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Epicondilite Medial (Cotovelo do Golfista)

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Reabilitação baseada em carga para cotovelo de golfista (tendinose dos flexores-pronadores), com triagem do nervo ulnar, carga excêntrica com o movimento inverso de Tyler-twist e um protocolo pós-operatório separado para a minoria que necessita de cirurgia.

Ilustração da face interna do cotovelo, mostrando os tendões flexores-pronadores se inserindo no epicôndilo medial, com o nervo ulnar passando logo atrás dele.
Cotovelo de golfista: desgaste dos tendões flexores-pronadores onde se inserem na protuberância óssea na parte interna do cotovelo (o epicôndilo medial). O nervo ulnar passa logo atrás dele. Kieran Hirpara 4.0

Esta página foi traduzida automaticamente e ainda não foi verificada por um médico. A versão em inglês é a versão oficial.

Esta página orienta a sua recuperação da epicondilite medial (comumente chamada de cotovelo de golfista) sob os cuidados do Dr. Kieran Hirpara no Mater Private Hospital Rockhampton. A maioria das pessoas se recupera completamente sem cirurgia, e a base do tratamento é um programa de exercícios baseado em carga constante, em vez de repouso. Ele começa com o seu programa de exercícios em casa, seguido pelo protocolo clínico estruturado escrito para o seu fisioterapeuta ou terapeuta da mão; traga esta página ou seu PDF para a sua primeira sessão de terapia para que a sua reabilitação permaneça coordenada. O seu terapeuta pode ajustar o plano dependendo de como a sua recuperação progride.

Se você desenvolver formigamento, dormência ou fraqueza no dedo mínimo e no dedo anelar, informe a recepção ou o seu terapeuta; o nervo ulnar passa logo atrás do cotovelo interno e, às vezes, precisa de atenção separada.

O que esperar

O cotovelo de golfista é um problema de desgaste (degenerativo) dos tendões na face interna do cotovelo: os tendões flexores-pronadores, que flexionam o punho e viram a palma para baixo, onde se inserem na saliência óssea chamada epicôndilo medial. Apesar do nome antigo "epicondilite", não se trata realmente de uma inflamação; o tendão tornou-se enfraquecido e desorganizado devido ao sobrecarga. É por isso que o tratamento moderno não é repouso e anti-inflamatórios, mas um programa gradual que carrega suavemente o tendão de volta à força total.

A recuperação exige paciência. O cotovelo de golfista é geralmente autolimitado, mas pode levar de 6 a 18 meses para resolver completamente. A boa notícia é que a grande maioria das pessoas melhora com um bom programa conservador e nunca precisa de cirurgia. A cirurgia só é considerada após pelo menos seis meses de terapia de qualidade terem falhado.

Uma característica que diferencia o cotovelo interno do cotovelo externo (de tênis) é o nervo ulnar (o nervo do "osso engraçado"), que passa em um sulco imediatamente atrás do epicôndilo medial. Cerca de metade das pessoas com cotovelo de golfista também apresentam alguma irritação deste nervo, por isso o seu terapeuta irá avaliá-lo em cada visita e poderá adicionar exercícios específicos de deslizamento nervoso.

Precauções e limitações

Fazer:

  • Continuar a usar o braço para tarefas diárias normais dentro de limites confortáveis.
  • Modificar, em vez de interromper completamente, as atividades que provocam exacerbação dos sintomas.
  • Usar uma órtese de contrapressão sobre o músculo do antebraço durante as atividades que agravam os sintomas, se for benéfico.
  • Realizar os alongamentos e os exercícios de carga regularmente; a consistência é mais importante do que a intensidade.

Não fazer:

  • Não imobilizar completamente o cotovelo nem colocá-lo em gesso; o tendão necessita de carga suave para cicatrizar.
  • Evitar atividades com carga valga intensa no início: golfe, lançamento (especialmente as fases de cocking e aceleração), natação e desportos de raquete, até que a força seja recuperada.
  • Não forçar qualquer exercício até à dor aguda, e não forçar os deslizes nervosos até à sensação de formigueiro ou dormência.
  • Se os sintomas do nervo ulnar (formigueiro ou dormência no dedo mínimo e no dedo anelar) piorarem, reduzir a intensidade e procurar reavaliação antes de progredir na carga.

