Skip to content

Diabetes and Upper-Limb Conditions

Why diabetes makes frozen shoulder, trigger finger, carpal tunnel syndrome and Dupuytren's more common, and how it affects healing and surgery.

Overview

Diabetes mellitus significantly alters the pathophysiology and clinical presentation of upper-limb conditions, necessitating heightened diagnostic vigilance. In asymptomatic type II diabetes, active glycaemic control and regular upper limb exercise may help delay degeneration of the supraspinatus tendon [1]. Shoulder pain in this population should raise suspicion for frozen shoulder, a condition where the prevalence of prediabetes reaches 37.5% [2, 11]. Furthermore, clinicians must consider spontaneous diabetic myonecrosis in patients presenting with atraumatic acute-onset pain and swelling in the hand to avoid misdiagnosis as inflammatory, infectious, or vascular pathology [3].

Infectious complications are more severe in diabetic cohorts, particularly when glycaemic control is poor [5]. Renal disease and diabetes independently increase the risk of failed outpatient management for cellulitic hand infections, often necessitating inpatient therapy [6]. In elective settings, monitoring HbA1c levels prior to surgery is critical to improving outcomes for diabetic patients undergoing procedures such as carpal tunnel release [9].

Carpal tunnel syndrome in diabetes is mechanistically linked to advanced glycation end products (AGEs) and RAGE expression within the flexor tendon synovium [9]. Obesity exerts a relationship with carpal tunnel syndrome that is similar to or more powerful than diabetes alone, even in the absence of mellitus [10]. The comorbidity of obesity and diabetes suggests an additive effect on the prevalence of this condition [10]. For frozen shoulder related to diabetes, emerging evidence comparing low-level laser therapy versus muscle energy technique may guide future clinical practice [4].

Background & Causes

Diabetes mellitus drives distinct pathological changes across the upper limb, ranging from early tendon degeneration to systemic inflammatory responses. In asymptomatic patients with type II diabetes, early degeneration of the supraspinatus tendon is detectable via shear wave elastography [1]. Altered molecular processes, including oxidative stress response and extracellular matrix organization, contribute to this tendon degeneration and impaired healing [24]. Furthermore, the HMGB1/RAGE/β-catenin axis mediates an aberrant osteogenic-tenogenic differentiation imbalance of tendon stem/progenitor cells in diabetic tendinopathy [25].

Frozen shoulder exhibits strong metabolic associations. Shoulder pain in people with diabetes may be indicative of frozen shoulder [2]. The prevalence of prediabetes is 37.5% in patients with primary frozen shoulder [11]. Type 2 diabetes and fasting glycemic traits are causal factors of frozen shoulder [12]. At the tissue level, matrix metalloproteinase-1 and matrix metalloproteinase-9 are highly expressed in the joint capsule of diabetic frozen shoulder [21]. However, older age and the presence of diabetes mellitus are negative prognostic factors for shoulder manipulation under ultrasound-guided cervical nerve root block for frozen shoulder [7].

Carpal tunnel syndrome in diabetes involves specific molecular and comorbid drivers. Higher RAGE expression is observed in the flexor tendon synovium of diabetic patients with more severe carpal tunnel syndrome [8]. Advanced glycation end products (AGEs) and RAGE expression play a role in the development of carpal tunnel syndrome in diabetic patients [9]. Obesity possesses a similar or more powerful relationship with carpal tunnel syndrome than diabetes alone, and comorbidity of obesity and diabetes suggests an additive effect on increased carpal tunnel syndrome prevalence [10]. Additionally, spontaneous diabetic myonecrosis can present as acute carpal tunnel syndrome in diabetic patients [3].

Systemic glycemic control influences infection severity and soft tissue mechanics. Poor glycaemic control is linked to increased severity of hand infections in diabetic patients [5]. While this section focuses on the upper limb, the broader impact of diabetes on connective tissue is evident in the lower extremity, where increased stiffness and tone in extrinsic foot muscles, Achilles tendon, and plantar fascia may contribute to abnormal foot loading patterns and increased risk of ulcer recurrence in patients with a history of diabetic foot ulcers [19].

