Skip to content

Ligaments & Tendons

DBT, UCL, and distal triceps tendon injuries: diagnosis, non-operative vs operative management, and relevant patient populations.

Overview

Tissue engineering approaches hold great promise for improving tendon and ligament repair but have not yet succeeded clinically [1]. Primary tendon repair is permissible only when strict criteria are met, including early presentation, minimal contamination, and favorable wound conditions; otherwise, secondary repair via tendon graft is recommended [13]. For specific pathologies, surgical intervention yields distinct outcomes: patients managed operatively for complete tears of the distal biceps tendon demonstrated high rates of success at long-term follow-up with respect to elbow function and clinical outcomes [4], while surgical treatment is the treatment of choice for Achilles tendon ruptures in more active patients due to significantly better functional results and a lower incidence of reruptures compared to non-surgical treatment [25].

Surgical indications vary by tendon and patient demand. Surgical repair is indicated in active persons with complete distal triceps ruptures and for incomplete tears with concomitant loss of strength, with good to excellent results reported [24], whereas acute repair is recommended for patients desiring return to sports following proximal hamstring tendon ruptures, while nonoperative management with delayed reconstruction is an option for low-demand patients [23]. In contrast, functional results were fair following surgical repair of spontaneously ruptured posterior tibial tendons [9], and in cases of tendon graft for extensor tendon ruptures in rheumatoid hands, the time to surgery should be considered, and there is concern over extension lag of the MP joint [3].

Technique selection and graft preparation significantly influence outcomes. Tenodesis and tenotomy of the long head of the biceps are both well-established techniques that similarly yield satisfactory outcomes [16], though when arthroscopic tenodesis of the long head of the biceps is indicated, bony fixation is recommended over soft tissue fixation because anchor fixation provides significant advantages concerning clinical and structural outcome [56]. Regarding graft preparation, twisting or braiding reduces the tensile strength and stiffness of human hamstring tendon grafts used for anterior cruciate ligament reconstruction [22], leading authors to caution against the use of twisted or braided four-strand hamstring tendon grafts for anterior cruciate ligament reconstruction [22]. Follow-up studies on eleven of eighteen Achilles tendons treated with the plantaris tendon as a reinforcing membrane revealed excellent results [2].

Anatomy & Pathophysiology

Ligamentous Stability

The posterolateral ligament of the elbow plays a significant role in the elbow's posterolateral stability [18]. The anterior bundle of the ulnar collateral ligament affects stability to over twice the magnitude of either the medial or lateral muscle groups [42], while the medial and lateral elbow musculature affect total elbow varus-valgus stability to roughly equal magnitudes [42]. Medial elbow joint space increases under a valgus load and decreases when a maximal grip contraction is performed [32]. An elbow with medial ulnar collateral ligament insufficiency experiences an increase in valgus angle and a propensity for the ulna to go into internal rotation under valgus stress [44]. Pitching 100 balls induces a significant reduction in dynamic stabilizing ability against elbow valgus laxity [37].

Musculotendinous Function

The biceps brachii contributes 46.7% to elbow flexion force, while the musculocutaneous nerve contributes 42% and the radial nerve contributes 27.5% [45]. The short head of the distal biceps tendon insertion allows it to be relatively more efficient at elbow flexion at 90 degrees [43], whereas the long head of the distal biceps tendon becomes relatively more efficient at supination in the supinated forearm [43]. The brachioradialis and supinator contribute 64.1% to forearm supination force [45]. The biomechanics and forces at the elbow during a baseball or softball swing represent a risk to individuals for distal biceps tendon rupture [31].

Kinematic Adaptations

Chronic structural adaptations of the shoulder and elbow are correlated in professional baseball pitchers, but no significant relationships exist between adaptations in shoulder strength or range of motion and chronic structural adaptations of the elbow [33].

Classification

Tissue Engineering Status: Clinical success for tendon and ligament repair via tissue engineering approaches has not yet been achieved, despite holding significant promise [1].

Achilles Tendon Reinforcement: Follow-up studies on eleven of eighteen Achilles tendons treated with the plantaris tendon as a reinforcing membrane revealed excellent results [2].

Flexor Hallucis Longus Management: Release of the flexor retinaculum permits the flexor hallucis longus tendon to move smoothly in its track, but the prognosis remains guarded as the tendon is weakened [5].

Collateral Ligament Management: Understanding anatomy, biomechanics, diagnostic modalities, treatment options, and outcomes is critical for the management of collateral ligament injuries [6].

Insertion Morphology: The normal morphology of tendon and ligament insertions follows a four-zone model consisting of tendon, fibrocartilage, mineralized fibrocartilage, and bone [7].

Elbow Ligament Anatomy: The posterolateral ligament of the elbow has a significant role in the elbow's posterolateral stability [18]. The anterior bundle, posterior bundle, and common tendon of the ulnar collateral ligament of the elbow can each be classified into an independent form and an unclear form [52].

Extensor Carpi Radialis Brevis (ECRB) Release: The anatomic location of the ECRB origin relative to surgically relevant landmarks confirms that the ECRB can be safely and completely released arthroscopically [63].

Tendo Achillis Repair: A repair using the tendo achillis itself has been suggested for defects in the tendo achillis [64].

Abductor Tendon Reconstruction: Surgical reconstruction of degenerate abductor tendons should be considered in the presence of an MRI-confirmed separation where clinical findings are consistent with known tendon disruption [14].

Other Considerations: The pathophysiology of tendinosis is characterized by degenerative rather than inflammatory changes, with susceptibility related to activity and age [15]. Tenocytes obtained from degenerative tendons exhibit greater dedifferentiation and a higher propensity to differentiate towards nontenogenic cell lineages compared to normal tendon [59]. Human muscle-derived cells contribute to structural and functional repair for injured tendons and are a potential cell source to participate in the repair process after tendon injury [61]. Sports medicine textbooks contain review questions and answers covering diagnosis, treatment, and rehabilitation of various musculoskeletal injuries [11].