Seus exercícios

Estes são os exercícios do seu material. Inicie-os conforme orientado pelo Dr. Hirpara e seu fisioterapeuta. Nas primeiras semanas, o foco é controlar a dor, realizar movimentos suaves e manter as contrações isométricas; o exercício de inversão Tyler excêntrica e o fortalecimento da pegada são adicionados à medida que você melhora. O deslize do nervo ulnar é incluído porque esse nervo está frequentemente envolvido na parte interna do cotovelo; mantenha-o suave.

Seu protocolo clínico

O restante desta página é o protocolo de reabilitação clínica. Esta seção deve ser fornecida ao seu fisioterapeuta ou terapeuta da mão. É baseado em critérios, e não apenas no tempo: o progresso entre as fases depende do cumprimento das metas listadas, e não simplesmente do calendário. O nervo ulnar é avaliado em todas as consultas (sinal de Tinel, subluxação), pois aproximadamente 50–60% dos casos mediais apresentam sintomas concomitantes do nervo ulnar, que são a principal razão para o fracasso do tratamento conservador.

Existem duas vias abaixo: o programa não operatório (de primeira linha, para a grande maioria) e o programa pós-operatório (para a minoria que prossegue para a cirurgia após o fracasso do tratamento conservador).

Via não cirúrgica

Fase I: Aguda / controle da dor (0–2 semanas)

Objetivos: controlar a dor; restaurar a amplitude de movimento completa sem carga.

  • Repouso relativo e modificação da atividade: usar a dor como limitante; evitar imobilização. Modificar o golfe, arremesso, natação, esportes de raquete, levantamento de peso e preensão repetitiva.
  • Tala contrapressão opcional sobre a massa flexora comum; uma tala de punho pode ser usada se houver dor aguda.
  • Adjuvantes para controle da dor: gelo, trabalho de tecidos moles / IASTM, amplitude de movimento ativa (AMA) suave sem dor, deslizamentos nervosos.
  • Rastrear o nervo ulnar (Tinel, subluxação).
  • Critérios para progressão: AMA completa sem carga e sem dor; programa domiciliar independente.

Fase II: Subaguda / início do carregamento (2–4 semanas)

Objetivos: iniciar o carregamento dos flexores-pronadores; abordar a cadeia proximal.

  • Carregamento isométrico dos flexores do punho e pronadores (leve).
  • Alongamento progressivo dos flexores do punho com o cotovelo em 90° de flexão.
  • Cadeia cinética proximal: estabilizadores da escápula (serrátil anterior, trapézio médio/inferior) e manguito rotador, críticos em arremessadores, onde a sobrecarga medial do cotovelo é impulsionada pelo valgo.
  • Critérios para progressão: amplitude de movimento (ADM) completa mantida; tolera o alongamento a 90°; ~70% da força do lado contralateral.

Fase III: Fortalecimento / retorno (4–6+ semanas)

Objetivos: restaurar a tolerância à carga e o retorno à função e ao esporte.

  • Carregamento excêntrico-concêntrico da flexão do punho e pronação do antebraço: o análogo medial do Tyler twist é o "reverse Tyler twist" (flexão excêntrica do punho em um FlexBar). O carregamento excêntrico-concêntrico combinado é favorecido; os isométricos permanecem úteis para analgesia inicial.
  • Mobilização com movimento; progressão do alongamento em direção à posição de extensão do cotovelo.
  • Fortalecimento da preensão, seguido de carregamento específico para o esporte; para arremessadores, um programa de arremesso por intervalos; a pliometria por último.
  • Desmame da tala contrapressão à medida que o cotovelo se torna assintomático; abordar equipamento e técnica.
  • Critérios de retorno ao esporte: ~90% da força do lado contralateral, função sem dor, autogestão.

Via pós-operatória (desbridamento dos flexores-pronadores ± reparo ± procedimento no nervo ulnar)

A cirurgia é reservada à minoria dos pacientes que falham no tratamento conservador por ≥6 meses. A operação aberta tipo Nirschl desbrida a origem patológica dos flexores-pronadores e comumente realiza seu reparo/reanexação; o nervo ulnar é avaliado e protegido, sendo realizada descompressão ou transposição anterior concomitantemente em uma proporção dos casos.

