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合成代谢类固醇、睾酮与肌腱断裂风险

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

Updated Aug 2026
一个小药瓶旁边的分子结构。
睾酮影响肌肉和骨骼；其水平及补充治疗具有值得了解的肌肉骨骼影响。 Kieran Hirpara 4.0

本页面由机器翻译，尚未经临床医生审核。英文版本为权威版本。

您的感受

您可能会注意到肩部疼痛，且在活动时加重。这种不适常在夜间发作，导致难以向患侧侧卧睡眠。您可能会发现难以将手伸到背后扣上胸罩或把衬衫塞进裤子里。提举物体或抬起手臂等简单任务也可能变得困难。

您的外科医生在评估这些症状时会考虑您的激素状况。睾酮水平低与关节磨损性关节炎风险增加有关。随着软骨退化，这种情况会导致僵硬和疼痛。维持最佳激素水平可能有助于保护关节健康，但激素缺乏会增加受伤或再次受伤的风险。

如果您被处方使用睾酮，请注意，它与肩袖撕裂风险增加相关。肩袖是一组稳定肩部的肌肉和肌腱。如果发生撕裂，您可能会经历突然的无力或疼痛。此外，后续需要进行修复手术以修复这些撕裂的风险也增加了。

在某些情况下，睾酮使用与全肩关节置换术后因感染导致的再次手术风险增加有关。全肩关节置换术是一种用人工部件替换受损关节表面的手术。您可能面临该手术后任何类型再次手术的风险增加。需要进一步研究以了解睾酮为何会增加肩关节置换术后需要再次手术的确切原因。

如果您正在使用合成代谢类固醇，您的外科医生应与讨论您的内分泌病史。合成代谢类固醇是与男性性激素睾酮类似的合成物质。其使用可能导致胸大肌断裂，即大块胸部肌肉的撕裂。这种损伤通常会引起肩部前方剧烈疼痛和瘀伤。

虽然在胸大肌断裂恢复期间继续使用合成代谢类固醇似乎不会对功能恢复产生负面影响，但仍建议谨慎。临床医生应审慎地处方睾酮替代疗法。这意味着要仔细权衡您独特情况下的获益与风险。您的外科医生会就这些风险对您进行咨询，以帮助您就您的护理做出明智的决定。

实际发生的情况

体内的睾酮水平就像关节和肌腱健康的调光开关。存在一个特定的阈值，当水平过低或过高时，都会削弱你的组织。当水平不理想时，覆盖在骨端的光滑涂层——称为软骨——可能会更快磨损。这种磨损性关节炎会减少关节的缓冲作用，使其更容易受损。

你的肌腱是连接肌肉和骨骼的纤维粗绳。在某些情况下，睾酮的使用与这些“绳索”撕裂的风险增加有关。例如，使用合成代谢类固醇的健美运动员出现了更多的大胸肌断裂。同样，被处方睾酮的患者面临更高的肩袖撕裂风险。这些撕裂发生是因为组织结构发生变化，使其承受应力的能力降低。

这种风险也延伸至全肩关节置换等大型手术。使用睾酮的男性在首次肩关节置换术后，需要二次手术的机会更高。这通常是由于感染或其他并发症阻碍了正常愈合。你的外科医生需要了解你完整的激素病史，因为低睾酮水平也会增加骨关节炎的风险。保持平衡的水平对于保持关节强壮和稳定至关重要。

虽然手术前短期使用睾酮可能有助于骨密度和身体成分，但长期使用或高剂量使用会带来风险。它可能导致翻修手术或感染，从而使你的恢复过程复杂化。你的外科医生将在决定任何激素治疗之前评估你独特的风险状况。了解这些联系有助于你和医疗团队在治疗和恢复期间保护你的关节。

预期情况

您的外科医生会将您的激素健康状况作为整体损伤风险的一部分进行评估。睾酮水平与肩部问题之间存在复杂的关联。睾酮水平低下与关节磨损性关节炎风险增加有关。维持健康的睾酮水平可能有助于保持关节强健。然而，使用睾酮或合成代谢类固醇也会改变您的肌腱承受压力的方式。