Symptoms & Presentation

Shoulder Pathology: Early degeneration of the supraspinatus tendon can occur in asymptomatic patients with type II diabetes mellitus [1]. Shoulder pain in people with diabetes may be indicative of frozen shoulder [2]. The prevalence of prediabetes is 37.5% in patients with primary frozen shoulder [11]. Type 2 diabetes and fasting glycemic traits are causal factors of frozen shoulder [12].

Carpal Tunnel Syndrome: Spontaneous diabetic myonecrosis can present as acute carpal tunnel syndrome, characterized by atraumatic acute-onset pain and swelling in the hand [3]. Higher RAGE expression in flexor tendon synovium is associated with more severe carpal tunnel syndrome in patients with diabetes [8]. Diabetic carpal tunnel syndrome presents with more profound electrophysiological abnormalities compared to non-diabetic cases [16]. Obesity has a similar or more powerful relationship with carpal tunnel syndrome than diabetes alone, and the comorbidity of obesity and diabetes suggests an additive effect on increased carpal tunnel syndrome prevalence [10].

Infection Severity: Diabetic patients with hand infections may present with increased severity of infection linked to poor glycaemic control [5].

Management

Diagnosis and Risk Assessment

Clinicians should maintain a high index of suspicion for frozen shoulder in diabetic patients presenting with shoulder pain [2]. In cases of atraumatic, acute-onset pain and swelling in the hand, spontaneous diabetic myonecrosis must be considered to distinguish it from inflammatory, infectious, or vascular etiologies [3]. For asymptomatic patients with type II diabetes mellitus, active glycemic control and regular upper limb exercise may help delay supraspinatus tendon degeneration [1].

Non-Operative Management

Glycemic Control: Strict glycemic control during the first 3 to 6 months following arthroscopic rotator cuff repair is a modifiable risk factor associated with improved healing rates [14]. Surgeons should consider involving endocrinology colleagues to optimize postoperative glycemic control in select patients undergoing this procedure [14].

Surgical Selection: The success of superior capsular reconstruction (SCR) using fascia lata autograft in strictly controlled diabetic patients should not be generalized to less rigorously managed populations [15]. While preclinical and observational studies provide preliminary support for SGLT2 inhibitors in diabetic rotator cuff disease, high-quality randomized clinical trials are currently lacking [22].

Operative Management

Frozen Shoulder: Older age and the presence of diabetes mellitus are negative prognostic factors for shoulder manipulation under ultrasound-guided cervical nerve root block [7]. There are no significant differences in outcomes between early and delayed arthroscopic release in patients with a history of diabetes mellitus [17].

Carpal Tunnel Release: Preoperative semaglutide use is not associated with a reduction in 90-day complications or 2-year reoperation-free survival in patients with type II diabetes mellitus undergoing carpal tunnel release [13].

Infection Management

Severity and Risk: During the COVID-19 pandemic, hand infections treated were more severe and linked to poor glycaemic control, despite lower attendance volumes [5]. Renal disease and diabetes increase the risk of failed outpatient management for cellulitic hand infections [6].

Disposition: Most patients with diabetic hand infections can be successfully treated as outpatients, although the presence of comorbidities should influence the consideration for inpatient therapy [6].

Key Considerations

Preoperative Assessment and Risk Stratification: Preoperative HbA1c is not a predictive factor for surgical failure requiring reoperation following arthroscopic rotator cuff repair [18]. Preoperative semaglutide use was not associated with a reduction in 90-day complications or 2-year reoperation-free survival in patients with type II diabetes mellitus undergoing carpal tunnel release [13]. Understanding perioperative management guidelines for diabetes is essential for hand surgeons to prevent unexpected day of surgery cancellations [23].

Diabetic Hand Infections: Clinicians should consider spontaneous diabetic myonecrosis in diabetic patients with atraumatic acute-onset pain and swelling in the hand to avoid confusion with other inflammatory, infectious, or vascular conditions [3]. During the COVID-19 pandemic, there was an increased severity of hand infections in treated diabetic patients, linked to poor glycaemic control [5]. Renal disease and diabetes increase the risk of failed outpatient management of cellulitic hand infections, influencing consideration for inpatient therapy [6].