Clinical Presentation

Tissue engineering approaches for tendon and ligament repair have not yet succeeded clinically despite holding great promise [1]. Understanding anatomy, biomechanics, diagnostic modalities, treatment options, and outcomes is critical for the management of collateral ligament injuries [6]. Normal tendon and ligament insertions are delineated by a four-zone model consisting of tendon, fibrocartilage, mineralized fibrocartilage, and bone [7]. The pathophysiology of tendinosis is characterized by degenerative rather than inflammatory changes, with susceptibility related to activity and age [15]. Distal biceps tendon tears in women present differently than in men [20].

Acute vs. Chronic Management: Primary tendon repair is permissible only when strict criteria are met, including early presentation, minimal contamination, and favorable wound conditions [13]. Secondary repair via tendon graft is recommended when strict criteria for primary repair are not met [13]. Acute diagnosis and early repair are recommended for distal triceps tendon ruptures [19]. Surgical reconstruction of degenerate abductor tendons should be considered in the presence of an MRI-confirmed separation where clinical findings are consistent with known tendon disruption [14].

Extensor and Flexor Pathology: In cases of tendon graft for extensor tendon ruptures in rheumatoid hands, the time to surgery should be considered due to concerns over extension lag of the metacarpophalangeal joint [3]. Release of the flexor retinaculum permits the flexor hallucis longus tendon to move smoothly in its track, but the prognosis is guarded as the tendon remains weakened [5]. Follow-up studies on eleven of eighteen Achilles tendons treated with the plantaris tendon as a reinforcing membrane revealed excellent results [2].

Collateral Ligament Outcomes: Completely ruptured collateral ligaments of the proximal interphalangeal joint frequently result in prolonged disability when treated non-operatively [8]. Surgical repair of fourteen fingers with complete collateral ligament rupture yielded satisfactory results with restored joint stability and pain relief [8]. The posterolateral ligament of the elbow has a significant role in the elbow's posterolateral stability [18].

Biceps and Long-Term Function: Patients managed operatively for complete tears of the distal biceps tendon demonstrated high rates of success at long-term follow-up regarding elbow function and clinical outcomes [4]. Tenodesis and tenotomy of the long head of the biceps are both well-established techniques that similarly yield satisfactory outcomes [16].

Investigations

Plain radiography: In adolescent baseball pitchers, plain radiographs show no relationship between ulnar collateral ligament (UCL) tear type and age, competition level, or radiographic abnormalities [66]. However, a high rate of abnormal MRI findings exists in the elbows of asymptomatic professional baseball players [70]. In asymptomatic high school-aged pitchers, thickening of the anterior band of the UCL and posteromedial ulnotrochlear subchondral sclerosis are common MRI findings that may be considered normal clinical findings [68]. For subscapularis tendon avulsion, the radiographic appearance of a bone fragment beneath the humeral head is a valuable sign, suggesting the condition may be more common than literature suggests [65].

MRI: Magnetic resonance imaging indicates that the donor site after autologous osteochondral mosaicplasty is resurfaced with fibrous tissue [67]. MRI is critical for surgical reconstruction of degenerate abductor tendons, which should be considered in the presence of an MRI-confirmed separation where clinical findings are consistent with known tendon disruption [14].

Other Considerations: Tissue engineering approaches for tendon and ligament repair have not yet succeeded clinically despite holding great promise [1]. Follow-up studies on eleven of eighteen tendons treated with the plantaris tendon as a reinforcing membrane revealed excellent results [2]. In cases of tendon graft for extensor tendon ruptures in rheumatoid hands, the time to surgery should be considered due to concerns over extension lag of the metacarpophalangeal joint [3]. Understanding anatomy, biomechanics, diagnostic modalities, treatment options, and outcomes is critical for the management of collateral ligament injuries [6]. A four-zone model of tendon and ligament insertions (tendon, fibrocartilage, mineralized fibrocartilage, and bone) has been established using light and electron microscopy [7]. Injured ulnar collateral ligaments in the thumb metacarpophalangeal joint were naturally stable after reduction and did not require surgical repair [10]. Distal biceps tendon tears in women present differently than in men [20]. Both the TightRope and traditional docking techniques restored native joint kinematics from 15 to 75 degrees of flexion under low loading conditions [21]. The long-term durability of arthroscopic ulnohumeral arthroplasty regarding preservation of range of motion and radiographic progression of arthritis remains unknown [27]. Excellent clinical outcomes suggest that pectoralis major tendon reconstruction using semitendinosus allograft is a reliable tool for uncommon pectoralis major tears at the musculotendinous junction [29]. Revision ulnar collateral ligament reconstruction is a rare procedure with outcomes that are not as promising as primary reconstruction [69].

Treatment

Non-Operative

Nonoperative management is indicated for low-demand patients following acute and chronic ruptures of the proximal hamstring tendons [23]. Injured ulnar collateral ligaments of the thumb metacarpophalangeal joint were naturally stable after reduction and did not require surgical repair [10]. For the athlete with chronic attenuation of the medial collateral ligament of the elbow, a trial of nonsurgical treatment is preferred [54]. Nonreconstructive options such as rehabilitation, biologic strategies, and repair may be beneficial for lower-demand athletes with UCL injuries [57]. These same nonreconstructive options may be beneficial for adolescents with UCL injuries [57]. Nonreconstructive options such as rehabilitation, biologic strategies, and repair may also be beneficial for aging athletes with UCL injuries [57]. Nonoperative treatment for partial distal biceps tendon tears yields moderate success rates (47%) [38]. There are no significant differences between nonoperative treatment strategies for partial distal biceps tendon tears [38]. Injection therapy offers the quickest relief for partial distal biceps tendon tears [38].

