamdaman mo ang biglaang paglala ng sakit. Ang kondisyong ito ay may kaugnayan sa mga sugat sa rotator cuff, na maaaring magdulot ng impingement dahil sa hindi normal na galaw. Bagama’t bihira, maaaring masugatan ang kasukasuan matapos ang trauma. Kung ikaw ay propesyonal na manlalaro ng tennis, karaniwang hindi inirerekomenda ang operasyon, ngunit maaaring kumpirmahin ng espesyalista ang diagnosis sa pamamagitan ng pagsusuri at imahen.

Reviewed by AI synthesis (v2) — pending human review · 18 May 2026.

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Evidence & references

Overview

  • In Thai patients with shoulder problems requiring MRI evaluation, the prevalence of os acromiale was 2.13% [1].
  • Os acromiale is associated with rotator cuff injuries [5].
  • A multicenter study aimed to determine the prevalence of and factors associated with os acromiale in the Japanese population [6].
  • Operative management of a symptomatic os acromiale that has failed initial nonoperative treatment leads to decreased symptoms and improvement in clinical outcomes [2].
  • Surgical options for symptomatic os acromiale include arthroscopic sub-total excision [16].
  • Surgical options for symptomatic os acromiale include arthroscopic subacromial decompression of stable fragments [16].
  • Surgical options for symptomatic os acromiale include open reduction and internal fixation of unstable fragments [16].
  • Surgical treatment is usually not indicated for os acromiale in the professional tennis player [7].
  • Ipsilateral os acromiale may be a relative contraindication to the clavicle hook plate [12].
  • Postoperative local tenderness at the os acromiale can be expected in 1 out of 4 patients after reverse total shoulder arthroplasty [3].
  • Postoperative local tenderness at the os acromiale resolves spontaneously over time in the majority of patients after reverse total shoulder arthroplasty [3].
  • The presence of os acromiale does not appear to have a negative impact on clinical outcomes after reverse total shoulder arthroplasty [4].
  • The outcome of reverse total shoulder arthroplasty does not seem to be negatively affected by the presence of an os acromiale [9].

Anatomy & Pathophysiology

  • The prevalence of os acromiale in Thai patients with shoulder problems requiring MRI evaluation is 2.13% [1].
  • Os acromiale is associated with rotator cuff injuries [5].
  • A tear of the rotator cuff may often be associated with os acromiale, likely due to impingement from abnormal motion at the fibrous union site [8].
  • Fused os acromiale, which has not been described previously, might be mistaken for a free ossicle in the clinical setting [10].
  • Awareness of the os acromiale in the young athlete is crucial to confirm diagnosis through appropriate clinical examination and image studies [11].
  • The synchondrosis of an os acromiale can be injured following trauma, though rarely [13].
  • Postoperative local tenderness at the os acromiale can be expected in 1 out of 4 patients after reverse total shoulder arthroplasty [3].
  • Postoperative local tenderness at the os acromiale resolves spontaneously over time in the majority of patients [3].
  • The presence of os acromiale does not appear to have a negative impact on clinical outcomes after reverse total shoulder arthroplasty [4].
  • The outcome of reverse total shoulder arthroplasty does not seem to be negatively affected by the presence of an os acromiale [9].
  • Reverse shoulder arthroplasty improves range of motion, decreases pain, and increases patient satisfaction in patients with os acromiale and cuff tear arthropathy [24].
  • Surgical treatment is usually not indicated for os acromiale in the professional tennis player [7].

Classification

  • The prevalence of os acromiale in Thai patients with shoulder problems requiring MRI evaluation is 2.13% [1].
  • Os acromiale is associated with rotator cuff injuries [5].
  • A tear of the rotator cuff may often be associated with os acromiale, likely due to impingement from abnormal motion at the fibrous union site [8].
  • Fused os acromiale, which has not been described previously, might be mistaken for a free ossicle in the clinical setting [10].
  • Awareness of the os acromiale in the young athlete, appropriate clinical examination, and image studies are crucial to confirm diagnosis [11].
  • The synchondrosis of an os acromiale can be injured following trauma, though rarely [13].
  • Meta-os acromiale is the rarest subtype of os acromiale [15].

