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Anabolic Steroids, Testosterone and Tendon Rupture Risk

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Anabolic steroids and testosterone are linked to a higher risk of tendon rupture, including the rotator cuff, biceps and quadriceps. How steroids and TRT affect tendons, joints, bone and recovery from surgery.

Updated Jul 2026
A molecular structure beside a small vial.
Testosterone influences muscle and bone; levels and supplementation carry musculoskeletal implications worth understanding. Kieran Hirpara 4.0

What you're feeling

You may notice pain in your shoulder that worsens with activity. This discomfort often flares up at night, making it hard to sleep on that side. You might find it difficult to reach behind your back to fasten a bra or tuck in a shirt. Simple tasks like lifting objects or raising your arm can become challenging.

Your surgeon will consider your hormonal status when assessing these symptoms. Low testosterone levels are linked to an increased risk of wear-and-tear arthritis in the joint. This condition can cause stiffness and pain as the cartilage breaks down. Maintaining optimal hormone levels may help protect your joint health, but deficiency can increase the risk of injury or re-injury.

If you have been prescribed testosterone, be aware that it is associated with a higher risk of rotator cuff tears. The rotator cuff is a group of muscles and tendons that stabilize your shoulder. You might experience sudden weakness or pain if a tear occurs. There is also an increased risk of needing subsequent repairs to fix these tears.

In some cases, testosterone use is linked to a higher risk of infection-related reoperations after total shoulder replacement. Total shoulder arthroplasty is a procedure where damaged joint surfaces are replaced with artificial parts. You may face a higher risk of any type of reoperation after this surgery. Further research is needed to understand exactly why testosterone increases the risk of needing another surgery after shoulder replacement.

If you are using anabolic steroids, your surgeon should discuss your endocrinologic history with you. Anabolic steroids are synthetic substances similar to the male sex hormone testosterone. Their use may contribute to pectoralis major rupture, which is a tear in the large chest muscle. This injury often causes sharp pain and bruising in the front of the shoulder.

While continuing anabolic steroids during recovery from a pectoralis major rupture does not seem to negatively affect functional recovery, caution is advised. Clinicians should prescribe testosterone replacement therapy judiciously. This means carefully weighing the benefits against the risks for your unique profile. Your surgeon will counsel you on these risks to help you make informed decisions about your care.

What's actually happening

Testosterone levels in your body act like a dimmer switch for joint and tendon health. There is a specific threshold where levels become too low or too high, and both extremes can weaken your tissues. When levels are suboptimal, the smooth coating on your bone ends—called cartilage—may wear down faster. This wear-and-tear arthritis reduces the cushioning in your joints, making them more prone to damage.

Your tendons are thick ropes of fibers that connect muscle to bone. In some cases, testosterone use is linked to a higher risk of these ropes tearing. For example, bodybuilders using anabolic steroids have seen more pectoralis major ruptures. Similarly, patients prescribed testosterone face an increased risk of rotator cuff tears in the shoulder. These tears happen because the tissue structure changes, making it less able to handle stress.

This risk extends to major surgeries like total shoulder replacement. Men using testosterone have a higher chance of needing a second surgery after their first shoulder replacement. This is often due to infections or other complications that prevent proper healing. Your surgeon needs to know your full hormone history because low testosterone can also increase the risk of osteoarthritis. Maintaining balanced levels is key to keeping your joints strong and stable.

While some short-term testosterone use before surgery might help with bone density and body composition, long-term or high-dose use carries risks. It can lead to reoperations or infections that complicate your recovery. Your surgeon will assess your unique risk profile before deciding on any hormone therapy. Understanding these connections helps you and your medical team protect your joints during treatment and recovery.

What to expect

Your surgeon will look at your hormonal health as part of your overall injury risk. Testosterone levels have a complex link to shoulder problems. Low testosterone is linked to a higher risk of wear-and-tear arthritis in the joint. Maintaining healthy levels may help keep your joints strong. However, using testosterone or anabolic steroids can also change how your tendons handle stress.