Operative

Indications: Surgical repair is indicated in active persons with complete distal triceps ruptures [24]. Surgical repair is indicated for incomplete distal triceps tears with concomitant loss of strength [24]. Acute diagnosis and early repair is recommended for distal triceps tendon ruptures [19]. Surgical treatment is the treatment of choice for more active patients with ruptures of the tendo achillis due to significantly better functional results and a lower incidence of reruptures compared to non-surgical treatment [25]. Acute repair is recommended for patients desiring return to sports following acute and chronic ruptures of the proximal hamstring tendons [23]. UK upper limb surgeons currently advise surgical repair of acute distal biceps tendon ruptures for the majority of their patients [48]. Most complete acute distal biceps tendon ruptures are best treated with primary repair using either a single-incision or double-incision approach with good clinical outcome [49]. Surgical treatment including tendon tear completion and anatomic repair to the radial tuberosity for partial tears of the distal biceps brachii tendon can yield satisfactory results [51]. Surgical treatment including tendon tear completion and anatomic repair to the radial tuberosity for partial tears of the distal biceps brachii tendon appears to provide predictable outcomes [51]. Surgical repair of fourteen fingers with complete rupture of collateral ligaments of the proximal interphalangeal joint yielded satisfactory results with restored joint stability and pain relief [8]. Completely ruptured collateral ligaments of the proximal interphalangeal joint frequently result in prolonged disability when treated non-operatively [8]. In cases of tendon graft for extensor tendon ruptures in rheumatoid hands, the time to surgery should be considered, and there is concern over extension lag of the MP joint [3].

Surgical Approach / Technique: Primary tendon repair is permissible only when strict criteria are met, including early presentation, minimal contamination, and favorable wound conditions [13]. Secondary repair via tendon graft is recommended when strict criteria for primary tendon repair are not met [13]. The single incision power optimizing cost-effective (SPOC) distal biceps repair requires no specialized anchors or equipment [53]. Follow-up studies on eleven of eighteen tendons treated with the plantaris tendon as a reinforcing membrane revealed excellent results [2].

Implant Selection: UCL reconstruction remains a mainstay for high-demand athletes with full-thickness tears [57]. UCL reconstruction is offered to the elite throwing athlete with acute deterioration in the setting of chronic UCL insufficiency [54]. At 2 years after ACL reconstruction with tibialis anterior allografts, the subject group displayed satisfactory functional outcomes [17]. Twisting or braiding four-strand hamstring tendon grafts reduces their tensile strength and stiffness [22]. The authors caution against the use of twisted or braided four-strand hamstring tendon grafts for anterior cruciate ligament reconstruction [22].

Other Considerations: Patients managed operatively for complete tears of the distal biceps tendon demonstrated high rates of success at long-term follow-up with respect to elbow function and clinical outcomes [4]. Tenodesis and tenotomy of the long head of the biceps are both well-established techniques that similarly yield satisfactory outcomes [16]. Conservative treatment or non-anatomical repair of the distal tendon of the biceps brachii results in significant loss of supination strength [34]. Conservative treatment or non-anatomical repair of the distal tendon of the biceps brachii results in variable loss of flexion strength [34]. Good to excellent results are reported following surgical repair of distal triceps ruptures [24]. The functional results were fair following surgical repair of the ruptured posterior tibial tendon [9]. Tissue engineering approaches hold great promise for improving tendon and ligament repair, but they have not yet succeeded clinically [1]. There is a paucity of evidence to support improved outcomes following surgical rather than non-operative management of acute distal biceps tendon ruptures [48].

Complications

Tendon and Ligament Repair Outcomes: Tissue engineering approaches for tendon and ligament repair have not yet succeeded clinically despite holding promise [1]. Surgical repair of completely ruptured collateral ligaments of the proximal interphalangeal joint yields satisfactory results with restored joint stability and pain relief, whereas non-operative treatment frequently results in prolonged disability [8]. In contrast, functional results following surgical repair of spontaneous posterior tibial tendon rupture are fair [9]. Release of the flexor retinaculum in partial rupture of the flexor hallucis longus tendon permits smooth tendon movement but results in a guarded prognosis due to tendon weakness [5]. Injured ulnar collateral ligaments of the thumb metacarpophalangeal joint were naturally stable after reduction and did not require surgical repair [10]. Acute diagnosis and early repair are recommended for distal triceps tendon ruptures [19].

Proximal Hamstring and Patellar Complications: Proximal hamstring tendon repair is associated with an overall complication rate of 15.4% and a major complication rate of 4.6% [46]. Soft tissue anchors used for restoration of patellar continuity in traumatic bilateral concurrent patellar tendon rupture resulted in no complications at 2-year follow-up [26].

Reconstruction Complications: Medial ulnar collateral ligament reconstruction with allograft in athletic patient populations is associated with a low incidence of postoperative complications [55].

Recovery

Light activity (weeks): Evidence regarding specific timelines for light activity or driving is not explicitly quantified in the provided source material. However, patients managed operatively for complete distal biceps tendon tears demonstrate high success rates at long-term follow-up regarding elbow function [4], and those with traumatic bilateral patellar tendon ruptures treated with soft tissue anchors achieved excellent functional outcomes with no complications at 2-year follow-up [26].

Full activity (months): Short-term results for knee-derived osteochondral autograft transplantation (OAT) procedures in the elbow indicate that approximately 80% of patients are completely pain-free and return to sport at 2-year follow-up [58]. At 2 years post-ACL reconstruction using tibialis anterior allografts, the subject group displayed satisfactory functional outcomes [17]. Conversely, a scoping review notes contradictory results regarding tendon-related outcomes, though studies suggest increasing tendon function after rehabilitation with blood flow restriction training [60].

