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Testosterone, Anabolic Steroids and Musculoskeletal Health

How testosterone, testosterone replacement therapy and anabolic steroids affect tendons, joints, bone and surgical outcomes — including the risks of TRT and the effects of anabolic-androgenic steroid use.

30 citationsUpdated Sep 2026

For patients: a plain-language version of this topic is available. See the patient guide.

Overview

Testosterone and anabolic agents exert a complex, bidirectional influence on musculoskeletal integrity, with hypogonadal status identified as having a detrimental effect on the system [15]. Epidemiological data indicate that low testosterone levels correlate with a non-linear relationship to osteoarthritis risk [7], while a bidirectional Mendelian randomized study identifies bioavailable testosterone as a causal risk factor for the condition [9]. Conversely, the use of anabolic androgenic steroids also appears to have a detrimental effect on musculoskeletal health [15]. In the perioperative setting, hypogonadal status should be considered in the management of patients undergoing total joint arthroplasty [13]. Four randomized controlled trials demonstrate that perioperative testosterone supplementation improves clinical outcomes, body composition, and bone mineral density in orthopaedic surgeries [5].

Supplemental testosterone and anabolic steroid use are associated with increased risks of tendon pathology and surgical intervention. Testosterone users face a 2.9-fold increased risk of tendon rupture compared to nonusers [14], with replacement therapy associated with increased odds of surgically treated tendon rupture [12]. Specific injuries include rotator cuff tears and repairs [10], quadriceps muscle or tendon injuries within one year of prescription [17], and distal biceps tendon injuries and repairs [16]. Selective androgen receptor modulators are linked to tendon damage despite increased muscle mass [19]. Anabolic steroids may contribute to pectoralis major rupture in bodybuilders, though continuation during recovery does not seem to negatively affect functional recovery [3].

Post-arthroplasty outcomes show that patients prescribed supplemental testosterone have a higher risk of all-cause reoperation and reoperation for infection after total shoulder arthroplasty [2, 20]. A propensity-matched analysis suggests a threshold-dependent relationship between testosterone and shoulder pathology [1]. While current literature fails to present strong evidence for or against the use of anabolic androgenic steroids in orthopaedics [25], it is premature to imply causation between testosterone replacement therapy and ACL injuries due to confounding variables [4]. Selective androgen receptor modulator use is also associated with hepatotoxicity, cardiotoxicity, and androgenic side effects throughout the body [19].

How It Works

Tendon Integrity and Injury Risk

Testosterone replacement therapy (TRT) is associated with a heightened risk of tendon pathology. Patients who filled a prescription for TRT were significantly more likely to experience a quadriceps muscle or tendon injury within one year of filling the prescription [17]. This risk extends to the shoulder, where patients prescribed testosterone face an increased risk of rotator cuff tears, initial rotator cuff repairs, and subsequent rotator cuff repairs [10]. Similarly, prior prescription testosterone exposure correlates with an increased rate of distal biceps tendon injury and biceps tendon repair compared with patients without such exposure [16]. While TRT is associated with increased tendon rupture risk in men but not women, potentially due to sex-specific differences in dosing [22], the underlying mechanism remains distinct from structural degradation. Anabolic steroids did not induce ultrastructural collagen changes that might predispose to tendon rupture in humans [23]. However, selective androgen receptor modulator (SARM) use is associated with tendon damage [19].

Joint Pathology and Osteoarthritis

Bioavailable testosterone levels are identified as a risk factor for osteoarthritis, supporting a causal relationship [9]. The association between testosterone and joint pathology is not linear; a non-linear relationship exists between testosterone levels and the risk of osteoarthritis [7]. Furthermore, testosterone levels and the risk of adhesive capsulitis demonstrate a threshold-dependent relationship [1].

Perioperative and Surgical Outcomes

Testosterone use impacts surgical outcomes across multiple orthopaedic procedures. Testosterone use is associated with a higher risk of both infection-related and all-cause reoperations after total shoulder arthroplasty [20]. In the context of rotator cuff repair, preoperative testosterone replacement therapy is a potential risk factor for complications and reoperation [21]. Consequently, cessation of TRT prior to rotator cuff repair should be considered on a patient-specific basis [21]. Patients on testosterone therapy should be counseled about their increased risk for complications following distal biceps tendon repair [11]. Conversely, four randomized controlled trials found that perioperative testosterone supplementation improved clinical outcomes, body composition, and bone mineral density in orthopaedic surgeries [5].

