Skip to content

Patients › Rehabilitation

肱骨内上髁炎（高尔夫球肘）

PDF Evidence

基于负荷的康复方案用于高尔夫球肘（屈肌-旋前肌腱病），包括尺神经筛查、离心反向泰勒扭转负荷训练，以及为少数需要手术的患者提供独立的术后康复路径。

肘关节内侧示意图，显示屈肌-旋前肌腱附着于内上髁，尺神经从其后方经过。
高尔夫球肘：屈肌-旋前肌腱在其附着于肘部内侧骨性突起（内上髁）处发生磨损。尺神经在其后方走行。 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。

本页面旨在指导您在基兰·希尔帕拉医生（Dr Kieran Hirpara）于洛克汉普顿 Mater 私人医院（Mater Private Hospital Rockhampton）的诊疗下，从内侧上髁炎（俗称高尔夫球肘）中康复。大多数人无需手术即可完全康复，治疗的核心是循序渐进的负荷训练计划，而非休息。康复从您的家庭锻炼计划开始，随后是专为您的物理治疗师或手部治疗师制定的结构化临床方案；请在首次就诊时携带此页面或其 PDF 文件，以确保您的康复过程协调一致。您的治疗师可能会根据您的康复进展调整该计划。

如果您在小指和无名指出现针刺感、麻木或无力，请告知诊室或您的治疗师；尺神经走行于肘内侧后方，有时需要单独处理。

预期情况

高尔夫球肘是肘关节内侧肌腱的磨损（退行性）问题：即屈肌-旋前肌腱，它们负责屈腕和使手掌向下，附着于被称为内上髁的骨性突起处。尽管旧称“外上髁炎”，但这实际上并非炎症；肌腱因过度负荷而变得薄弱且结构紊乱。因此，现代治疗并非休息和抗炎药物，而是一个逐步负荷肌腱以恢复其全部力量的计划。

恢复需要耐心。高尔夫球肘通常具有自限性，但完全缓解可能需要 6 到 18 个月。好消息是，绝大多数患者通过良好的保守治疗计划即可康复，且无需手术。只有在至少六个月的高质量治疗后仍无效时，才会考虑手术。

内侧肘关节与外侧（网球）肘关节的一个不同之处在于尺神经（即“麻筋”神经），它走行于内上髁后方紧邻的沟槽内。约半数高尔夫球肘患者同时伴有该神经的刺激症状，因此您的治疗师会在每次就诊时检查该神经，并可能添加特定的神经滑动练习。

注意事项与限制

建议：

  • 在舒适范围内，继续使用患肢进行日常活动。
  • 对诱发症状的活动进行调整，而非完全停止。
  • 若有帮助，在进行可能加重症状的活动时，可在前臂肌肉处佩戴反作用力护具。
  • 规律进行拉伸和负荷训练；坚持比强度更重要。

不建议：

  • 不要完全休息肘部或将其打石膏固定；肌腱需要适度的负荷才能愈合。
  • 早期避免进行重度外翻负荷活动：如高尔夫、投掷（尤其是引臂和加速阶段）、游泳和球拍类运动，直至力量恢复。
  • 不要将任何练习推进至剧烈疼痛，也不要将神经滑动练习推进至刺痛或麻木感。
  • 如果尺神经症状（小指和环指的刺痛或麻木）加重，请退阶并寻求复查，然后再增加负荷。

您的锻炼

这些是您讲义中的锻炼项目。请按照 Hirpara 医生和治疗师的指导开始锻炼。在早期阶段，重点是缓解疼痛、进行轻柔的活动以及等长收缩练习；随着您的改善，将加入离心反向泰勒扭转（eccentric reverse Tyler twist）和握力强化训练。尺神经滑动练习被纳入其中，因为该神经在内肘部位常受累；请保持动作轻柔。

您的临床方案

本页面其余部分为临床康复方案。此部分应提供给您的物理治疗师或手治疗师。该方案基于达标标准而非单纯的时间节点：各阶段之间的进展取决于是否达成所列目标，而非仅仅依据日历时间。每次就诊时均筛查尺神经（Tinel征、半脱位），因为约50%–60%的内侧病例伴有尺神经症状，这是保守治疗失败的主要原因。

以下提供两条路径：非手术方案（一线方案，适用于绝大多数患者）和术后方案（适用于少数保守治疗失败后接受手术的患者）。

非手术路径

第一阶段：急性期/疼痛控制（0–2周）

目标： 控制疼痛；恢复完全无负重的活动范围。

  • 相对休息和活动调整：以疼痛为限制因素；避免固定。调整高尔夫、投掷、游泳、球拍类运动、举重和重复性抓握活动。
  • 可选的加压护具覆盖共同屈肌群；若急性疼痛明显，可使用腕部夹板。
  • 疼痛控制辅助措施：冰敷、软组织手法/IASTM（冲击波或筋膜松解）、轻柔的无痛主动活动范围（AROM）、神经滑动练习。
  • 筛查尺神经（Tinel征、半脱位）。
  • 进阶标准： 无痛的完全无负重主动活动范围；能够独立执行家庭锻炼计划。