Complete recovery / outcome plateau (months): Long-term durability of arthroscopic ulnohumeral arthroplasty regarding preservation of ROM and radiographic progression of arthritis remains unknown [27]. Patients with a preoperative duration of symptomatic medial knee overload or arthritis of two years or greater do not experience inferior patient-reported outcomes or clinical outcomes compared to those with a symptom duration of less than 2 years at mid-term follow-up after high tibial osteotomy [62]. In cases of tendon graft for extensor tendon ruptures in rheumatoid hands, there is concern over extension lag of the MP joint, necessitating consideration of the time to surgery [3].

Rehabilitation protocol: Tissue engineering approaches hold great promise for improving tendon and ligament repair but have not yet succeeded clinically [1]. Release of the flexor retinaculum permits the flexor hallucis longus tendon to move smoothly in its track, though the prognosis is guarded as the tendon is weakened [5]. Follow-up studies on eleven of eighteen tendons treated with the plantaris tendon as a reinforcing membrane revealed excellent results [2]. Surgical repair of fourteen fingers with complete rupture of collateral ligaments yielded satisfactory results with restored joint stability and pain relief [8], whereas completely ruptured collateral ligaments of the proximal interphalangeal joint frequently result in prolonged disability when treated non-operatively [8]. Injured ulnar collateral ligaments of the thumb metacarpophalangeal joint were naturally stable after reduction and did not need surgical repair [10].

Functional milestones: The functional results were fair following surgical repair of a spontaneously ruptured posterior tibial tendon [9]. Forty-seven (96 per cent) of the forty-nine shoulders had a good clinical result after distal release of deltoid muscle contracture [30]. Degeneration in human supraspinatus tendons is caused by trauma incurred during the life of the individual [28].

Other Considerations: No specific rehabilitation protocols, PROM trajectories, or additional recovery-relevant predictors are detailed in the provided evidence base beyond the functional outcomes and procedural considerations listed above.