General Musculoskeletal Effects

Hypogonadism and the use of anabolic steroids seem to have a detrimental effect on the musculoskeletal system [15]. Targeting the androgen/AR axis in the periosteum may provide a novel therapy approach to improve fracture healing [24].

What the Evidence Shows

Tendon and Ligament Injury Risk

Testosterone replacement therapy (TRT) is associated with distinct musculoskeletal risks depending on the anatomical site and surgical context. In the shoulder, patients prescribed supplemental testosterone demonstrated a higher risk of all-cause reoperation and reoperation for infection following total shoulder arthroplasty [2]. Conversely, preoperative TRT use was not linked to increased short-term complications after arthroscopic rotator cuff repair [32], suggesting that cessation of TRT prior to rotator cuff repair should be considered on a patient-specific basis [21].

In the lower extremity, patients who filled a prescription for TRT were much more likely to experience a quadriceps muscle or tendon injury within 1 year of filling their prescription and were at increased risk of undergoing surgical repair of the quadriceps tendon [17]. Regarding the knee, patients prescribed at least 3 months of TRT had a significantly higher incidence of ACL injuries compared to controls within a 2-year follow-up period [30]. Furthermore, injectable TRT use within 1 year of primary ACL reconstruction is associated with a 3.3-fold increase in ACL reconstruction revision rates with 2 years of follow-up [29].

For the upper extremity, patients on testosterone therapy should be counseled about their increased risk for complications following distal biceps tendon repair, and both preoperative risk stratification and optimization should be employed to minimize perioperative risk [11]. Anabolic steroids use may contribute to pectoralis major rupture, but continuation during recovery does not seem to have a negative effect on functional recovery [3].

Joint Health and Osteoarthritis

A bidirectional Mendelian randomized study supported a causal relationship between bioavailable testosterone levels and osteoarthritis, identifying bioavailable testosterone levels as a risk factor for osteoarthritis [9].

Perioperative and Surgical Outcomes

Four randomized controlled trials found that perioperative testosterone supplementation improved clinical outcomes, body composition, and bone mineral density in orthopaedic surgeries [5].

General Musculoskeletal Effects

Hypogonadism and the use of anabolic androgenic steroids seem to have a detrimental effect on the musculoskeletal system [15]. Targeting the androgen/androgen receptor axis in the periosteum may provide a novel therapy approach to improve fracture healing [24].

Practical Considerations

Tendon and Ligament Injury Risk

Testosterone therapy is associated with increased odds of quadriceps tendon injury [6]. While anabolic steroids and selective androgen receptor modulators (SARMs) are often used to enhance performance, their impact on connective tissue integrity is a critical surgical concern. Case reports indicate that SARM users frequently consume these compounds at doses significantly higher than intended, which increases the risk of harmful side effects, including tendon damage [28]. Clinicians must recognize that exogenous androgen exposure alters the risk profile for soft tissue injury, necessitating specific vigilance in patients with a history of such use.

Joint Pathology and Osteoarthritis

Bioavailable testosterone levels are identified as a risk factor for osteoarthritis in a bidirectional Mendelian randomized study [9]. Furthermore, a non-linear relationship between testosterone levels and the risk of osteoarthritis suggests that maintaining optimal testosterone levels may be important for joint health [7]. These findings imply that both deficiency and excess may carry distinct risks for degenerative joint disease. Surgeons should consider hormonal status when evaluating patients with early-onset or atypical osteoarthritis, as endocrine factors may contribute to the pathogenesis and progression of joint pathology.

Perioperative and Surgical Outcomes

Patients on testosterone therapy should be counseled about their increased risk for complications, and both preoperative risk stratification and optimization should be employed to minimize perioperative risk [11]. Conversely, four randomized controlled trials found that perioperative testosterone supplementation improved clinical outcomes, body composition, and BMD [5]. The surgical team must balance the potential benefits of optimized hormonal status against the known risks of exogenous administration. Preoperative assessment should include a detailed review of any ongoing hormone replacement or performance-enhancing drug use to tailor the perioperative management plan appropriately.

Clinical Counseling and Assessment

Hormonal status should be considered in musculoskeletal risk assessment [1]. Surgeons should be more intentional about discussing endocrinologic history with patients and counseling those with testosterone deficiency on the risks for injury or re-injury [6]. Clinicians should remain vigilant and prescribe TRT judiciously with a thorough assessment of each patient's unique risk profile due to confounding variables regarding ACL injury risk [4]. A comprehensive history that includes endocrine function is essential for accurate preoperative planning and postoperative rehabilitation guidance.