Frozen Shoulder Management: Shoulder pain in people with diabetes could be indicative of frozen shoulder [2]. Older age and the presence of diabetes mellitus are negative prognostic factors for shoulder manipulation under ultrasound-guided cervical nerve root block for frozen shoulder [7]. The findings of a study comparing low-level laser therapy versus muscle energy technique may provide evidence on the efficacy of these interventions and guide clinical practice for frozen shoulder related to diabetes [4].

Carpal Tunnel Syndrome (CTS): Among patients with diabetes who had carpal tunnel syndrome, higher RAGE expression was observed in those with more severe disease, suggesting RAGE-mediated pathways may play a role in the pathophysiology of CTS in patients with diabetes [8]. Diabetic carpal tunnel syndrome had more profound electrophysiological abnormalities compared to non-diabetic cases [16]. There were no significant differences in outcomes between early and delayed arthroscopic release in patients with a history of diabetes mellitus [17].

Rotator Cuff and General Considerations: Active control of diabetes and regular upper limb exercise may help delay supraspinatus tendon degeneration in asymptomatic type II diabetes patients [1]. The success of superior capsular reconstruction using fascia lata autograft in a selected population of strictly controlled patients with diabetes should not be generalized to a less rigorously managed diabetic population [15].

Key Evidence

  • [L3] Active control of the condition of diabetes patients and regular upper limb exercise might help delay the degeneration of supraspinatus tendons. (10.1186/s12891-025-08864-w)
  • [L2] Clinicians should remain alert that shoulder pain in people with diabetes could be indicative of a frozen shoulder. (10.1186/s12891-025-08672-2)
  • [L4] Clinicians should consider this diagnosis in diabetic patients with atraumatic acute-onset pain and swelling in the hand to avoid confusion with other inflammatory, infectious, or vascular conditions. (10.1016/j.jhsg.2021.10.006)
  • [L2] The findings of the study may provide evidence on the efficacy of these interventions and most likely, the optimal treatment approach for frozen shoulder related to diabetes, which may guide clinical practice. (10.1186/s13018-024-04735-7)
  • [L4] While fewer patients attended the service during the pandemic, there was an increased severity of hand infections in those treated, linked to poor glycaemic control. (10.1177/17531934231196026)
  • [L3] These comorbidities should influence consideration for inpatient therapy though most patients can undergo successful treatment as outpatients. (10.1186/s13018-023-03911-5)
  • [L3] Older age and the presence of diabetes mellitus are negative prognostic factors for shoulder manipulation under ultrasound-guided cervical nerve root block. (10.1016/j.jseint.2024.11.022)
  • [L2] Among patients with diabetes who had CTS, higher RAGE expression was observed in those with more severe disease, suggesting that RAGE-mediated pathways may play a role in the pathophysiology of CTS in patients with diabetes. (10.1097/corr.0000000000003800)
  • [Paper] This CORR Insights commentary highlights the role of advanced glycation end products (AGEs) and RAGE expression in the development of carpal tunnel syndrome in diabetic patients, emphasizing the importance of monitoring HbA1c levels before elective surgery to improve outcomes. (10.1097/corr.0000000000003820)
  • [L2] Obesity even without diabetes mellitus may possess a similar or more powerful relationship with carpal tunnel syndrome than diabetes alone, and comorbidity of obesity and diabetes suggests an additive effect on increased carpal tunnel syndrome prevalence. (10.1016/j.jhsg.2025.01.016)
  • [L4] The prevalence of prediabetes is 37.5% in patients with primary frozen shoulder. (10.1016/j.jseint.2023.08.017)
  • [L1] This study supports a genetic causal relationship between type 2 diabetes and fasting glucose and frozen shoulder. (10.1016/j.jse.2023.08.006)
  • [L3] Preoperative semaglutide use was not associated with a reduction in 90-day complications or 2-year reoperation-free survival in patients with type II diabetes mellitus undergoing carpal tunnel release. (10.1016/j.jhsa.2025.09.003)
  • [L5] Strict glycemic control in the first 3 to 6 months after arthroscopic rotator cuff repair is a modifiable risk factor associated with better healing rates, and surgeons should consider engaging endocrinology colleagues to improve postoperative glycemic control in select patients. (10.1016/j.arthro.2022.09.017)
  • [Commentary] The success of SCR using fascia lata autograft in a selected population of strictly controlled patients with diabetes should not be generalized to a less rigorously managed diabetic population. (10.1016/j.arthro.2024.10.015)
  • [L4] Diabetic CTS had more profound electrophysiological abnormalities. (10.1186/s12891-023-06881-1)
  • [L3] There were no significant differences in outcomes between early and delayed arthroscopic release in patients with a history of diabetes mellitus. (10.1016/j.jseint.2023.06.007)
  • [L3] In patients with diabetes mellitus, preoperative HbA1c is not a predictive factor for surgical failure requiring reoperation. (10.1016/j.jse.2023.06.034)
  • [L3] The increased stiffness and tone in these structures may contribute to abnormal foot loading patterns, potentially increasing the risk of ulcer recurrence. (10.1186/s12891-025-08791-w)
  • [L4] The findings of this study demonstrate the potential involvement of MMP-1 and 9 in the pathophysiology of diabetic FS. (10.1016/j.jse.2024.03.062)
  • [L4] Preclinical and observational studies provide preliminary support for the therapeutic benefits of SGLT2 inhibitors in diabetic rotator cuff disease, although high-quality randomized clinical trials are lacking. (10.5397/cise.2024.00969)
  • [L5] Understanding these perioperative management guidelines is essential for hand surgeons to prevent unexpected day of surgery cancellations. (10.1016/j.jhsa.2024.05.018)
  • [L5] Bioinformatic analyses suggested several altered molecular processes, including oxidative stress response and extracellular matrix organization, may contribute to tendon degeneration and impaired healing in diabetes patients. (10.1016/j.jse.2025.07.012)
  • [L5] The findings revealed the critical role of the HMGB1/RAGE/β-catenin axis in the differentiation imbalance of TSPCs and diabetic tendinopathy, highlighting a novel essential mechanism involved in the pathogenesis of diabetic tendinopathy and providing a promising therapeutic target and approach for diabetic tendinopathy. (10.1186/s13018-025-06572-8)