Key Evidence

  • [L4] Follow-up studies on eleven of eighteen tendons so treated revealed excellent results. (10.2106/00004623-196648020-00005)
  • [L4] In cases of tendon graft, the time to surgery should be considered, and there is concern over extension lag of MP joint. (10.1186/s12891-022-05815-7)
  • [L4] Patients managed operatively demonstrated high rates of success at long-term follow-up with respect to elbow function and clinical outcomes. (10.1177/23259671241283787)
  • [L4] Release of the flexor retinaculum permits the tendon to move smoothly in its track, but the prognosis is guarded as the tendon is weakened. (10.2106/00004623-197961010-00031)
  • [L4] Completely ruptured collateral ligaments frequently result in prolonged disability when treated non-operatively, whereas surgical repair of fourteen fingers with complete rupture yielded satisfactory results with restored joint stability and pain relief. (10.2106/00004623-196749020-00009)
  • [L4] The functional results were fair following surgical repair of the ruptured tendon. (10.2106/00004623-196951040-00014)
  • [L4] Injured UCL ligaments were naturally stable after reduction and did not need surgical repair. (10.1177/1753193418790502)
  • [L5] Primary tendon repair is permissible only when strict criteria are met, including early presentation, minimal contamination, and favorable wound conditions; otherwise, secondary repair via tendon graft is recommended. (10.2106/00004623-195941040-00001)
  • [L4] Surgical reconstruction of degenerate abductor tendons should be considered in the presence of an MRI confirmed separation where clinical findings are consistent with the known tendon disruption. (10.1016/j.arth.2019.11.012)
  • [L1] Tenodesis and tenotomy are both well-established techniques that similarly yield satisfactory outcomes. (10.1177/1758573220942923)
  • [L4] At 2 years after ACL reconstruction with tibialis anterior allografts, this subject group displayed satisfactory functional outcomes. (10.1007/s00167-003-0371-x)
  • [L4] The PLL of the elbow has a significant role in the elbow's posterolateral stability. (10.1016/j.jse.2023.08.033)
  • [L4] Acute diagnosis and early repair is recommended for distal triceps tendon ruptures. (10.1016/j.jse.2016.12.062)
  • [L4] Distal biceps tendon tears in women present differently than in men. (10.1016/j.jse.2010.01.015)
  • [L5] Both the TR and DO techniques restored native joint kinematics from 15 to 75 degrees of flexion under low loading conditions. (10.1177/0363546513482567)
  • [L5] The authors caution against the use of twisted or braided four-strand hamstring tendon grafts for anterior cruciate ligament reconstruction. (10.1177/03635465030310062201)
  • [L3] Acute repair is recommended for patients desiring return to sports, while nonoperative management with delayed reconstruction is an option for low-demand patients. (10.1177/2325967113s00061)
  • [L5] Surgical repair is indicated in active persons with complete tears and for incomplete tears with concomitant loss of strength, with good to excellent results reported. (10.5435/00124635-201001000-00005)
  • [L3] Surgical treatment is the treatment of choice and should be recommended for more active patients due to significantly better functional results and a lower incidence of reruptures compared to non-surgical treatment. (10.2106/00004623-197658070-00015)
  • [L4] Soft tissue anchors were used for restoration of patellar continuity in a healthy patient with traumatic bilateral concurrent patellar tendon rupture, resulting in excellent functional outcomes and no complications at 2-year follow-up. (10.1007/s00167-002-0332-9)
  • [L4] The long-term durability of this procedure with regard to preservation of ROM and radiographic progression of arthritis remains unknown. (10.1016/j.jse.2006.09.001)
  • [L5] The study concludes that degeneration in human supraspinatus tendons is caused by trauma incurred during the life of the individual. (10.2106/00004623-194830030-00025)
  • [L4] The excellent clinical outcomes suggest that the described technique can be a reliable tool in the orthopedic surgeon's armamentarium when approaching this uncommon PM tear. (10.1016/j.jses.2019.08.007)
  • [L3] Forty-seven (96 per cent) of the forty-nine shoulders had a good clinical result after distal release of the contracture. (10.2106/00004623-199802000-00010)
  • [Case_report] Given the documented biomechanics and forces at the elbow during the course of the baseball or softball swing, it is not surprising that this activity could represent a risk to individuals at risk for this injury. (10.1016/j.xrrt.2022.10.004)
  • [L4] Medial elbow joint space increases under a valgus load and then decreases when a maximal grip contraction is performed. (10.1177/0363546518755149)
  • [L3] However, no significant relationships between adaptations in shoulder strength or ROM were related to chronic structural adaptations of the elbow. (10.1177/03635465251317509)
  • [L4] Conservative treatment or non-anatomical repair results in significant loss of supination strength and variable loss of flexion strength. (10.2106/00004623-198567030-00011)
  • [L5] Pitching 100 balls induces a significant reduction in dynamic stabilizing ability against elbow valgus laxity. (10.1016/j.jse.2023.11.001)
  • [L3] Nonoperative treatment for partial distal biceps tendon tears yields moderate success rates (47%) with no significant differences between strategies, though injection therapy offers the quickest relief. (10.1016/j.jse.2025.04.017)
  • [L5] The medial and lateral elbow musculature affect total elbow varus-valgus stability to roughly equal magnitudes, while the anterior bundle of the UCL affects stability to over twice the magnitude of either muscle group. (10.1016/j.jse.2008.08.004)
  • [L5] The short head's insertion allows it to be relatively more efficient at elbow flexion at 90 degrees, while the long head becomes relatively more efficient at supination in the supinated forearm. (10.1016/j.jse.2011.04.030)
  • [L5] An MUCL insufficient elbow experiences an increase in valgus angle and a propensity for the ulna to go into internal rotation under valgus stress. (10.1016/j.jse.2016.12.043)
  • [L4] The musculocutaneous and radial nerves contribute 42% and 27.5% respectively to elbow flexion force, while the biceps brachii contributes 46.7% and the brachioradialis and supinator contribute 64.1% to forearm supination force. (10.1177/1753193408087036)
  • [L1] Proximal hamstring tendon repair is associated with an overall complication rate of 15.4%, including a 4.6% rate of major complications. (10.1177/2325967123s00208)
  • [L4] UK upper limb surgeons currently advise surgical repair of acute distal biceps tendon ruptures for the majority of their patients, despite a paucity of evidence to support improved outcomes following surgical rather than non-operative management. (10.1177/17585732211032960)
  • [L4] Most complete tears are best treated with primary repair using either a single-incision or double-incision approach with good clinical outcome. (10.1302/2058-5241.6.200145)
  • [L4] Surgical treatment including tendon tear completion and anatomic repair to the radial tuberosity can yield satisfactory results and appears to provide predictable outcomes. (10.1016/j.jhsa.2016.04.019)
  • [L5] These results suggest that the anterior bundle, posterior bundle, and common tendon each can be classified into an independent form and an unclear form. (10.1177/2325967120952415)
  • [L4] No specialized anchors or equipment are required. (10.1016/j.jse.2012.10.044)
  • [L5] For the athlete with chronic attenuation, a trial of nonsurgical treatment is preferred; however, UCL reconstruction is offered to the elite throwing athlete with acute deterioration in the setting of chronic UCL insufficiency. (10.1016/j.jhsa.2014.04.011)
  • [L4] Soft-tissue allograft for MUCLR in athletic patient populations provides excellent clinical outcomes, high rates of return to play, and low rates of postoperative complications and graft failure at short-term follow-up. (10.1016/j.arthro.2024.03.045)
  • [L3] When arthroscopic tenodesis of the LHB is indicated, the authors recommend a bony fixation over soft tissue fixation because anchor fixation provides significant advantages concerning the clinical and structural outcome. (10.1177/0363546510390777)
  • [L5] While UCL reconstruction remains a mainstay for high-demand athletes with full-thickness tears, nonreconstructive options such as rehabilitation, biologic strategies, and repair may be beneficial for specific clinical scenarios including lower-demand athletes, adolescents, and aging athletes. (10.1177/0363546517692548)
  • [L4] Short-term results for knee-derived OAT procedures in the elbow have been universally favorable, with about 80% of patients completely pain free and back to their sport at 2-year follow-up. (10.1016/j.jhsa.2013.09.003)
  • [L4] Tenocytes obtained from degenerative tendons exhibited greater dedifferentiation and a higher propensity to differentiate towards nontenogenic cell lineages compared to normal tendon. (10.1016/j.jseint.2025.101417)
  • [L4] The present scoping review shows contradictory results regarding tendon-related outcomes although studies point to increasing tendon function after rehabilitation. (10.1186/s12891-025-08734-5)
  • [L5] Human MDCs contribute to structural and functional repair for the injured tendon and are a potential cell source to participate in the repair process after tendon injury. (10.1177/03635465221147486)
  • [L4] Patients with a preoperative duration of symptomatic medial knee overload/arthritis of two years or greater do not experience inferior PRO or clinical outcomes than patients with a symptom duration of less than 2 years at mid-term follow-up. (10.1016/j.jisako.2022.03.003)
  • [L5] The study defines the anatomic location of the ECRB origin relative to surgically relevant landmarks and confirms that the ECRB can be safely and completely released arthroscopically using these landmarks. (10.1016/j.jse.2008.02.021)
  • [L4] A repair using the tendo achillis itself has been suggested. (10.2106/00004623-195638010-00011)
  • [Case_report] Avulsion of the subscapularis tendon may be more common than literature suggests, and the radiographic appearance of a bone fragment beneath the humeral head is a valuable sign. (10.2106/00004623-198769090-00024)
  • [L3] There was no relationship between UCL tear type and age, competition level, and plain radiographic abnormalities. (10.1177/03635465221094326)
  • [L4] However, magnetic resonance imaging indicates that the donor site is resurfaced with fibrous tissue. (10.1177/0363546507306465)
  • [L3] Thickening of the anterior band of the UCL and the presence of posteromedial ulnotrochlear subchondral sclerosis are common MRI findings in the asymptomatic high school–aged pitcher and may be considered normal clinical findings in the absence of symptom complaints. (10.1177/0363546510390185)
  • [L5] Revision ulnar collateral ligament reconstruction is a rare procedure with outcomes that are not as promising as primary reconstruction; proper diagnosis, surgical technique, and rehabilitation are paramount. (10.5435/jaaos-d-16-00341)
  • [L4] This study demonstrates a high rate of abnormal magnetic resonance imaging findings in asymptomatic throwers' elbows. (10.1177/0363546503262646)

See Also

References

[1] Chapter 62 Tendons and Ligaments. 2019.