Clinical Presentation

  • The prevalence of os acromiale in Thai patients with shoulder problems requiring MRI evaluation was 2.13% [1].
  • Os acromiale is associated with rotator cuff injuries [5].
  • A tear of the rotator cuff may often be associated with os acromiale, likely due to impingement from abnormal motion at the fibrous union site [8].
  • The presence of os acromiale does not appear to have a negative impact on clinical outcomes after reverse total shoulder arthroplasty (rTSA) [4].
  • The outcome of reverse total shoulder arthroplasty (RTSA) does not seem to be negatively affected by the presence of an os acromiale [9].
  • Postoperative local tenderness at the os acromiale can be expected in 1 out of 4 patients following rTSA [3].
  • Postoperative local tenderness at the os acromiale resolves spontaneously over time in the majority of patients [3].
  • Surgical treatment is usually not indicated for os acromiale in professional tennis players [7].
  • Awareness of the os acromiale, appropriate clinical examination, and image studies are crucial to confirm diagnosis in young athletes [11].
  • Ipsilateral os acromiale may be a relative contraindication to the clavicle hook plate [12].
  • The synchondrosis of an os acromiale can be injured following trauma, though rarely [13].
  • Fused os acromiale, which has not been described previously, might be mistaken for a free ossicle in the clinical setting [10].
  • Meta-os acromiale is the rarest subtype of os acromiale [15].
  • Liberson reviewed 1800 shoulder girdles and identified an incidence of os acromiale of 1.4% [14].
  • The lesion of os acromiale is bilateral in 62% of patients according to Liberson's review [14].

Investigations

  • The prevalence of os acromiale in Thai patients with shoulder problems requiring MRI evaluation is 2.13% [1].
  • Os acromiale is associated with rotator cuff injuries [5].
  • A tear of the rotator cuff may often be associated with os acromiale, likely due to impingement from abnormal motion at the fibrous union site [8].
  • Awareness of the os acromiale in the young athlete, appropriate clinical examination, and image studies are crucial to confirm diagnosis [11].
  • The synchondrosis of an os acromiale can be injured following trauma, though rarely [13].
  • Appropriate radiographic investigation for os acromiale injury includes axillary views [13].
  • Fused os acromiale, which has not been described previously, might be mistaken for a free ossicle in the clinical setting [10].
  • Liberson reviewed 1800 shoulder girdles and identified an incidence of os acromiale of 1.4% [14].
  • The lesion of os acromiale is bilateral in 62% of patients according to Liberson's review [14].

Treatment

  • Operative management of a symptomatic os acromiale that has failed initial nonoperative treatment leads to decreased symptoms and improvement in clinical outcomes [2].
  • Surgical options for symptomatic os acromiale include arthroscopic sub-total excision, arthroscopic subacromial decompression of stable fragments, and open reduction and internal fixation of unstable fragments [16].
  • Open reduction and internal fixation using cannulated screws or tension band wiring have superior outcomes in the literature in the treatment of symptomatic os acromiale [19].
  • A new arthroscopic technique of fixation of os acromiale with absorbable screws provides promising clinical, cosmetic, and radiologic results with high patient satisfaction [17].
  • A symptomatic os acromiale in a competitive female fastball pitcher was treated successfully with open reduction and internal fixation [21].
  • Special consideration must be given to the type of tension-band construct used to achieve adequate compression and fixation for meta-os acromiale, the rarest subtype of os acromiale [15].
  • Surgical treatment is usually not indicated for os acromiale in the professional tennis player [7].
  • Ipsilateral os acromiale may be a relative contraindication to the clavicle hook plate [12].
  • Postoperative local tenderness at the os acromiale can be expected in 1 out of 4 patients but resolves spontaneously over time in the majority of patients [3].
  • The presence of os acromiale does not appear to have a negative impact on the clinical outcomes after reverse total shoulder arthroplasty (rTSA) [4].
  • The outcome of reverse total shoulder arthroplasty (RTSA) does not seem to be negatively affected by the presence of an os acromiale [9].