如果您被处方使用睾酮，您可能面临更高的肩袖肌腱撕裂风险。这一组患者接受修复这些撕裂的后续手术的情况也更多。如果您使用合成代谢类固醇，则存在胸大肌断裂的特定风险。这种情况在健美运动员中最为常见。如果您已经发生过胸大肌断裂，继续使用类固醇似乎不会影响您的功能恢复。

对于接受肩关节置换手术的男性，睾酮使用与风险增加有关。您可能面临更高的因感染而需要再次手术的风险。在初次肩关节置换术后，您可能也面临任何类型再次手术的风险增加。您的外科医生将与您讨论您的内分泌病史。如果您存在睾酮缺乏，他们将就受伤或再次受伤的风险为您提供咨询。

如果您需要睾酮替代疗法，处方时会谨慎处理。目前尚早，不能直接断言其会导致膝关节韧带损伤（如前交叉韧带撕裂）。但您的独特风险状况至关重要。一些研究表明，在手术前后补充睾酮可以改善您的身体成分和骨密度。它还可能改善骨科手术后的临床结果。

关于其他风险（如年轻成年人中风）的数据仍然有限。您的外科医生需要权衡这些益处与肌腱撕裂和再次手术风险增加之间的关系。请如实告知您的类固醇或睾酮使用情况。这有助于您的医疗团队为您的恢复和长期关节健康规划最安全的路径。

Reviewed by Kieran Hirpara · 13 June 2026.

Want the clinical detail? Read the clinician version.

Talk to your treating clinician for advice specific to you.

For an appointment with the CQ Hand + Upper Limb team, ask your GP about a referral or visit www.cqupperlimb.com.

Evidence & references

This is the clinical evidence summary written for health professionals. It is technical, and it lists the research this page was built from. You do not need to read it to understand your treatment or to make a decision about it.

Overview

  • Testosterone replacement therapy is associated with increased odds of surgically treated tendon rupture [1].
  • Testosterone users had a 2.9-fold increased risk of tendon rupture compared to nonusers [2].
  • It is premature to imply causation between testosterone replacement therapy and anterior cruciate ligament injuries based solely on existing results due to confounding variables [3].
  • Clinicians should remain vigilant and prescribe testosterone replacement therapy judiciously with a thorough assessment of each patient's unique risk profile [3].
  • There is a threshold-dependent relationship between testosterone levels and shoulder pathology [4].
  • Hormonal status should be considered in musculoskeletal risk assessment [4].
  • The use of prescription testosterone is associated with an increased likelihood of experiencing a distal biceps tendon injury [5].
  • The use of prescription testosterone is associated with an increased likelihood of subsequently requiring surgical repair for distal biceps tendon injury [5].
  • Patients with prior prescription testosterone exposure have an increased rate of distal biceps tendon injury compared with patients without such exposure [5].
  • Patients with prior prescription testosterone exposure have an increased rate of biceps tendon repair compared with patients without such exposure [5].
  • Surgeons should be more intentional about discussing endocrinologic history with patients [6].
  • Surgeons should counsel patients with testosterone deficiency on the risks for injury or re-injury [6].
  • Testosterone replacement therapy is associated with increased tendon rupture risk in men [7].
  • Testosterone replacement therapy is not associated with increased tendon rupture risk in women [7].
  • The lack of increased tendon rupture risk in women may be due to sex-specific differences in dosing [7].
  • 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 [8].
  • Patients who filled a prescription for testosterone replacement therapy were at increased risk of undergoing surgical repair of the quadriceps tendon [8].
  • Anabolic steroid use may contribute to pectoralis major rupture in body builders [9].
  • Continuation of anabolic steroids during recovery from pectoralis major rupture does not seem to have a negative effect on functional recovery [9].
  • Selective androgen receptor modulator (SARM) use is associated with tendon damage [10].
  • Preoperative testosterone replacement therapy is a potential risk factor for complications after rotator cuff repair [11].
  • Preoperative testosterone replacement therapy is a potential risk factor for reoperation after rotator cuff repair [11].
  • Cessation of testosterone replacement therapy prior to rotator cuff repair should be considered on a patient-specific basis [11].