[2] Repair of the Torn Achilles Tendon, Using the Plantaris Tendon as a Reinforcing Membrane. The Journal of Bone & Joint Surgery. 1966. DOI: 10.2106/00004623-196648020-00005

[3] Long-term clinical outcome of tendon transfer and tendon graft for extensor tendon ruptures in rheumatoid hands. BMC Musculoskeletal Disorders. 2022. DOI: 10.1186/s12891-022-05815-7

[4] Long-term Outcomes of Complete Tears of the Distal Biceps Tendon: An Analysis of Surgical Management at a Median Follow-up of 14.7 Years. Orthopaedic Journal of Sports Medicine. 2024. DOI: 10.1177/23259671241283787

[5] Partial rupture of the flexor hallucis longus tendon in classical ballet dancers. The Journal of Bone & Joint Surgery. 1979. DOI: 10.2106/00004623-197961010-00031

[6] Chapter 17 Collateral Ligament Injuries. 2019.

[7] Tendon and Ligament Insertion: A LIGHT AND ELECTRON MICROSCOPIC STUDY.. The Journal of Bone and Joint Surgery. American Volume. 1970.

[8] Rupture of a Collateral Ligament of the Proximal Interphalangeal Joint of the Fingers. The Journal of Bone & Joint Surgery. 1967. DOI: 10.2106/00004623-196749020-00009

[9] Spontaneous Rupture of the Posterior Tibial Tendon. The Journal of Bone & Joint Surgery. 1969. DOI: 10.2106/00004623-196951040-00014

[10] Arthroscopic findings of injured ulnar and radial collateral ligaments in the thumb metacarpophalangeal joint. Journal of Hand Surgery (European Volume). 2018. DOI: 10.1177/1753193418790502

[11] Chapter 157 Sports Medicine. 2019.

[13] Primary Tendon Repair. The Journal of Bone & Joint Surgery. 1959. DOI: 10.2106/00004623-195941040-00001

[14] Primary Open Abductor Reconstruction: A 5 to 10-Year Study. The Journal of Arthroplasty. 2020. DOI: 10.1016/j.arth.2019.11.012

[15] Instructional Course Lectures, The American Academy of Orthopaedic Surgeons - Tendon Problems in Athletic Individuals+.. The Journal of Bone and Joint Surgery. American Volume*. 1997.

[16] Long head of biceps tenotomy versus tenodesis: a systematic review and meta-analysis of randomized controlled trials. Shoulder & Elbow. 2020. DOI: 10.1177/1758573220942923

[17] Two‐year outcomes following ACL reconstruction with allograft tibialis anterior tendons: a retrospective study. Knee Surgery, Sports Traumatology, Arthroscopy. 2003. DOI: 10.1007/s00167-003-0371-x

[18] The posterolateral ligament of the elbow: anatomy and clinical relevance. Journal of Shoulder and Elbow Surgery. 2024. DOI: 10.1016/j.jse.2023.08.033

[19] Outcomes following distal triceps tendon repair. Journal of Shoulder and Elbow Surgery. 2017. DOI: 10.1016/j.jse.2016.12.062

[20] Distal biceps tendon tears in women. Journal of Shoulder and Elbow Surgery. 2010. DOI: 10.1016/j.jse.2010.01.015

[21] Biomechanical Evaluation of the TightRope Versus Traditional Docking Ulnar Collateral Ligament Reconstruction Technique. The American Journal of Sports Medicine. 2013. DOI: 10.1177/0363546513482567

[22] Twisting and Braiding Reduces the Tensile Strength and Stiffness of Human Hamstring Tendon Grafts Used for Anterior Cruciate Ligament Reconstruction. The American Journal of Sports Medicine. 2003. DOI: 10.1177/03635465030310062201

[23] Functional Outcomes Following Surgical Repair of Acute and Chronic Ruptures of the Proximal Hamstring Tendons. Orthopaedic Journal of Sports Medicine. 2013. DOI: 10.1177/2325967113s00061

[24] Distal Triceps Rupture. American Academy of Orthopaedic Surgeon. 2010. DOI: 10.5435/00124635-201001000-00005

[25] Ruptures of the tendo achillis. An objective assessment of surgical and non-surgical treatment. The Journal of Bone & Joint Surgery. 1976. DOI: 10.2106/00004623-197658070-00015

[26] Traumatic bilateral concurrent patellar tendon rupture: an alterative fixation method. Knee Surgery, Sports Traumatology, Arthroscopy. 2003. DOI: 10.1007/s00167-002-0332-9

[27] Arthroscopic ulnohumeral arthroplasty for degenerative arthritis of the elbow in patients under fifty years of age. Journal of Shoulder and Elbow Surgery. 2007. DOI: 10.1016/j.jse.2006.09.001

[28] EXPERIMENTAL DEGENERATION OF THE SUPRASPINATUS TENDON. The Journal of Bone & Joint Surgery. 1948. DOI: 10.2106/00004623-194830030-00025

[29] Pectoralis major tendon reconstruction using semitendinosus allograft following rupture at the musculotendinous junction. JSES Open Access. 2019. DOI: 10.1016/j.jses.2019.08.007