Complications

  • The prevalence of os acromiale in Thai patients with shoulder problems requiring MRI evaluation was 2.13% [1].
  • Operative management of a symptomatic os acromiale that has failed initial nonoperative treatment leads to decreased symptoms and improvement in clinical outcomes [2].
  • Postoperative local tenderness at the os acromiale can be expected in 1 out of 4 patients following reverse total shoulder arthroplasty [3].
  • Postoperative local tenderness at the os acromiale resolves spontaneously over time in the majority of patients [3].
  • The presence of os acromiale does not appear to have a negative impact on clinical outcomes after reverse total shoulder arthroplasty [4].
  • Reverse total shoulder arthroplasty remains a safe and effective treatment option in the presence of os acromiale [4].
  • Os acromiale is associated with rotator cuff injuries [5].
  • A tear of the rotator cuff may often be associated with os acromiale, likely due to impingement from abnormal motion at the fibrous union site [8].
  • Surgical treatment is usually not indicated for os acromiale in professional tennis players [7].
  • Fused os acromiale, which has not been described previously, might be mistaken for a free ossicle in the clinical setting [10].
  • The incidence of os acromiale identified by Liberson was 1.4% [14].
  • The lesion of os acromiale was bilateral in 62% of patients in Liberson's review [14].

Recovery

  • Operative management of a symptomatic os acromiale that has failed initial nonoperative treatment leads to decreased symptoms and improvement in clinical outcomes [2].
  • Postoperative local tenderness at the os acromiale can be expected in 1 out of 4 patients but resolves spontaneously over time in the majority of patients [3].
  • The presence of os acromiale does not appear to have a negative impact on the clinical outcomes after reverse total shoulder arthroplasty (rTSA) [4].
  • Reverse total shoulder arthroplasty (rTSA) remains a safe and effective treatment option in patients with os acromiale [4].
  • The outcome of reverse total shoulder arthroplasty (RTSA) does not seem to be negatively affected by the presence of an os acromiale [9].
  • Surgical treatment is usually not indicated for os acromiale in professional tennis players [7].

Key Evidence

  • [L3] In Thai patients with shoulder problems who required MRI evaluation, the prevalence of os acromiale was 2.13%. [1] (10.1177/23259671221078806)
  • [L4] Operative management of a symptomatic os acromiale that has failed initial nonoperative treatment leads to decreased symptoms and improvement in clinical outcomes. [2] (10.1016/j.jse.2019.05.047)
  • [L3] Postoperative local tenderness at the os acromiale can be expected in 1 out of 4 patients but resolves spontaneously over time in the majority of patients. [3] (10.1177/2325967120965131)
  • [L4] The presence of os acromiale does not appear to have a negative impact on the clinical outcomes after surgery and rTSA remains a safe and effective treatment option. [4] (10.1016/j.xrrt.2025.01.002)
  • [L3] The study supports previous findings that os acromiale is associated with rotator cuff injuries. [5] (10.1016/j.jseint.2025.05.015)
  • [L3] This multicenter study aimed to determine the prevalence of and factors associated with os acromiale in the Japanese population. [6] (10.1016/j.jse.2025.01.008)
  • [L4] Surgical treatment is usually not indicated for os acromiale in the professional tennis player. [7] (10.1177/2325967118773723)
  • [L4] A tear of the rotator cuff may often be associated with os acromiale, likely due to impingement from abnormal motion at the fibrous union site. [8] (10.2106/00004623-198466080-00029)
  • [L4] The outcome of RTSA does not seem to be negatively affected by the presence of an os acromiale. [9] (10.1016/j.jse.2017.02.012)
  • [L4] An anatomical study showed that fused os acromiale, which has not been described previously, might be mistaken for a free ossicle in the clinical setting. [10] (10.2106/00004623-200003000-00010)
  • [L4] Awareness of the os acromiale in the young athlete, appropriate clinical examination, and image studies are crucial to confirm diagnosis. [11] (10.1016/j.jseint.2020.02.008)
  • [L4] Ipsilateral os acromiale may be a relative contraindication to the clavicle hook plate. [12] (10.1186/s12891-021-04841-1)
  • [L4] This case highlights that the synchondrosis of an os acromiale can be injured following trauma, though rarely, and emphasizes the need for appropriate radiographic investigation including axillary views and a flexible surgical approach. [13] (10.1016/j.jse.2008.02.012)
  • [L4] Meta–os acromiale is the rarest subtype of os acromiale, and special consideration must be given to the type of tension-band construct used to achieve adequate compression and fixation. [15] (10.1177/03635465211028238)
  • [L5] Surgical options for symptomatic os acromiale include arthroscopic sub-total excision, arthroscopic subacromial decompression of stable fragments, and open reduction and internal fixation of unstable fragments. [16] (10.5435/jaaos-d-17-00011)
  • [L4] This new arthroscopic technique of fixation of os acromiale with absorbable screws provides promising clinical, cosmetic, and radiologic results with high patient satisfaction. [17] (10.1016/j.jse.2011.12.011)
  • [L4] Open reduction and internal fixation using cannulated screws, or tension band wiring have superior outcomes in the literature in the treatment of symptomatic os acromiale. [19] (10.1302/2058-5241.4.180100)
  • [L4] A symptomatic os acromiale in a competitive female fastball pitcher was treated successfully with open reduction and internal fixation. [21] (10.1177/0363546506288305)
  • [L4] Reverse shoulder arthroplasty improved ROM, decreased pain, and increased patient satisfaction in patients with os acromiale and cuff tear arthropathy. [24] (10.5397/cise.2019.00409)