How It Works

  • It is premature to imply causation between testosterone replacement therapy and ACL injuries based solely on existing results due to confounding variables [3].
  • Clinicians should remain vigilant and prescribe TRT judiciously with a thorough assessment of each patient's unique risk profile [3].
  • Findings suggest a threshold-dependent relationship between testosterone and shoulder pathology [4].
  • The use of prescription testosterone is associated with an increased likelihood of experiencing a distal biceps tendon injury and subsequently requiring surgical repair [5].
  • Patients with prior prescription testosterone exposure have an increased rate of distal biceps tendon injury and biceps tendon repair compared with patients without such exposure [5].
  • 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].
  • TRT is associated with increased tendon rupture risk in men but not women [7].
  • The association between TRT and increased tendon rupture risk in men but not women may be due to sex-specific differences in dosing [7].
  • Testosterone therapy is associated with increased odds of quadriceps tendon injury [8].
  • Anabolic steroids use may contribute to pectoralis major rupture injury [9].
  • SARM use is associated with tendon damage [10].
  • Cessation of TRT prior to rotator cuff repair should be considered on a patient-specific basis [11].
  • Further research is needed to understand the mechanism by which testosterone increases the risk of reoperation after total shoulder arthroplasty [12].
  • Prescription testosterone is associated with increased risk of infection-related and all-cause reoperations after primary total shoulder arthroplasty in male patients [13].
  • Testosterone use is associated with a higher risk of both infection-related and all-cause reoperations after total shoulder arthroplasty [13].
  • There is increased risk of rotator cuff tears (RCTs), rotator cuff repairs (RCRs), and subsequent RCRs in patients prescribed testosterone [14].
  • The observed non-linear relationship between low testosterone levels and osteoarthritis risk suggests that maintaining optimal testosterone levels may be important for joint health [15].

What the Evidence Shows

  • The use of prescription testosterone is associated with an increased likelihood of subsequently requiring surgical repair of the distal biceps tendon [5].
  • TRT is associated with increased tendon rupture risk in men [7].
  • TRT is not associated with increased tendon rupture risk in women [7].
  • The association between TRT and tendon rupture risk may be due to sex-specific differences in dosing [7].
  • Anabolic steroids use may contribute to pectoralis major rupture [9].
  • SARM use is associated with increased muscle mass [10].
  • SARM use is associated with hepatotoxicity [10].
  • SARM use is associated with cardiotoxicity [10].
  • SARM use is associated with androgenic side effects throughout the body [10].
  • Supplemental testosterone increases the risk of reoperation after total shoulder arthroplasty [12].
  • Further research is needed to understand the mechanism by which testosterone increases the risk of reoperation after TSA [12].
  • Prescription testosterone is associated with an increased risk of infection-related reoperations after primary total shoulder arthroplasty in male patients [13].
  • Prescription testosterone is associated with an increased risk of all-cause reoperations after primary total shoulder arthroplasty in male patients [13].
  • There is an increased risk of rotator cuff tears (RCTs) in patients prescribed testosterone [14].
  • There is an increased risk of rotator cuff repairs (RCRs) in patients prescribed testosterone [14].
  • There is an increased risk of subsequent rotator cuff repairs (RCRs) in patients prescribed testosterone [14].
  • Four randomized controlled trials found that testosterone supplementation improved clinical outcomes in orthopaedic surgeries [17].
  • Four randomized controlled trials found that testosterone supplementation improved body composition in orthopaedic surgeries [17].
  • Four randomized controlled trials found that testosterone supplementation improved bone mineral density (BMD) in orthopaedic surgeries [17].
  • Evidence regarding orthopaedic perioperative use of testosterone replacement therapy is heterogeneous [17].
  • 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 [18].
  • Injectable TRT use within 1 year of primary ACL reconstruction is associated with a 3.3-fold increase in ACLR revision rates with 2 years of follow-up [19].
  • Data regarding the safety of testosterone supplementation and its association with stroke in young adults remains limited and underexplored [20].