[30] Contracture of the Deltoid Muscle. The Journal of Bone and Joint Surgery (American Volume). 1998. DOI: 10.2106/00004623-199802000-00010

[31] Distal biceps tendon rupture during softball swing: case report of a previously unreported mechanism of injury. JSES Reviews, Reports, and Techniques. 2023. DOI: 10.1016/j.xrrt.2022.10.004

[32] Medial Elbow Joint Space Increases With Valgus Stress and Decreases When Cued to Perform A Maximal Grip Contraction. The American Journal of Sports Medicine. 2018. DOI: 10.1177/0363546518755149

[33] Chronic Structural Adaptations of the Shoulder and Elbow Are Correlated in Professional Baseball Pitchers. The American Journal of Sports Medicine. 2025. DOI: 10.1177/03635465251317509

[34] Rupture of the distal tendon of the biceps brachii. A biomechanical study.. The Journal of Bone & Joint Surgery. 1985. DOI: 10.2106/00004623-198567030-00011

[37] Weakening and factors of medial elbow dynamic stabilizers against elbow valgus laxity after repetitive pitching in high school baseball players. Journal of Shoulder and Elbow Surgery. 2024. DOI: 10.1016/j.jse.2023.11.001

[38] Efficacy of conservative treatment strategies for partial distal biceps tendon ruptures: a case-control study. Journal of Shoulder and Elbow Surgery. 2026. DOI: 10.1016/j.jse.2025.04.017

[42] The role of the elbow musculature, forearm rotation, and elbow flexion in elbow stability: An in vitro study. Journal of Shoulder and Elbow Surgery. 2009. DOI: 10.1016/j.jse.2008.08.004

[43] Anatomic and biomechanical analysis of the short and long head components of the distal biceps tendon. Journal of Shoulder and Elbow Surgery. 2012. DOI: 10.1016/j.jse.2011.04.030

[44] Kinematics of the ulna with medial ulnar collateral ligament insufficiency. Journal of Shoulder and Elbow Surgery. 2017. DOI: 10.1016/j.jse.2016.12.043

[45] The Role of the Musculocutaneous and Radial Nerves in Elbow Flexion and Forearm Supination: A Biomechanical Study. Journal of Hand Surgery (European Volume). 2008. DOI: 10.1177/1753193408087036

[46] Poster 224: Complications Associated with Proximal Hamstring Tendon Repair: A Systematic Review. Orthopaedic Journal of Sports Medicine. 2023. DOI: 10.1177/2325967123s00208

[48] Treatment of acute distal biceps tendon ruptures – A survey of the British Elbow and Shoulder Society surgical membership. Shoulder & Elbow. 2021. DOI: 10.1177/17585732211032960

[49] Acute complete and partial distal biceps tendon ruptures: what have we learned? A review. EFORT Open Reviews. 2021. DOI: 10.1302/2058-5241.6.200145

[51] Partial Tears of the Distal Biceps Brachii Tendon: A Systematic Review of Surgical Outcomes. The Journal of Hand Surgery. 2016. DOI: 10.1016/j.jhsa.2016.04.019

[52] Morphological Features of the Ulnar Collateral Ligament of the Elbow and Common Tendon of Flexor-Pronator Muscles. Orthopaedic Journal of Sports Medicine. 2020. DOI: 10.1177/2325967120952415

[53] Single incision power optimizing cost-effective (SPOC) distal biceps repair. Journal of Shoulder and Elbow Surgery. 2013. DOI: 10.1016/j.jse.2012.10.044

[54] Medial Collateral Ligament of the Elbow: Acute Deterioration in Throwing Athletes. The Journal of Hand Surgery. 2014. DOI: 10.1016/j.jhsa.2014.04.011

[55] Medial Ulnar Collateral Ligament Reconstruction With Allograft Provides Excellent Clinical Outcomes, High Rates of Return to Play, and a Low Incidence of Postoperative Complications: A Systematic Review. Arthroscopy. 2024. DOI: 10.1016/j.arthro.2024.03.045

[56] Arthroscopic Soft Tissue Tenodesis Versus Bony Fixation Anchor Tenodesis of the Long Head of the Biceps Tendon. The American Journal of Sports Medicine. 2011. DOI: 10.1177/0363546510390777

[57] Avoiding Tommy John Surgery: What Are the Alternatives?. The American Journal of Sports Medicine. 2017. DOI: 10.1177/0363546517692548

[58] Osteochondral Autograft Transplantation in the Elbow. The Journal of Hand Surgery. 2014. DOI: 10.1016/j.jhsa.2013.09.003

[59] Mitochondria dysfunction and increased expression of WNT5A and BNIP3 in tenocytes obtained from patients with tendinopathy. JSES International. 2026. DOI: 10.1016/j.jseint.2025.101417

[60] The impact of blood flow restriction training on tendon adaptation and tendon rehabilitation – a scoping review. BMC Musculoskeletal Disorders. 2025. DOI: 10.1186/s12891-025-08734-5

[61] Human Muscle–Derived Cells Are Capable of Tenogenic Differentiation and Contribution to Tendon Repair. The American Journal of Sports Medicine. 2023. DOI: 10.1177/03635465221147486

[62] Preoperative symptom duration does not affect clinical outcomes after high tibial osteotomy at a minimum of 2-year follow-up. Journal of ISAKOS. 2022. DOI: 10.1016/j.jisako.2022.03.003

[63] Lateral epicondylitis: Anatomic relationships of the extensor tendon origins and implications for arthroscopic treatment. Journal of Shoulder and Elbow Surgery. 2008. DOI: 10.1016/j.jse.2008.02.021

[64] REPAIR OF DEFECTS IN THE TENDO ACHILLIS. The Journal of Bone & Joint Surgery. 1956. DOI: 10.2106/00004623-195638010-00011

[65] Avulsion of the subscapularis tendon. A case report. The Journal of Bone & Joint Surgery. 1987. DOI: 10.2106/00004623-198769090-00024