If you are prescribed testosterone, you may face a higher risk of tearing the rotator cuff tendons in your shoulder. This group of patients also sees more follow-up surgeries to repair these tears. If you use anabolic steroids, there is a specific risk of rupturing the large chest muscle. This is most common in body builders. If you have already suffered this chest muscle rupture, continuing steroid use does not seem to hurt your functional recovery.

For men undergoing shoulder replacement surgery, testosterone use is linked to higher risks. You may face a greater chance of infection-related reoperations. You may also face a higher risk of any type of reoperation after your primary shoulder replacement. Your surgeon will discuss your endocrinologic history with you. They will counsel you on the risks of injury or re-injury if you have testosterone deficiency.

If you need testosterone replacement therapy, it is prescribed with care. It is too early to say it directly causes knee ligament injuries like ACL tears. But your unique risk profile matters. Some studies show that giving testosterone around the time of surgery can improve your body composition and bone density. It may also improve your clinical outcomes after orthopaedic surgery.

Data on other risks, like stroke in young adults, remains limited. Your surgeon needs to weigh these benefits against the increased risk of tendon tears and reoperations. Be honest about your steroid or testosterone use. This helps your team plan the safest path for your recovery and long-term joint health.

Reviewed by Kieran Hirpara · 13 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

Overview

  • Testosterone replacement therapy is associated with increased odds of surgically treated tendon rupture [1].
  • Testosterone users had a 2.9-fold increased risk of tendon rupture compared to nonusers [2].
  • It is premature to imply causation between testosterone replacement therapy and anterior cruciate ligament injuries based solely on existing results due to confounding variables [3].
  • Clinicians should remain vigilant and prescribe testosterone replacement therapy judiciously with a thorough assessment of each patient's unique risk profile regarding anterior cruciate ligament injury risk [3].
  • There is a threshold-dependent relationship between testosterone levels and shoulder pathology [4].
  • Hormonal status should be considered in musculoskeletal risk assessment [4].
  • The use of prescription testosterone is associated with an increased likelihood of experiencing a distal biceps tendon injury [5].
  • The use of prescription testosterone is associated with an increased likelihood of subsequently requiring surgical repair for distal biceps tendon injury [5].
  • Patients with prior prescription testosterone exposure have an increased rate of distal biceps tendon injury compared with patients without such exposure [5].
  • Patients with prior prescription testosterone exposure have an increased rate of biceps tendon repair compared with patients without such exposure [5].
  • Surgeons should be more intentional about discussing endocrinologic history with patients regarding quadriceps tendon injury risk [6].
  • Surgeons should counsel patients with testosterone deficiency on the risks for injury or re-injury [6].
  • Patients who filled a prescription for testosterone replacement therapy were much more likely to experience a quadriceps muscle or tendon injury within 1 year of filling their prescription [7].
  • Patients who filled a prescription for testosterone replacement therapy were at increased risk of undergoing surgical repair of the quadriceps tendon [7].
  • Testosterone replacement therapy is associated with increased tendon rupture risk in men [8].
  • Testosterone replacement therapy is not associated with increased tendon rupture risk in women [8].
  • The association between testosterone replacement therapy and increased tendon rupture risk may be due to sex-specific differences in dosing [8].
  • Anabolic steroid use may contribute to pectoralis major rupture [9].
  • Continuation of anabolic steroids during recovery from pectoralis major rupture does not seem to have a negative effect on functional recovery [9].
  • Selective androgen receptor modulator (SARM) use is associated with tendon damage [10].
  • Prescription testosterone is associated with a higher risk of infection-related reoperations after primary total shoulder arthroplasty in male patients [13].
  • Prescription testosterone is associated with a higher risk of all-cause reoperations after primary total shoulder arthroplasty in male patients [13].