Fase 1: Proteção (0–2 semanas)

  • Tala longa posterior (cotovelo + punho) por 10–14 dias; talabarte para uso comunitário.
  • Elevação e controle do edema; AROM dos dedos/deslizamento tendinoso; AROM do ombro; AROM cervical suave.
  • Precauções: NÃO levantar, empurrar, puxar ou realizar preensão vigorosa: proteger o reparo.

Fase 2: Restauração da ROM (2–6 semanas)

  • Na consulta de ~2 semanas: remoção dos pontos; transição para órtese de punho em neutro em tempo integral (removida para higiene); Tubigrip no cotovelo para o inchaço.
  • Iniciar AROM do cotovelo flexão/extensão (2–4 sem), depois AROM do punho em 4 direções + rotação do antebraço e AROM dos dedos/polegar (4–6 sem).
  • Deslizamentos do nervo ulnar introduzidos nas semanas 4–6 (adição específica do lado medial).
  • Estabilização escapular (resistência à gravidade). Nenhuma fortalecimento com resistência até após 6 semanas.

Fase 3: Fortalecimento (6–12 semanas)

  • Desmame da órtese conforme tolerado (o uso noturno pode continuar no início).
  • Fortalecimento resistivo progressivo do punho e antebraço. Sem supinação/pronação resistida no início; iniciar levantamento em supinação/neutro, com levantamento pronado leve a partir de ~semana 9.

Fase 4: Retorno à atividade / esporte (12–16+ semanas)

  • Progressão do levantamento em todas as posições do antebraço conforme tolerado; retorno total à atividade por ~12–16 semanas; programa de arremesso específico para o esporte / por intervalos para atletas. A recuperação completa é comumente de 3–6 meses.

Precauções do nervo ulnar: se uma transposição anterior foi realizada, limitar a flexão do cotovelo no final do arco de movimento no início e progressão gradual da excursão nervosa. Sintomas ulnares persistentes ou piores justificam revisão cirúrgica antes de avançar a carga.

Retorno ao trabalho e às atividades

A rapidez do seu retorno depende do protocolo que está a seguir e das exigências do seu trabalho e desporto.

Não cirúrgico. Geralmente pode continuar a trabalhar e manter-se ativo durante todo o processo, modificando as tarefas que provocam exacerbação da dor no cotovelo, em vez de parar completamente. O golfe, os desportos de lançamento, a natação e os desportos de raquete são reintroduzidos gradualmente durante a fase de fortalecimento, quando a força for aproximadamente 90% da do lado contralateral e a função estiver livre de dor. Como a epicondilite medial é autolimitada, a resolução completa pode demorar entre 6 e 18 meses, embora a função no dia a dia melhore muito antes.

Pós-operatório. O uso leve e restrito inicia-se precocemente, mas o levantamento de pesos mais pesados e a preensão são adiados para proteger a reparação. A maioria das pessoas retorna à atividade completa por volta das 12 às 16 semanas, com a recuperação total a demorar habitualmente entre 3 e 6 meses. Os atletas de lançamento seguem um programa de lançamentos graduais e intervalados antes de regressar à competição.

Condução: evite conduzir enquanto estiver com uma tala ou uma bandagem, ou enquanto o cotovelo estiver demasiado doloroso para controlar o veículo com segurança. Retome a condução quando deixar de usar a tala e conseguir mover o braço confortavelmente, conforme confirmado na sua consulta de acompanhamento.

Após o seu protocolo

Este protocolo complementa as orientações gerais de recuperação da clínica; consulte o manejo da dor pós-operatória, o cuidado com a ferida e os fundamentos da terapia manual. O cotovelo de golfista compartilha sua abordagem baseada em carga com sua contraparte no cotovelo externo, o cotovelo de tenista; pergunte ao seu terapeuta se deseja as orientações equivalentes para epicondilite lateral. Sua recuperação contínua é orientada individualmente pelo seu fisioterapeuta ou terapeuta manual, de acordo com a evolução do seu cotovelo.