[66] Adolescent Baseball Pitchers With Ulnar Collateral Ligament Tears Exhibit a High Proportion of Partial Tears. The American Journal of Sports Medicine. 2022. DOI: 10.1177/03635465221094326

[67] Donor Site Evaluation after Autologous Osteochondral Mosaicplasty for Cartilaginous Lesions of the Elbow Joint. The American Journal of Sports Medicine. 2007. DOI: 10.1177/0363546507306465

[68] Magnetic Resonance Imaging of the Throwing Elbow in the Uninjured, High School–Aged Baseball Pitcher. The American Journal of Sports Medicine. 2011. DOI: 10.1177/0363546510390185

[69] Revision Ulnar Collateral Ligament Reconstruction. Journal of the American Academy of Orthopaedic Surgeons. 2018. DOI: 10.5435/jaaos-d-16-00341

[70] Evidence of Subclinical Medial Collateral Ligament Injury and Posteromedial Impingement in Professional Baseball Players. The American Journal of Sports Medicine. 2004. DOI: 10.1177/0363546503262646

Creative Commons BY-NC 4.0

CC Creative Commons licence
BY Attribution — you must credit the source
NC NonCommercial — not for commercial use

Attribution-NonCommercial 4.0 International

Creative Commons Corporation ("Creative Commons") is not a law firm and does not provide legal services or legal advice. Distribution of Creative Commons public licenses does not create a lawyer-client or other relationship. Creative Commons makes its licenses and related information available on an "as-is" basis. Creative Commons gives no warranties regarding its licenses, any material licensed under their terms and conditions, or any related information. Creative Commons disclaims all liability for damages resulting from their use to the fullest extent possible.

Using Creative Commons Public Licenses

Creative Commons public licenses provide a standard set of terms and conditions that creators and other rights holders may use to share original works of authorship and other material subject to copyright and certain other rights specified in the public license below. The following considerations are for informational purposes only, are not exhaustive, and do not form part of our licenses.

Considerations for licensors: Our public licenses are intended for use by those authorized to give the public permission to use material in ways otherwise restricted by copyright and certain other rights. Our licenses are irrevocable. Licensors should read and understand the terms and conditions of the license they choose before applying it. Licensors should also secure all rights necessary before applying our licenses so that the public can reuse the material as expected. Licensors should clearly mark any material not subject to the license. This includes other CC- licensed material, or material used under an exception or limitation to copyright. More considerations for licensors: wiki.creativecommons.org/Considerations_for_licensors

Considerations for the public: By using one of our public licenses, a licensor grants the public permission to use the licensed material under specified terms and conditions. If the licensor's permission is not necessary for any reason--for example, because of any applicable exception or limitation to copyright--then that use is not regulated by the license. Our licenses grant only permissions under copyright and certain other rights that a licensor has authority to grant. Use of the licensed material may still be restricted for other reasons, including because others have copyright or other rights in the material. A licensor may make special requests, such as asking that all changes be marked or described. Although not required by our licenses, you are encouraged to respect those requests where reasonable. More considerations for the public: wiki.creativecommons.org/Considerations_for_licensees

Creative Commons Attribution-NonCommercial 4.0 International Public License

By exercising the Licensed Rights (defined below), You accept and agree to be bound by the terms and conditions of this Creative Commons Attribution-NonCommercial 4.0 International Public License ("Public License"). To the extent this Public License may be interpreted as a contract, You are granted the Licensed Rights in consideration of Your acceptance of these terms and conditions, and the Licensor grants You such rights in consideration of benefits the Licensor receives from making the Licensed Material available under these terms and conditions.

Section 1 -- Definitions.

a. Adapted Material means material subject to Copyright and Similar Rights that is derived from or based upon the Licensed Material and in which the Licensed Material is translated, altered, arranged, transformed, or otherwise modified in a manner requiring permission under the Copyright and Similar Rights held by the Licensor. For purposes of this Public License, where the Licensed Material is a musical work, performance, or sound recording, Adapted Material is always produced where the Licensed Material is synched in timed relation with a moving image.

b. Adapter's License means the license You apply to Your Copyright and Similar Rights in Your contributions to Adapted Material in accordance with the terms and conditions of this Public License.

c. Copyright and Similar Rights means copyright and/or similar rights closely related to copyright including, without limitation, performance, broadcast, sound recording, and Sui Generis Database Rights, without regard to how the rights are labeled or categorized. For purposes of this Public License, the rights specified in Section 2(b)(1)-(2) are not Copyright and Similar Rights.

d. Effective Technological Measures means those measures that, in the absence of proper authority, may not be circumvented under laws fulfilling obligations under Article 11 of the WIPO Copyright Treaty adopted on December 20, 1996, and/or similar international agreements.

e. Exceptions and Limitations means fair use, fair dealing, and/or any other exception or limitation to Copyright and Similar Rights that applies to Your use of the Licensed Material.

f. Licensed Material means the artistic or literary work, database, or other material to which the Licensor applied this Public License.

g. Licensed Rights means the rights granted to You subject to the terms and conditions of this Public License, which are limited to all Copyright and Similar Rights that apply to Your use of the Licensed Material and that the Licensor has authority to license.

h. Licensor means the individual(s) or entity(ies) granting rights under this Public License.

i. NonCommercial means not primarily intended for or directed towards commercial advantage or monetary compensation. For purposes of this Public License, the exchange of the Licensed Material for other material subject to Copyright and Similar Rights by digital file-sharing or similar means is NonCommercial provided there is no payment of monetary compensation in connection with the exchange.

j. Share means to provide material to the public by any means or process that requires permission under the Licensed Rights, such as reproduction, public display, public performance, distribution, dissemination, communication, or importation, and to make material available to the public including in ways that members of the public may access the material from a place and at a time individually chosen by them.

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.