Background & Causes

  • Testosterone replacement therapy is associated with increased odds of surgically treated tendon rupture [1].
  • Testosterone users had a 2.9-fold increased risk of tendon rupture compared to nonusers [2].
  • It is premature to imply causation between testosterone replacement therapy and anterior cruciate ligament injuries based solely on existing results due to confounding variables [3].
  • There is a threshold-dependent relationship between testosterone levels and shoulder pathology [4].
  • Prescription testosterone use is associated with an increased likelihood of experiencing a distal biceps tendon injury [5].
  • Patients with prior prescription testosterone exposure have an increased rate of biceps tendon repair compared with patients without such exposure [5].
  • Testosterone therapy is associated with increased odds of quadriceps tendon injury [6].
  • Patients who filled a prescription for testosterone replacement therapy were much more likely to experience a quadriceps muscle or tendon injury within 1 year of filling their prescription [7].
  • Patients who filled a prescription for testosterone replacement therapy were at increased risk of undergoing surgical repair of the quadriceps tendon [7].
  • Testosterone replacement therapy is associated with increased tendon rupture risk in men but not women [8].
  • The association between testosterone replacement therapy and increased tendon rupture risk in men but not women may be due to sex-specific differences in dosing [8].
  • Anabolic steroid use may contribute to pectoralis major rupture [9].
  • Continuation of anabolic steroids during recovery from pectoralis major rupture does not seem to have a negative effect on functional recovery [9].
  • Selective androgen receptor modulator (SARM) use is associated with tendon damage [10].
  • Testosterone replacement therapy within 1 year of rotator cuff repair appears to be a risk factor for multiple postoperative complications [11].
  • Testosterone replacement therapy within 1 year of rotator cuff repair appears to be a risk factor for subsequent shoulder surgery [11].
  • Further research is needed to understand the mechanism by which testosterone increases the risk of reoperation after total shoulder arthroplasty [12].
  • Prescription testosterone is associated with an increased risk of infection-related reoperations after primary total shoulder arthroplasty in male patients [13].
  • Prescription testosterone is associated with an increased risk of all-cause reoperations after primary total shoulder arthroplasty in male patients [13].
  • Bioavailable testosterone levels are a risk factor for osteoarthritis [17].
  • There is a causal relationship between bioavailable testosterone levels and osteoarthritis [17].
  • Low testosterone levels are independently associated with an increased risk of osteoarthritis in the U.S. population [18].

Symptoms & Presentation

  • Testosterone replacement therapy is associated with increased odds of surgically treated tendon rupture [1].
  • Testosterone users had a 2.9-fold increased risk of tendon rupture compared to nonusers [2].
  • It is premature to imply causation between testosterone replacement therapy and anterior cruciate ligament injuries based solely on existing results due to confounding variables [3].
  • There is a threshold-dependent relationship between testosterone levels and shoulder pathology [4].
  • Prescription testosterone use is associated with an increased likelihood of experiencing a distal biceps tendon injury [5].
  • Patients with prior prescription testosterone exposure have an increased rate of biceps tendon repair compared with patients without such exposure [5].
  • Testosterone therapy is associated with increased odds of quadriceps tendon injury [6].
  • Patients who filled a prescription for testosterone replacement therapy were much more likely to experience a quadriceps muscle or tendon injury within 1 year of filling their prescription [7].
  • Patients who filled a prescription for testosterone replacement therapy were at increased risk of undergoing surgical repair of the quadriceps tendon [7].
  • Testosterone replacement therapy is associated with increased tendon rupture risk in men but not women [8].
  • Anabolic steroid use may contribute to pectoralis major rupture [9].
  • Selective androgen receptor modulator (SARM) use is associated with tendon damage [10].
  • Testosterone replacement therapy within 1 year of rotator cuff repair appears to be a risk factor for multiple postoperative complications [11].
  • Testosterone replacement therapy within 1 year of rotator cuff repair appears to be a risk factor for subsequent shoulder surgery [11].
  • Supplemental testosterone increases the risk of reoperation after total shoulder arthroplasty [12].
  • Prescription testosterone is associated with an increased risk of infection-related reoperations after primary total shoulder arthroplasty in male patients [13].
  • Prescription testosterone is associated with an increased risk of all-cause reoperations after primary total shoulder arthroplasty in male patients [13].
  • Testosterone therapy is associated with rotator cuff tears, repairs, and revision repairs [15].
  • Testosterone deficiency is associated with poorer postoperative outcomes in total joint arthroplasty [16].