第二阶段：亚急性期/早期负荷（2–4周）

目标： 开始屈肌-旋前肌群负荷；处理近端动力链。

  • 等长腕屈肌和旋前肌负荷（轻量）。
  • 在肘关节屈曲90°位对腕屈肌进行渐进性拉伸。
  • 近端动力链： 肩胛稳定肌（前锯肌、中/下斜方肌）和肩袖肌群，对于投掷运动员至关重要，因为其内侧肘部过载是由 valgus（外翻）应力驱动的。
  • 进阶标准： 维持完全活动范围；耐受90°拉伸位；达到对侧力量的约70%。

第三阶段：强化/回归（4–6周及以上）

目标： 恢复负荷耐受性，回归功能和运动。

  • 腕屈曲和前臂旋前的离心-向心负荷：内侧版的Tyler twist是“反向Tyler twist”（在FlexBar上进行腕屈曲离心训练）。推荐联合离心-向心负荷；等长收缩在早期镇痛方面仍有价值。
  • 伴随运动的关节松动术；渐进性拉伸逐渐过渡至肘关节伸直位。
  • 握力强化，随后进行专项运动负荷；对于投掷运动员，实施分级投掷计划；增强式训练（Plyometrics）放在最后。
  • 随着肘部症状消失，逐步停用加压护具；检查并调整器材和技术动作。
  • 回归运动标准： 达到对侧力量的约90%，无痛功能，具备自我管理能力。

术后路径（屈肌-旋前肌清创术 ± 修复术 ± 尺神经手术）

手术仅适用于保守治疗 ≥6 个月失败的患者。开放式 Nirschl 型手术清创病变的屈肌-旋前肌起点，并通常进行修复/重新附着；评估并保护尺神经，在部分病例中同期进行减压或前移术。

第一阶段：保护期（0–2 周）

  • 后侧长臂夹板（肘部 + 腕部）固定 10–14 天；外出时使用悬臂带。
  • 抬高患肢并控制水肿；手指/肌腱滑动主动活动度（AROM）训练；肩关节主动活动度训练；轻柔的颈椎主动活动度训练。
  • 注意事项： 禁止提举、推、拉或用力抓握：以保护修复部位。

第二阶段：活动度恢复（2–6 周）

  • 约 2 周复诊：拆除缝线；全天佩戴腕部中立位支具（洗漱时取下）；肘部使用 Tubigrip 弹性绷带以控制肿胀。
  • 开始肘关节主动活动度（AROM）屈曲/伸展（2–4 周），随后进行腕关节 4 向主动活动度 + 前臂旋转以及手指/拇指主动活动度训练（4–6 周）。
  • 第 4–6 周引入尺神经滑动练习（这是针对内侧的特有添加内容）。
  • 肩胛骨稳定训练（抗重力）。6 周前不进行抗阻力量训练。

第三阶段：力量强化（6–12 周）

  • 根据耐受情况逐渐停用支具（早期夜间可能仍需佩戴）。
  • 渐进式抗阻力量训练腕部及前臂。早期避免抗阻旋后/旋前；开始提举时保持旋后/中立位，约第 9 周开始进行轻度旋前位提举。

第四阶段：恢复活动/运动（12–16+ 周）

  • 根据耐受情况在所有前臂位置下增加提举负荷；约 12–16 周完全恢复活动；运动员需进行专项运动/间歇性投掷训练计划。完全恢复通常需要 3–6 个月。

尺神经注意事项： 若进行了前移术，早期限制肘关节屈曲终末端活动，并逐步增加神经滑动幅度。若尺神经症状持续或加重，在增加负荷前需由外科医生复查。

重返工作与活动

您恢复的速度取决于您所处的康复路径以及您工作和运动的需求。

非手术治疗。 您通常在整个过程中可以继续工作并保持活跃，通过调整那些会诱发肘部疼痛的任务，而不是完全停止活动。在强化阶段，当您的力量恢复到健侧的约 90% 且功能无痛时，可逐步恢复高尔夫、投掷类运动、游泳和球拍类运动。由于高尔夫球肘具有自限性，尽管日常功能会较早改善，但完全恢复可能需要 6 到 18 个月。

术后。 早期开始轻度、受限的使用，但会推迟重体力劳动和抓握，以保护修复部位。大多数人约在 12 到 16 周时恢复全部活动，完全康复通常需要 3 到 6 个月。投掷类运动员在重返比赛前需遵循渐进式间隔投掷计划。

驾驶：在佩戴支具或悬吊带期间，或肘部疼痛严重到无法安全控制车辆时，应避免驾驶。在复查确认您已取下支具并能舒适地活动手臂后，可恢复驾驶。

协议之后

本协议与诊所的一般康复建议并行；请参阅术后疼痛管理、伤口护理和手部治疗基础。高尔夫球肘与网球肘（其外侧肘部对应病症）共享基于负荷的方法；如果您需要相应的肱骨外上髁炎指导，请咨询您的治疗师。您的持续康复由您的物理治疗师或手部治疗师根据您的肘部进展情况进行个体化指导。

Reviewed by Dr Kieran Hirpara · 18 June 2026.

Talk to your treating clinician for advice specific to you.

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

Evidence & references

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

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

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

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

A. NON-OPERATIVE REHABILITATION (phased)

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

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

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

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

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

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

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

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

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

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

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

C. PHASED TIMELINE SUMMARY

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

D. KEY CONTROVERSIES / EVIDENCE QUALITY

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

E. EVIDENCE STRENGTH FLAGS (summary)

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

CITATIONS

RAG corpus (180,000+ Orthopaedic articles)

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

Published protocols (URLs)

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.