Reviewed by Dr Kieran Hirpara · 18 June 2026.

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

Medial Epicondylitis (Golfer's Elbow) — Flexor-Pronator Tendinosis: Conservative Loading & Post-operative Rehabilitation

Topic scope: (A) the loading-based non-operative rehabilitation of medial epicondylitis — a degenerative tendinopathy of the flexor-pronator origin (chiefly flexor carpi radialis and pronator teres) at the medial epicondyle — with mandatory ulnar-nerve screening; and (B) post-operative rehabilitation after open flexor-pronator debridement (± repair, ± concurrent ulnar nerve decompression/transposition), reserved for the minority failing ≥6 months of quality conservative care.

Defining principle: medial epicondylitis is not an inflammatory condition but a degenerative tendinosis, so the treatment is graded tendon loading, not rest. The protocol mirrors lateral elbow tendinopathy but with two practice-defining differences Dr Hirpara emphasises: (1) the loaded group is the wrist flexors/pronators (hence the eccentric "reverse Tyler twist" rather than the lateral Tyler twist), and (2) the ulnar nerve lies immediately behind the medial epicondyle, so concomitant ulnar neuritis (~50–60% of cases) is screened at every visit and is the leading reason conservative care fails. Surgery is a last resort after ≥6 months.

Medial epicondylitis is far less studied than its lateral counterpart — it is ~5–10× less common (prevalence ~0.4% vs 1.3%; ~10–20% of all epicondylitis). Most evidence is extrapolated from lateral elbow tendinopathy and from older operative case series; dedicated medial RCTs are sparse. Phase timelines below come from institutional Standard-of-Care protocols (Mass General Brigham combined medial/lateral; UVA medial debridement; Campbell's / Nirschl) plus operative series.

A. NON-OPERATIVE REHABILITATION (phased)

First-line; the majority resolve without surgery. Largely the SAME phased structure as the lateral elbow (Mass General Brigham publishes ONE combined medial/lateral protocol), with the loading target shifted to the flexor-pronator mass. Expected resolution 6–18 months (self-limited).

Phase I — Acute / pain control (~0–2 weeks). Relative rest + activity modification using pain as the limiter (avoid immobilisation). Aggravators to modify: golf, throwing (esp. late-cocking / acceleration valgus load), swimming, bowling, racquet sports, weightlifting, repetitive gripping. Optional counterforce brace over the common flexor mass; wrist splint if acutely painful. Pain-control adjuncts: ice, soft-tissue / IASTM, gentle pain-free AROM, dry needling, nerve glides. Screen the ulnar nerve (Tinel, subluxation). Criterion to progress: full unloaded AROM without pain; independent home program.

Phase II — Sub-acute / early loading (~2–4 weeks). Isometric wrist-flexor and pronator loading (minimal load). Progressive stretching of the wrist flexors at 90° elbow flexion. Proximal kinetic chain: scapular stabilisers and rotator cuff — critical in throwers, where medial elbow overload is valgus-driven. Criteria to progress: full ROM maintained; tolerates the 90° stretch; ~70% contralateral strength.

Phase III — Late / strengthening & return (~4–6+ weeks). Eccentric and concentric loading of wrist flexion and forearm pronation — the medial analogue of the Tyler twist is a "reverse Tyler twist" (eccentric wrist flexion on the FlexBar). Combined eccentric-concentric loading is favoured; isometrics for early analgesia. Mobilisation-with-movement; progress stretching to the elbow-extended position. Grip strengthening, then sport-specific loading; for throwers, an interval throwing program; plyometrics last. Wean counterforce brace as asymptomatic; equipment/technique modification. Return-to-sport criteria: ~90% contralateral strength, pain-free function, self-management.