Anabolic Steroid and SARM Considerations

Hypogonadism and the use of AASs seem to have a detrimental effect on the musculoskeletal system [15]. SARM use is associated with increased muscle mass, hepatotoxicity, cardiotoxicity, tendon damage, and androgenic side effects throughout the body [19]. Although SARMs may increase lean body mass at low doses, case reports suggest users consume them at much higher doses, increasing the risk of harmful side effects such as liver injury and cardiovascular events [28]. Athlete SARMs abuse is substantial yet unsafe, and public health oversight bodies should advocate for regulation of these gray-market compounds [27]. Surgeons must be aware of these systemic and local adverse effects when evaluating patients with unexplained musculoskeletal complaints.

Systemic Safety and Detection

Data regarding the safety and association of testosterone supplementation with stroke in young adults remains limited and underexplored [8]. The importance of adapting criteria is highlighted if one wishes to increase the sensitivity of exogenous testosterone detection based on carbon isotope ratio profiling [18]. Accurate detection of exogenous hormone use is critical for both clinical management and anti-doping compliance. Surgeons should be aware of the limitations in current detection methods and the ongoing research into the systemic safety profile of testosterone supplementation in younger populations.

Key Evidence

  • [L3] These findings suggest a threshold-dependent relationship between testosterone and shoulder pathology and highlight the need to consider hormonal status in musculoskeletal risk assessment. [1] (10.1016/j.jse.2026.01.012)
  • [L3] Patients prescribed supplemental testosterone had a higher risk of all cause reoperation and reoperation for infection after TSA. [2] (10.1177/2325967124s00118)
  • [L4] Anabolic steroids use may contribute to the injury, but continuation during recovery does not seem to have a negative effect on functional recovery. [3] (10.1186/s12891-023-06382-1)
  • [L5] It is premature to imply causation between testosterone replacement therapy and ACL injuries based solely on existing results due to confounding variables; clinicians should remain vigilant and prescribe TRT judiciously with a thorough assessment of each patient's unique risk profile. [4] (10.1016/j.arthro.2024.11.086)
  • [L2] Although evidence regarding orthopaedic perioperative use of testosterone replacement therapy is heterogeneous, 4 randomized controlled trials reviewed here found that testosterone supplementation improved clinical outcomes, body composition, and BMD. [5] (10.1016/j.arthro.2024.12.026)
  • [L5] The author advises surgeons to be more intentional about discussing endocrinologic history with patients and counseling those with testosterone deficiency on the risks for injury or re-injury. [6] (10.1097/corr.0000000000002835)
  • [L3] The observed non-linear relationship suggests that maintaining optimal testosterone levels may be important for joint health. [7] (10.1186/s12891-024-08272-6)
  • [L4] The review highlights that while testosterone supplementation is increasing, data regarding its safety and association with stroke in young adults remains limited and underexplored. [8] (10.3389/fneur.2024.1422931)
  • [L1] The results of our study supported a causal relationship between bioavailable testosterone levels and OA, identifying bioavailable testosterone levels as a risk factor for OA. [9] (10.1186/s12891-025-08626-8)
  • [L3] There is increased risk of RCTs, RCRs, and subsequent RCRs in patients prescribed testosterone. [10] (10.5435/jaaos-d-22-00554)
  • [L3] Patients on testosterone therapy should be counseled about their increased risk for these complications, and both preoperative risk stratification and optimization should be employed to minimize perioperative risk. [11] (10.1177/2325967126s00288)
  • [L3] Testosterone replacement therapy is associated with increased odds of surgically treated tendon rupture. [12] (10.1177/2325967125s00009)
  • [L3] These findings suggest that hypogonadal status should be considered in the perioperative management of patients undergoing total joint arthroplasty. [13] (10.5435/jaaos-d-25-00190)
  • [L3] Testosterone users had a 2.9-fold increased risk of tendon rupture compared to nonusers. [14] (10.1177/2325967124s00339)
  • [Paper] Hypogonadism and the use of AASs seem to have a detrimental effect on the musculoskeletal system. [15] (10.2106/jbjs.rvw.24.00061)
  • [L3] Patients with prior prescription testosterone exposure have an increased rate of distal biceps tendon injury and biceps tendon repair compared with patients without such exposure. [16] (10.1016/j.jse.2023.02.122)
  • [L3] Patients who filled a prescription for testosterone replacement therapy were much more likely to experience a quadriceps muscle or tendon injury within 1 year of filling their prescription and were at increased risk of undergoing surgical repair of the quadriceps tendon. [17] (10.1097/corr.0000000000002744)
  • [L4] The results obtained with the tested diet groups highlight the importance of adapting the criteria if one wishes to increase the sensitivity of exogenous testosterone detection. [18] (10.1136/bjsm.2009.058669)
  • [L4] SARM use is associated with increased muscle mass, hepatotoxicity, cardiotoxicity, tendon damage, and androgenic side effects throughout the body. [19] (10.1177/03635465241252435)
  • [L2] Testosterone use is associated with a higher risk of both infection-related and all-cause reoperations after total shoulder arthroplasty. [20] (10.1016/j.jseint.2026.101634)
  • [L3] Cessation of TRT prior to rotator cuff repair should be considered on a patient-specific basis. [21] (10.1016/j.jseint.2025.10.002)
  • [L3] TRT is associated with increased tendon rupture risk in men but not women, potentially due to sex-specific differences in dosing. [22] (10.1177/23259671261430731)
  • [L4] The authors conclude that anabolic steroids did not induce ultrastructural collagen changes that might predispose to tendon rupture in humans. [23] (10.1016/s0020-1383(98)00183-1)
  • [L5] Targeting androgen/AR axis in the periosteum may provide a novel therapy approach to improve fracture healing. [24] (10.1038/s41419-022-04595-1)
  • [L4] Current literature fails to present strong evidence for or against the use of AASs in orthopaedics, but there is continuous research on this topic. [25] (10.5435/jaaosglobal-d-21-00156)
  • [L4] Athlete SARMs abuse is substantial yet unsafe, and public health oversight bodies should advocate for regulation of these gray-market compounds. [27] (10.1016/j.jisako.2023.03.427)
  • [L4] Although SARMs may increase lean body mass at low doses, case reports suggest users consume them at much higher doses, increasing the risk of harmful side effects such as liver injury, cardiovascular events, and tendon damage. [28] (10.1177/2325967123s00352)
  • [L3] Injectable TRT use within 1 year of primary ACLR is associated with a 3.3-fold increase in ACLR revision rates with 2 years of follow-up. [29] (10.1177/23259671251399845)
  • [L3] This study found that patients prescribed at least 3 months of TRT had a significantly higher incidence of ACL injuries compared to controls within a 2-year follow-up period. [30] (10.1016/j.arthro.2024.10.032)
  • [L2] Preoperative TRT use was not linked to increased short-term complications after arthroscopic rotator cuff repair. [32] (10.1016/j.jse.2025.12.013)