References

[1] Shear wave elastography of the supraspinatus tendon with early degeneration in asymptomatic type II diabetes mellitus patients: a multicenter study. BMC Musculoskeletal Disorders. 2025. DOI: 10.1186/s12891-025-08864-w

[2] Type 2 diabetes, metabolic health, and the development of frozen shoulder: a cohort study in UK electronic health records. BMC Musculoskeletal Disorders. 2025. DOI: 10.1186/s12891-025-08672-2

[3] Spontaneous Diabetic Myonecrosis Presenting as Acute Carpal Tunnel Syndrome. Journal of Hand Surgery Global Online. 2022. DOI: 10.1016/j.jhsg.2021.10.006

[4] Comparative effectiveness of low-level laser therapy versus muscle energy technique among diabetic patients with frozen shoulder: a study protocol for a parallel group randomised controlled trial. Journal of Orthopaedic Surgery and Research. 2024. DOI: 10.1186/s13018-024-04735-7

[5] The incidence and severity of diabetic hand infection presentations during the COVID-19 pandemic. Journal of Hand Surgery (European Volume). 2023. DOI: 10.1177/17531934231196026

[6] Renal disease and diabetes increase the risk of failed outpatient management of cellulitic hand infections: a retrospective cohort study. Journal of Orthopaedic Surgery and Research. 2023. DOI: 10.1186/s13018-023-03911-5

[7] Older age and diabetes mellitus are negative prognostic factors for shoulder manipulation under ultrasound-guided cervical nerve root block for frozen shoulder: a retrospective cohort study. JSES International. 2025. DOI: 10.1016/j.jseint.2024.11.022

[8] Is RAGE Expression in Flexor Tendon Synovium Associated With Carpal Tunnel Syndrome in Patients With Diabetes?. Clinical Orthopaedics & Related Research. 2025. DOI: 10.1097/corr.0000000000003800