Management

  • Testosterone replacement therapy is associated with increased odds of surgically treated tendon rupture [1].
  • Testosterone users had a 2.9-fold increased risk of tendon rupture compared to nonusers [2].
  • It is premature to imply causation between testosterone replacement therapy and ACL injuries based solely on existing results due to confounding variables [3].
  • Clinicians should remain vigilant and prescribe TRT judiciously with a thorough assessment of each patient's unique risk profile [3].
  • Findings suggest a threshold-dependent relationship between testosterone and shoulder pathology [4].
  • Hormonal status should be considered in musculoskeletal risk assessment [4].
  • The use of prescription testosterone is associated with an increased likelihood of experiencing a distal biceps tendon injury [5].
  • The use of prescription testosterone is associated with an increased likelihood of subsequently requiring surgical repair for distal biceps tendon injury [5].
  • Patients with prior prescription testosterone exposure have an increased rate of distal biceps tendon injury compared with patients without such exposure [5].
  • Patients with prior prescription testosterone exposure have an increased rate of biceps tendon repair compared with patients without such exposure [5].
  • Surgeons should be more intentional about discussing endocrinologic history with patients [6].
  • Surgeons should counsel patients with testosterone deficiency on the risks for injury or re-injury [6].
  • Patients who filled a prescription for testosterone replacement therapy were much more likely to experience a quadriceps muscle or tendon injury within 1 year of filling their prescription [7].
  • Patients who filled a prescription for testosterone replacement therapy were at increased risk of undergoing surgical repair of the quadriceps tendon [7].
  • TRT is associated with increased tendon rupture risk in men [8].
  • TRT is not associated with increased tendon rupture risk in women [8].
  • The association between TRT and tendon rupture risk in men but not women may be due to sex-specific differences in dosing [8].
  • Anabolic steroids use may contribute to pectoralis major rupture injury [9].
  • Continuation of anabolic steroids during recovery from pectoralis major rupture does not seem to have a negative effect on functional recovery [9].
  • SARM use is associated with tendon damage [10].
  • TRT within 1 year of rotator cuff repair appears to be a risk factor for multiple postoperative complications [11].
  • TRT within 1 year of rotator cuff repair appears to be a risk factor for subsequent shoulder surgery [11].
  • Further research is needed to understand the mechanism by which testosterone increases the risk of reoperation after total shoulder arthroplasty [12].
  • Testosterone use is associated with a higher risk of infection-related reoperations after total shoulder arthroplasty in male patients [13].
  • Testosterone use is associated with a higher risk of all-cause reoperations after total shoulder arthroplasty in male patients [13].
  • Patients prescribed at least 3 months of TRT had a significantly higher incidence of ACL injuries compared to controls within a 2-year follow-up period [14].

Key Considerations

  • Testosterone replacement therapy is associated with increased odds of surgically treated tendon rupture [1].
  • Testosterone users had a 2.9-fold increased risk of tendon rupture compared to nonusers [2].
  • It is premature to imply causation between testosterone replacement therapy and anterior cruciate ligament injuries based solely on existing results due to confounding variables [3].
  • Clinicians should remain vigilant and prescribe testosterone replacement therapy judiciously with a thorough assessment of each patient's unique risk profile [3].
  • Findings suggest a threshold-dependent relationship between testosterone and shoulder pathology [4].
  • Hormonal status should be considered in musculoskeletal risk assessment [4].
  • The use of prescription testosterone is associated with an increased likelihood of experiencing a distal biceps tendon injury [5].
  • The use of prescription testosterone is associated with an increased likelihood of subsequently requiring surgical repair for distal biceps tendon injury [5].
  • Patients with prior prescription testosterone exposure have an increased rate of distal biceps tendon injury compared with patients without such exposure [5].
  • Patients with prior prescription testosterone exposure have an increased rate of biceps tendon repair compared with patients without such exposure [5].
  • Surgeons should be more intentional about discussing endocrinologic history with patients [6].
  • Surgeons should counsel patients with testosterone deficiency on the risks for injury or re-injury [6].
  • Patients who filled a prescription for testosterone replacement therapy were much more likely to experience a quadriceps muscle or tendon injury within 1 year of filling their prescription [7].
  • Patients who filled a prescription for testosterone replacement therapy were at increased risk of undergoing surgical repair of the quadriceps tendon [7].
  • Testosterone replacement therapy is associated with increased tendon rupture risk in men [8].
  • Testosterone replacement therapy is not associated with increased tendon rupture risk in women [8].
  • The association between testosterone replacement therapy and increased tendon rupture risk in men but not women may be due to sex-specific differences in dosing [8].
  • Anabolic steroid use may contribute to pectoralis major rupture in body builders [9].
  • Continuation of anabolic steroids during recovery from pectoralis major rupture does not seem to have a negative effect on functional recovery [9].
  • Testosterone replacement therapy within 1 year of rotator cuff repair appears to be a risk factor for multiple postoperative complications [11].
  • Testosterone replacement therapy within 1 year of rotator cuff repair appears to be a risk factor for subsequent shoulder surgery [11].
  • Further research is needed to understand the mechanism by which testosterone increases the risk of reoperation after total shoulder arthroplasty [12].