See Also

  • Osteoarthritis

References

[1] Testosterone levels and risk of adhesive capsulitis: a 1:1 propensity matched analysis. Journal of Shoulder and Elbow Surgery. 2026. DOI: 10.1016/j.jse.2026.01.012

[2] Poster 149: Supplemental Testosterone Increases Risk of Reoperation after Total Shoulder Arthroplasty. Orthopaedic Journal of Sports Medicine. 2024. DOI: 10.1177/2325967124s00118

[3] Pectoralis major rupture in body builders: a case series including anabolic steroid use. BMC Musculoskeletal Disorders. 2023. DOI: 10.1186/s12891-023-06382-1

[4] Editorial Commentary: Testosterone Replacement Therapy and Anterior Cruciate Ligament Injury Risk: Insights and Cautions for Clinical Application. Arthroscopy. 2024. DOI: 10.1016/j.arthro.2024.11.086

[5] Perioperative Testosterone Supplementation Improves Outcomes of Orthopaedic Surgeries: A Systematic Review of Heterogeneous Studies. Arthroscopy. 2024. DOI: 10.1016/j.arthro.2024.12.026

[6] CORR Insights®: Testosterone Therapy Is Associated With Increased Odds of Quadriceps Tendon Injury. Clinical Orthopaedics & Related Research. 2023. DOI: 10.1097/corr.0000000000002835

[7] Correlation between low testosterone levels and the risk of osteoarthritis: a cross-sectional analysis of NHANES data (2011–2016). BMC Musculoskeletal Disorders. 2025. DOI: 10.1186/s12891-024-08272-6

[8] Testosterone supplementation and stroke in young adults: a review of the literature. Frontiers in Neurology. 2024. DOI: 10.3389/fneur.2024.1422931