B. POST-OPERATIVE REHABILITATION (flexor-pronator debridement ± repair, ± ulnar nerve procedure)

Surgery is for the minority failing ≥6 months of conservative care. The open Nirschl-type operation debrides the pathologic flexor-pronator origin (incision posterior to the medial epicondyle to spare the medial antebrachial cutaneous nerve), with repair/reattachment commonly by suture anchor. The ulnar nerve must be assessed and protected: ulnar neuritis is addressed concurrently (decompression or anterior transposition) in roughly 20–50% of operative series. The phase timeline blends the UVA "Golfer's Elbow Debridement (with tendon repair)" protocol and the Verma / Midwest-Orthopaedics-at-Rush medial/lateral debridement protocol.

Phase 1 — Protect / immobilise (Weeks 0–2). Posterior long-arm splint (elbow + wrist) for 10–14 days; sling for community use. Elevation; oedema control; finger/tendon-glide AROM; unaffected-joint motion; active shoulder ROM; gentle cervical AROM. Precautions: NO lifting / pushing / pulling / forceful gripping; protect the repair.

Phase 2 — ROM restoration (Weeks 2–6). At the 2-wk visit: suture removal; transition to a wrist orthosis in neutral full-time (off for hygiene); Tubigrip at the elbow for swelling. Begin AROM elbow flexion/extension (2–4 wk), then 4-way wrist AROM + forearm rotation, finger/thumb AROM (4–6 wk). Ulnar nerve glides introduced ~weeks 4–6 (the explicit medial-specific addition). Scapular stabilisation (gravity-resisted). No resistance strengthening until after 6 weeks.

Phase 3 — Strengthening (Weeks 6–12). Wean the orthosis as tolerated (consider night use early). Progressive resistive strengthening of wrist and forearm; per Verma, no resisted supination/pronation early, lifting begun in supination/neutral, with light pronated lifting from ~week 9.

Phase 4 — Return to activity / sport (Weeks 12–16+). Progress lifting in all forearm positions as tolerated; full return to activity by ~12–16 weeks; sport-specific / interval throwing program for athletes. Full recovery commonly 3–6 months.

Ulnar nerve precautions: if an anterior transposition was performed, limit end-range elbow flexion early and progress nerve excursion gradually; persistent or worsening ulnar symptoms warrant surgeon review before advancing loading.

C. PHASED TIMELINE SUMMARY

Pathway Phase Window Immobilisation Loading / key actions Criteria / milestone
Non-op I — Pain control 0–2 wk None (avoid casting); optional counterforce brace Activity modification; pain-free AROM; nerve glides; ulnar screen Full unloaded AROM, pain-free
Non-op II — Early loading 2–4 wk None Isometric flexor/pronator load; 90° wrist-flexor stretch; scapular/cuff ~70% contralateral strength
Non-op III — Strengthen / return 4–6+ wk Wean brace Reverse Tyler twist (eccentric); grip; sport-specific; throwers' interval program ~90% strength, pain-free → RTS
Post-op 1 — Protect 0–2 wk Posterior long-arm splint 10–14 d + sling Finger glides, shoulder ROM; oedema control No resistance; repair protected
Post-op 2 — ROM restore 2–6 wk Neutral wrist orthosis Elbow AROM → 4-way wrist + forearm rotation; ulnar glides wk 4–6 No resistance until >6 wk
Post-op 3 — Strengthen 6–12 wk Wean orthosis Progressive resistance; supinated/neutral lifting → light pronated ~wk 9 Restored strength in safe positions
Post-op 4 — Return 12–16+ wk None Lifting all forearm positions; interval throwing Full return ~12–16 wk; recovery 3–6 mo