Key Evidence

  • [L3] Testosterone replacement therapy is associated with increased odds of surgically treated tendon rupture. [1] (10.1177/2325967125s00009)
  • [L3] Testosterone users had a 2.9-fold increased risk of tendon rupture compared to nonusers. [2] (10.1177/2325967124s00339)
  • [L5] It is premature to imply causation between testosterone replacement therapy and ACL injuries based solely on existing results due to confounding variables; clinicians should remain vigilant and prescribe TRT judiciously with a thorough assessment of each patient's unique risk profile. [3] (10.1016/j.arthro.2024.11.086)
  • [L3] These findings suggest a threshold-dependent relationship between testosterone and shoulder pathology and highlight the need to consider hormonal status in musculoskeletal risk assessment. [4] (10.1016/j.jse.2026.01.012)
  • [L3] Patients with prior prescription testosterone exposure have an increased rate of distal biceps tendon injury and biceps tendon repair compared with patients without such exposure. [5] (10.1016/j.jse.2023.02.122)
  • [L5] The author advises surgeons to be more intentional about discussing endocrinologic history with patients and counseling those with testosterone deficiency on the risks for injury or re-injury. [6] (10.1097/corr.0000000000002835)
  • [L3] Patients who filled a prescription for testosterone replacement therapy were much more likely to experience a quadriceps muscle or tendon injury within 1 year of filling their prescription and were at increased risk of undergoing surgical repair of the quadriceps tendon. [7] (10.1097/corr.0000000000002744)
  • [L3] TRT is associated with increased tendon rupture risk in men but not women, potentially due to sex-specific differences in dosing. [8] (10.1177/23259671261430731)
  • [L4] Anabolic steroids use may contribute to the injury, but continuation during recovery does not seem to have a negative effect on functional recovery. [9] (10.1186/s12891-023-06382-1)
  • [L4] SARM use is associated with increased muscle mass, hepatotoxicity, cardiotoxicity, tendon damage, and androgenic side effects throughout the body. [10] (10.1177/03635465241252435)
  • [L3] TRT within 1 year of rotator cuff repair appears to be a risk factor for multiple postoperative complications and subsequent shoulder surgery. [11] (10.1016/j.jseint.2025.10.002)
  • [L3] Further research is needed to understand the mechanism by how testosterone increases the risk of reoperation after TSA. [12] (10.1177/2325967124s00118)
  • [L2] Testosterone use is associated with a higher risk of both infection-related and all-cause reoperations after total shoulder arthroplasty. [13] (10.1016/j.jseint.2026.101634)
  • [L3] This study found that patients prescribed at least 3 months of TRT had a significantly higher incidence of ACL injuries compared to controls within a 2-year follow-up period. [14] (10.1016/j.arthro.2024.10.032)
  • [L3] This finding may represent a musculoskeletal consequence of TRT and is important for patients and clinicians to understand. [15] (10.5435/jaaos-d-22-00554)
  • [L3] Testosterone deficiency is associated with poorer postoperative outcomes in total joint arthroplasty, with distinct patterns observed in THA and TKA. [16] (10.5435/jaaos-d-25-00190)
  • [L1] The results of our study supported a causal relationship between bioavailable testosterone levels and OA, identifying bioavailable testosterone levels as a risk factor for OA. [17] (10.1186/s12891-025-08626-8)
  • [L3] Low testosterone levels are independently associated with an increased risk of OA in the U.S. population. [18] (10.1186/s12891-024-08272-6)