[9] CORR Insights®: Is RAGE Expression in Flexor Tendon Synovium Associated With Carpal Tunnel Syndrome in Patients With Diabetes?. Clinical Orthopaedics & Related Research. 2026. DOI: 10.1097/corr.0000000000003820

[10] Obesity as a Risk Factor for Carpal Tunnel Syndrome Independent of Diabetes Mellitus: A Nationwide Study. Journal of Hand Surgery Global Online. 2025. DOI: 10.1016/j.jhsg.2025.01.016

[11] Prevalence of prediabetes in patients with idiopathic frozen shoulder: a prospective study. JSES International. 2024. DOI: 10.1016/j.jseint.2023.08.017

[12] Type 2 diabetes and fasting glycemic traits are causal factors of frozen shoulder: a 2-sample Mendelian randomization analysis. Journal of Shoulder and Elbow Surgery. 2024. DOI: 10.1016/j.jse.2023.08.006

[13] Endoscopic and Open Carpal Tunnel Release in Patients With Type II Diabetes Mellitus: Influence of Preoperative Semaglutide Use on Postoperative Outcomes. The Journal of Hand Surgery. 2025. DOI: 10.1016/j.jhsa.2025.09.003

[14] Editorial Commentary : Rotator Cuff Repair in Patients With Diabetes: Stricter Glycemic Control for the First 6 Months Is Associated With Better Healing. Arthroscopy. 2023. DOI: 10.1016/j.arthro.2022.09.017

[15] Editorial Commentary: Both Rotator Cuff Repair and Superior Capsular Reconstruction in Patients With Diabetes Show Good Outcomes When Glucose Is Well Managed. Arthroscopy: The Journal of Arthroscopic & Related Surgery. 2025. DOI: 10.1016/j.arthro.2024.10.015

[16] Characteristics of diabetic and non-diabetic carpal tunnel syndrome in terms of clinical, electrophysiological, and Sonographic features: a cross-sectional study. BMC Musculoskeletal Disorders. 2023. DOI: 10.1186/s12891-023-06881-1

[17] Effect of surgical timing in outcomes in Hispanic patients after arthroscopic capsular release in diabetic and idiopathic adhesive capsulitis. JSES International. 2023. DOI: 10.1016/j.jseint.2023.06.007

[18] Elevated HbA1c is not associated with reoperation following arthroscopic rotator cuff repair in patients with diabetes mellitus. Journal of Shoulder and Elbow Surgery. 2024. DOI: 10.1016/j.jse.2023.06.034

[19] Mechanical properties of extrinsic foot muscles, Achilles tendon, and plantar fascia in patients with a history of diabetic foot ulcers. BMC Musculoskeletal Disorders. 2025. DOI: 10.1186/s12891-025-08791-w

[21] Matrix metalloproteinase-1 and matrix metalloproteinase-9 are highly expressed in the joint capsule of diabetic frozen shoulder. Journal of Shoulder and Elbow Surgery. 2025. DOI: 10.1016/j.jse.2024.03.062

[22] Potentials of SGLT2 inhibitors in the treatment of diabetic rotator cuff diseases: a comprehensive review. Clinics in Shoulder and Elbow. 2025. DOI: 10.5397/cise.2024.00969

[23] Update on Perioperative Medication Management for the Hand Surgeon: A Focus on Diabetes, Weight Loss, Rheumatologic, and Antithrombotic Medications. The Journal of Hand Surgery. 2024. DOI: 10.1016/j.jhsa.2024.05.018

[24] Genome-wide transcriptional analysis of tendon tissue-related genes and pathways in the torn rotator cuff of diabetes patients. Journal of Shoulder and Elbow Surgery. 2026. DOI: 10.1016/j.jse.2025.07.012

[25] The HMGB1/RAGE/β-catenin axis mediates aberrant osteogenic-tenogenic differentiation imbalance of tendon stem/progenitor cells in diabetic tendinopathy. Journal of Orthopaedic Surgery and Research. 2025. DOI: 10.1186/s13018-025-06572-8

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.