References

[1] Prevalence of Os Acromiale in Thai Patients With Shoulder Problems: A Magnetic Resonance Imaging Study. Orthopaedic Journal of Sports Medicine. 2022. DOI: 10.1177/23259671221078806 [2] Os acromiale: systematic review of surgical outcomes. Journal of Shoulder and Elbow Surgery. 2020. DOI: 10.1016/j.jse.2019.05.047 [3] Os Acromiale in Reverse Total Shoulder Arthroplasty: A Cohort Study. Orthopaedic Journal of Sports Medicine. 2020. DOI: 10.1177/2325967120965131 [4] Clinical implications of reverse total shoulder arthroplasty with an os acromiale: a systematic review. JSES Reviews, Reports, and Techniques. 2025. DOI: 10.1016/j.xrrt.2025.01.002 [5] Prevalence and factors associated with os acromiale: a multicenter study. JSES International. 2025. DOI: 10.1016/j.jseint.2025.05.015 [6] The prevalence and associated factors of os acromiale: a multicenter study. Journal of Shoulder and Elbow Surgery. 2025. DOI: 10.1016/j.jse.2025.01.008 [7] Os Acromiale in Professional Tennis Players. Orthopaedic Journal of Sports Medicine. 2018. DOI: 10.1177/2325967118773723 [8] Rotator cuff tears associated with os acromiale.. The Journal of Bone & Joint Surgery. 1984. DOI: 10.2106/00004623-198466080-00029 [9] Reverse shoulder arthroplasty in patients with os acromiale. Journal of Shoulder and Elbow Surgery. 2017. DOI: 10.1016/j.jse.2017.02.012 [10] Os Acromiale: Frequency, Anatomy, and Clinical Implications. The Journal of Bone and Joint Surgery-American Volume. 2000. DOI: 10.2106/00004623-200003000-00010 [11] The unstable os acromiale: a cause of pain in the young athlete. JSES International. 2020. DOI: 10.1016/j.jseint.2020.02.008 [12] Os acromiale may be a contraindication of the clavicle hook plate: case reports and literature review. BMC Musculoskeletal Disorders. 2021. DOI: 10.1186/s12891-021-04841-1 [13] Fracture of an os acromiale with associated rupture of the coracoclavicular ligaments. Journal of Shoulder and Elbow Surgery. 2008. DOI: 10.1016/j.jse.2008.02.012 [14] Types of os acromiale according to Liberson. 2006. [15] Rare Symptomatic Meta–Os Acromiale in an Athlete. The American Journal of Sports Medicine. 2021. DOI: 10.1177/03635465211028238 [16] Symptomatic, Unstable Os Acromiale. Journal of the American Academy of Orthopaedic Surgeons. 2018. DOI: 10.5435/jaaos-d-17-00011 [17] Arthroscopically assisted internal fixation of the symptomatic unstable os acromiale with absorbable screws. Journal of Shoulder and Elbow Surgery. 2012. DOI: 10.1016/j.jse.2011.12.011 [19] Os acromiale: a review of its incidence, pathophysiology, and clinical management. EFORT Open Reviews. 2019. DOI: 10.1302/2058-5241.4.180100 [21] Surgical Stabilization of Os Acromiale in a Fast-Pitch Softball Pitcher. The American Journal of Sports Medicine. 2006. DOI: 10.1177/0363546506288305 [24] Reverse shoulder arthroplasty with os acromiale. Clinics in Shoulder and Elbow*. 2020. DOI: 10.5397/cise.2019.00409

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b. produce, reproduce, and Share Adapted Material for NonCommercial purposes only.

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.