References

[1] Testosterone Replacement Therapy Increases Odds of Tendon Ruptures Treated Surgically. Orthopaedic Journal of Sports Medicine. 2025. DOI: 10.1177/2325967125s00009 [2] Poster 374: Tendon Tears Among Patients Treated with Exogenous Therapeutic Anabolic Steroids: An Eight Year Retrospective Analysis in a Single Institution. Orthopaedic Journal of Sports Medicine. 2024. DOI: 10.1177/2325967124s00339 [3] Editorial Commentary: Testosterone Replacement Therapy and Anterior Cruciate Ligament Injury Risk: Insights and Cautions for Clinical Application. Arthroscopy. 2024. DOI: 10.1016/j.arthro.2024.11.086 [4] Testosterone levels and risk of adhesive capsulitis: a 1:1 propensity matched analysis. Journal of Shoulder and Elbow Surgery. 2026. DOI: 10.1016/j.jse.2026.01.012 [5] The use of prescription testosterone is associated with an increased likelihood of experiencing a distal biceps tendon injury and subsequently requiring surgical repair. Journal of Shoulder and Elbow Surgery. 2023. DOI: 10.1016/j.jse.2023.02.122 [6] CORR Insights®: Testosterone Therapy Is Associated With Increased Odds of Quadriceps Tendon Injury. Clinical Orthopaedics & Related Research. 2023. DOI: 10.1097/corr.0000000000002835 [7] Testosterone Therapy Is Associated With Increased Odds of Quadriceps Tendon Injury. Clinical Orthopaedics & Related Research. 2023. DOI: 10.1097/corr.0000000000002744 [8] Testosterone Therapy and Associated Rates of Tendon Tear and Surgical Repair: A Retrospective Analysis. Orthopaedic Journal of Sports Medicine. 2026. DOI: 10.1177/23259671261430731 [9] Pectoralis major rupture in body builders: a case series including anabolic steroid use. BMC Musculoskeletal Disorders. 2023. DOI: 10.1186/s12891-023-06382-1 [10] Athlete Selective Androgen Receptor Modulators Abuse: A Systematic Review. The American Journal of Sports Medicine. 2025. DOI: 10.1177/03635465241252435 [11] Preoperative testosterone replacement therapy: a potential risk-factor for complications and reoperation after rotator cuff repair. JSES International. 2026. DOI: 10.1016/j.jseint.2025.10.002 [12] Poster 149: Supplemental Testosterone Increases Risk of Reoperation after Total Shoulder Arthroplasty. Orthopaedic Journal of Sports Medicine. 2024. DOI: 10.1177/2325967124s00118 [13] Prescription testosterone is associated with increased risk of infection-related and all-cause reoperations after primary total shoulder arthroplasty in male patients. JSES International. 2026. DOI: 10.1016/j.jseint.2026.101634 [14] Prescription Testosterone Is Associated With an Increased Risk of Anterior Cruciate Ligament Injury. Arthroscopy. 2024. DOI: 10.1016/j.arthro.2024.10.032 [15] The Relationship Between Testosterone Therapy and Rotator Cuff Tears, Repairs, and Revision Repairs. Journal of the American Academy of Orthopaedic Surgeons. 2023. DOI: 10.5435/jaaos-d-22-00554 [16] Testosterone Deficiency and Total Joint Arthroplasty Outcomes—A Large Claims Database Study. Journal of the American Academy of Orthopaedic Surgeons. 2025. DOI: 10.5435/jaaos-d-25-00190 [17] The causal impact of bioavailable testosterone levels on osteoarthritis: a bidirectional Mendelian randomized study. BMC Musculoskeletal Disorders. 2025. DOI: 10.1186/s12891-025-08626-8 [18] Correlation between low testosterone levels and the risk of osteoarthritis: a cross-sectional analysis of NHANES data (2011–2016). BMC Musculoskeletal Disorders. 2025. DOI: 10.1186/s12891-024-08272-6

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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.