[9] The causal impact of bioavailable testosterone levels on osteoarthritis: a bidirectional Mendelian randomized study. BMC Musculoskeletal Disorders. 2025. DOI: 10.1186/s12891-025-08626-8

[10] The Relationship Between Testosterone Therapy and Rotator Cuff Tears, Repairs, and Revision Repairs. Journal of the American Academy of Orthopaedic Surgeons. 2023. DOI: 10.5435/jaaos-d-22-00554

[11] Paper 30. Comparative Outcomes of Distal Biceps Tendon Repair in Patients With and Without Testosterone Therapy. Orthopaedic Journal of Sports Medicine. 2026. DOI: 10.1177/2325967126s00288

[12] Testosterone Replacement Therapy Increases Odds of Tendon Ruptures Treated Surgically. Orthopaedic Journal of Sports Medicine. 2025. DOI: 10.1177/2325967125s00009

[13] Testosterone Deficiency and Total Joint Arthroplasty Outcomes—A Large Claims Database Study. Journal of the American Academy of Orthopaedic Surgeons. 2025. DOI: 10.5435/jaaos-d-25-00190

[14] Poster 374: Tendon Tears Among Patients Treated with Exogenous Therapeutic Anabolic Steroids: An Eight Year Retrospective Analysis in a Single Institution. Orthopaedic Journal of Sports Medicine. 2024. DOI: 10.1177/2325967124s00339

[15] Testosterone. JBJS Reviews. 2024. DOI: 10.2106/jbjs.rvw.24.00061

[16] The use of prescription testosterone is associated with an increased likelihood of experiencing a distal biceps tendon injury and subsequently requiring surgical repair. Journal of Shoulder and Elbow Surgery. 2023. DOI: 10.1016/j.jse.2023.02.122

[17] Testosterone Therapy Is Associated With Increased Odds of Quadriceps Tendon Injury. Clinical Orthopaedics & Related Research. 2023. DOI: 10.1097/corr.0000000000002744

[18] Detection of testosterone administration based on the carbon isotope ratio profiling of endogenous steroids: international reference populations of professional soccer players. British Journal of Sports Medicine. 2009. DOI: 10.1136/bjsm.2009.058669

[19] Athlete Selective Androgen Receptor Modulators Abuse: A Systematic Review. The American Journal of Sports Medicine. 2025. DOI: 10.1177/03635465241252435

[20] Prescription testosterone is associated with increased risk of infection-related and all-cause reoperations after primary total shoulder arthroplasty in male patients. JSES International. 2026. DOI: 10.1016/j.jseint.2026.101634

[21] Preoperative testosterone replacement therapy: a potential risk-factor for complications and reoperation after rotator cuff repair. JSES International. 2026. DOI: 10.1016/j.jseint.2025.10.002

[22] Testosterone Therapy and Associated Rates of Tendon Tear and Surgical Repair: A Retrospective Analysis. Orthopaedic Journal of Sports Medicine. 2026. DOI: 10.1177/23259671261430731

[23] Ultrastructural analysis of ruptured tendon from anabolic steroid users. Injury. 1998. DOI: 10.1016/s0020-1383(98)00183-1

[24] Targeted activation of androgen receptor signaling in the periosteum improves bone fracture repair. Cell Death & Disease. 2022. DOI: 10.1038/s41419-022-04595-1

[25] Anabolic Androgenic Steroids in Orthopaedic Surgery: Current Concepts and Clinical Applications. JAAOS: Global Research and Reviews. 2022. DOI: 10.5435/jaaosglobal-d-21-00156

[27] Athlete SARMs Abuse: A Systematic Review. Journal of ISAKOS. 2023. DOI: 10.1016/j.jisako.2023.03.427

[28] Poster 390: Systematic Review of SARMs Abuse in Athletes. Orthopaedic Journal of Sports Medicine. 2023. DOI: 10.1177/2325967123s00352

[29] Injectable Testosterone Replacement Therapy Within 1 Year Before ACL Reconstruction Is Associated With Increased Revision Rates. Orthopaedic Journal of Sports Medicine. 2026. DOI: 10.1177/23259671251399845

[30] Prescription Testosterone Is Associated With an Increased Risk of Anterior Cruciate Ligament Injury. Arthroscopy. 2024. DOI: 10.1016/j.arthro.2024.10.032

[32] Association of preoperative testosterone replacement therapy with postoperative complications following rotator cuff repair. Journal of Shoulder and Elbow Surgery. 2026. DOI: 10.1016/j.jse.2025.12.013

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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.