D. KEY CONTROVERSIES / EVIDENCE QUALITY

  1. Sparse high-level evidence. Almost no medial-specific RCTs; recommendations are extrapolated from lateral elbow and from retrospective operative series (Kurvers & Verhaar 1995 remains a cornerstone). Strength of evidence is materially weaker than for lateral epicondylitis.
  2. Ulnar nerve is the dominant modifier. Concomitant ulnar neuropathy (reported 23–60%) worsens prognosis and is the leading reason conservative care fails; whether and how to address it surgically (decompression vs transposition vs medial epicondylectomy) is debated. Outcomes are reliably worse when ulnar symptoms coexist and are untreated.
  3. PRP may rival surgery for type-1 disease. Bohlen et al (OJSM 2020) found 2 leukocyte-rich PRP injections matched surgery for recalcitrant type-1 medial epicondylitis (29/33 success each) with faster recovery (pain-free ~56 vs ~108 days; full ROM ~42 vs ~96 days) — the surgical delay partly attributed to post-op bracing. Small evidence base.
  4. Corticosteroid: short-term only. As with the lateral elbow, steroid gives transient relief without durable benefit and risks recurrence; repeated injections show diminishing returns.
  5. Eccentric vs concentric. Same unsettled debate as the lateral elbow; combined eccentric-concentric flexor-pronator loading is the pragmatic standard, but direct medial trial data are minimal.
  6. Surgical technique. Open Nirschl debridement with repair is reliable in case series; arthroscopic medial debridement is emerging (claimed ulnar-nerve protection) but is technically demanding and under-evidenced. Debridement alone vs with repair remains unsettled.

E. EVIDENCE STRENGTH FLAGS (summary)

  • MODERATE (non-operative rehab): the phased loading program — extrapolated largely from lateral elbow tendinopathy and combined medial/lateral institutional protocols; combined eccentric-concentric flexor-pronator loading is the pragmatic standard.
  • LOW–MODERATE (post-operative rehab): phase timelines from institutional debridement protocols (UVA; Verma/Rush) and operative case series; no defining post-op rehab RCT.
  • MODERATE (PRP for type-1 disease): single comparative study (Bohlen OJSM 2020) matching surgery with faster recovery; small sample.
  • CONSENSUS / EXPERT: ulnar-nerve screening at every visit, ulnar-glide timing (wk 4–6 post-op), and the forearm-position lifting progression — drawn from surgeon-guidance protocols and operative practice rather than trial data.

CITATIONS

RAG corpus (180,000+ Orthopaedic articles)

  • Kurvers H, Verhaar J. The results of operative treatment of medial epicondylitis. J Bone Joint Surg Am. 1995. (ulnar neuritis coexistence 23–50%)
  • Bohlen HL, et al. Platelet-rich plasma is an equal alternative to surgery in the treatment of type 1 medial epicondylitis. Orthop J Sports Med. 2020. DOI: 10.1177/2325967120908952
  • Platelet-rich plasma versus Tenex in the treatment of medial and lateral epicondylitis. J Shoulder Elbow Surg. 2019.
  • Ellenbecker TS, Nirschl R, Renstrom P. Current concepts in examination and treatment of elbow tendon injury. Sports Health. 2012.
  • Rehabilitation of the thrower's elbow. Clin Sports Med. 2004.
  • Nirschl surgical technique for concomitant lateral and medial elbow tendinosis. Am J Sports Med. 2011.
  • Imaging of the elbow in the overhead throwing athlete. Am J Sports Med. 2003. (ulnar neuritis in ~60% of throwers with medial epicondylitis)
  • Outcome of partial medial epicondylectomy for cubital tunnel syndrome. Clin Orthop Relat Res. 2006.
  • Coonrad RW, Hooper WR. Tennis elbow: its course, natural history, conservative and surgical management (includes medial). J Bone Joint Surg Am. 1973.
  • Green's Operative Hand Surgery. 2021. (medial vs lateral prevalence; combined treatment chapter; Nirschl technique)
  • Campbell's Operative Orthopaedics. 2020. (Box 46.3 Rehabilitation Protocol for Epicondylitis [Wilk/Arrigo/Andrews]; Nirschl medial technique, posterior incision sparing the MABC nerve)

Published protocols (URLs)

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k. Sui Generis Database Rights means rights other than copyright resulting from Directive 96/9/EC of the European Parliament and of the Council of 11 March 1996 on the legal protection of databases, as amended and/or succeeded, as well as other essentially equivalent rights anywhere in the world.

l. You means the individual or entity exercising the Licensed Rights under this Public License. Your has a corresponding meaning.

Section 2 -- Scope.

a. License grant.

1. Subject to the terms and conditions of this Public License, the Licensor hereby grants You a worldwide, royalty-free, non-sublicensable, non-exclusive, irrevocable license to exercise the Licensed Rights in the Licensed Material to:

a. reproduce and Share the Licensed Material, in whole or in part, for NonCommercial purposes only; and

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.