Practical Considerations

  • The association between testosterone replacement therapy and increased tendon rupture risk in men but not women may be due to sex-specific differences in dosing [7].
  • Anabolic steroid use may contribute to pectoralis major rupture [9].
  • Prescription testosterone is associated with increased risk of infection-related reoperations after primary total shoulder arthroplasty in male patients [13].
  • Prescription testosterone is associated with increased risk of all-cause reoperations after primary total shoulder arthroplasty in male patients [13].
  • Authors suggest future areas of investigation that may provide guidance on how surgeons can mitigate adverse risks while optimizing benefits of testosterone replacement therapy in the orthopaedic patient [16].

Key Evidence

  • [L3] Testosterone replacement therapy is associated with increased odds of surgically treated tendon rupture. [1] (10.1177/2325967125s00009)
  • [L3] Testosterone users had a 2.9-fold increased risk of tendon rupture compared to nonusers. [2] (10.1177/2325967124s00339)
  • [L5] It is premature to imply causation between testosterone replacement therapy and ACL injuries based solely on existing results due to confounding variables; clinicians should remain vigilant and prescribe TRT judiciously with a thorough assessment of each patient's unique risk profile. [3] (10.1016/j.arthro.2024.11.086)
  • [L3] These findings suggest a threshold-dependent relationship between testosterone and shoulder pathology and highlight the need to consider hormonal status in musculoskeletal risk assessment. [4] (10.1016/j.jse.2026.01.012)
  • [L3] Patients with prior prescription testosterone exposure have an increased rate of distal biceps tendon injury and biceps tendon repair compared with patients without such exposure. [5] (10.1016/j.jse.2023.02.122)
  • [L5] The author advises surgeons to be more intentional about discussing endocrinologic history with patients and counseling those with testosterone deficiency on the risks for injury or re-injury. [6] (10.1097/corr.0000000000002835)
  • [L3] TRT is associated with increased tendon rupture risk in men but not women, potentially due to sex-specific differences in dosing. [7] (10.1177/23259671261430731)
  • [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. [8] (10.1097/corr.0000000000002744)
  • [L4] Anabolic steroids use may contribute to the injury, but continuation during recovery does not seem to have a negative effect on functional recovery. [9] (10.1186/s12891-023-06382-1)
  • [L4] SARM use is associated with increased muscle mass, hepatotoxicity, cardiotoxicity, tendon damage, and androgenic side effects throughout the body. [10] (10.1177/03635465241252435)
  • [L3] Cessation of TRT prior to rotator cuff repair should be considered on a patient-specific basis. [11] (10.1016/j.jseint.2025.10.002)
  • [L3] Further research is needed to understand the mechanism by how testosterone increases the risk of reoperation after TSA. [12] (10.1177/2325967124s00118)
  • [L2] Testosterone use is associated with a higher risk of both infection-related and all-cause reoperations after total shoulder arthroplasty. [13] (10.1016/j.jseint.2026.101634)
  • [L3] There is increased risk of RCTs, RCRs, and subsequent RCRs in patients prescribed testosterone. [14] (10.5435/jaaos-d-22-00554)
  • [L3] The observed non-linear relationship suggests that maintaining optimal testosterone levels may be important for joint health. [15] (10.1186/s12891-024-08272-6)
  • [L5] The authors suggest future areas of investigation that may provide guidance on how surgeons can mitigate adverse risks while optimizing benefits of TRT in the orthopaedic patient. [16] (10.5435/jaaos-d-23-00348)
  • [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. [17] (10.1016/j.arthro.2024.12.026)
  • [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. [18] (10.1016/j.arthro.2024.10.032)
  • [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. [19] (10.1177/23259671251399845)
  • [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. [20] (10.3389/fneur.2024.1422931)

References

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

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

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

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

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

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

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

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

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

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

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

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

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

[14] 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

[15] 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

[16] Testosterone Replacement Therapy in Orthopaedic Surgery. Journal of the American Academy of Orthopaedic Surgeons. 2024. DOI: 10.5435/jaaos-d-23-00348

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

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

[19] 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

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

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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.