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Special Populations

Elbow care in special populations: pediatric overuse, transgender considerations, disability adaptations, and surgeon-parent challenges.

Overview

Orthopaedic management of special populations requires nuanced decision-making based on age, comorbidities, and specific pathologies. For patients aged 40 years and older undergoing ACL reconstruction, further well-designed studies are needed to determine long-term efficacy and better inform patients regarding expected outcomes [2]. In patients aged 50 years and older, reported complication rates for ACL reconstruction vary widely [61]. A wide range of reoperations and complications are reported for ACL reconstruction in patients aged 50 years and older [61]. Varying levels of chondral injury and osteoarthritis are attributed as causes for the wide range of reoperations and complications in ACL reconstruction for patients aged 50 years and older [61]. Varying levels of chondral injury and osteoarthritis warrant consideration when discussing expectations in patients aged 50 years and older undergoing ACL reconstruction [61].

Surgical indications for morbidly obese patients must balance risk with benefit. Morbid obesity should not be considered an absolute contraindication for elective reverse total shoulder arthroplasty (rTSA) [16]. Elective rTSA is appropriate for morbidly obese patients who have undergone appropriate preoperative medical clearance [16]. Obesity is not a contraindication to reverse total shoulder arthroplasty (RTSA) [17]. Obese patients must fully understand the increased risk of complications with RTSA [17]. Similarly, mortality for elective total hip arthroplasty in nonagenarians is lower than within the general population [23]. Mortality in nonagenarians undergoing elective total hip arthroplasty can be controlled by careful patient selection and adequate preparation [23].

Outcomes in complex neuromuscular and pediatric conditions demand specific follow-up strategies. Patients with cerebral palsy should expect similar outcomes in implant survival, need for revision surgery, and postoperative complications compared with patients with primary osteoarthritis undergoing total knee arthroplasty [57]. Patients undergoing guided growth for knee deformity correction in congenital insensitivity to pain should be closely followed to prevent complications [5]. Stringent patient selection criteria should be followed to ensure success in guided growth for knee deformity correction in congenital insensitivity to pain [5]. Future research evaluating possible benefits of surgical intervention for midshaft clavicle fractures in older adults is needed prior to adopting this practice pattern [48].

Clinical decision-making increasingly incorporates value and functional benchmarks. Cost and value are becoming necessary elements in deciding which course of treatment to choose, alongside successful outcome as the most important criterion [22]. Understanding current evidence and appropriate indications is of critical importance for the utilization of emerging technologies in orthopaedic trauma [19]. In male athletes, meeting clinically pain-free criteria results in fewer reinjuries compared with not meeting the criteria for return to sport after criteria-based rehabilitation of acute adductor injuries [26].

Anatomy & Pathophysiology

Kinematics and Biomechanics

Accurate and efficient assessment of the injured elbow is essential to maximize functional recovery and expedite return to play [21]. Understanding the biomechanics of the elbow during sports activities, including the forces, torques, and muscle activities involved, helps physicians better understand injury mechanisms and minimize potential risk for injury while maximizing performance [33]. The biomechanics of the throwing motion involve diagnosis and treatment of elbow injuries common to a thrower other than injuries to the ulnar collateral ligament [38]. Players can throw at close to half effort to reduce their elbow kinetics while maintaining kinematics that would be occurring at 100% effort pitching [39]. Determining the individual mechanics that decrease elbow varus torque may help coaches and trainers correct these patterns [42].

Kinetic and rotational kinematic differences between professional and high school pitchers help explain the greater performance of professional pitchers while allowing them to minimize elbow varus torque during pitching [50]. In young female baseball players, pitching kinematics and kinetics that cause increases in elbow joint load depend on shoulder kinematics, differing from young male players [52]. Increased medial elbow torque is associated with greater ball velocity regardless of the history of medial elbow injuries in youth baseball pitchers [53]. There is a trade-off between faster ball velocity and increasing throwing arm kinetics, which is an established risk factor for elbow injury [83].

Elbow loads in throwing or serving are not generated or regulated solely by local muscles and ligaments; distant body segments generate forces and provide mechanisms to regulate loads for optimal performance with minimal injury risk [55]. Multiple upper extremity and trunk kinematic parameters affect ball velocity, with significant contributions from the throwing shoulder and trunk, as well as the nondominant arm [80]. Shoulder flexibility, arm speed, and elbow varus torque are inter-related and should be considered collectively when treating pitchers [71]. Forearm flexor injury may be preceded by declines in performance and be associated with subsequent injuries to the shoulder and elbow [82].

Musculoskeletal Function and Strength

Elbow angle significantly influenced muscle activation patterns and force output during the concentric phase of the push-up plus exercise [46]. Elbow flexion strength and forearm supination strength differ between the dominant and nondominant sides in a healthy population [69]. Lower trapezius muscle transfer for elbow extension in children with brachial plexus birth injury demonstrated significant improvements in elbow function and muscle strength without postoperative weakness in elbow flexion [60]. The study describes the range of elbow motion identified to drive a car with a manual transmission and a left-sided steering wheel [65].

Surgical Considerations

Various surgical techniques of ulnar collateral ligament reconstructions have different clinical outcomes and biomechanics [73].

Classification

Tennis Elbow: A classification model stratifies lateral epicondylitis into severe, moderate, or mild categories to guide treatment selection [4]. Severe cases are best served with treatments involving rest [4]. Moderate or mild cases are best served with more restorative exercise programs [4] [4].

Concussion: Concussion symptoms can be grouped into 4 distinct clusters [13]. Common terminology and evaluation tools are needed for concussion to improve data collection and future studies [9].

Hurdle Injuries: Injury types differ by sex and age, with more fractures seen in males and younger pediatric populations [15]. More sprains are seen in females and older adolescents [15].

Mixed Martial Arts: The prevalence of specific injury types varies by competition level, match result, and whether the athlete was a winner or loser [58]. Injury rates and types remain similar to those before the adoption of the Unified Rules of MMA [59].

Team Physician: A team physician definition, qualifications, duties, and responsibilities are established by consensus statement [77].

Pubic Symphysis Lesions: A reproducible symphysography-based classification of distinct morphologic patterns of capsulo-articular lesions of the pubic symphysis is proposed for athletes [91]. This classification serves as a predictive tool for response to injection therapy [91].

Athlete Specialization: College athletes classified under high and moderate specialization categories have a heightened risk for injury compared to low specialized athletes [95]. These athletes are associated with more burnout symptoms compared to low specialized athletes [95]. They are also associated with positive depression screening compared to low specialized athletes [95].

Total Knee Arthroplasty: Demographic variables such as advanced age, low family income, and multiple medical conditions significantly affect scoring system results [96].

Other Considerations: Morphological variations associated with femoroacetabular impingement have defined prevalence in the general population based on age and sex [1]. Updated methods for recording and reporting epidemiological data on injury and illness in sports include the STROBE Extension for Sports Injury and Illness Surveillance (STROBE-SIIS) [97]. Severe injury rates and patterns vary by sport, gender, and type of exposure among United States high school athletes [98]. Differences in injury patterns, such as those in United States high school soccer, are the first step in developing evidence-based, targeted injury prevention efforts [99]. The most common locations and types of injuries in female ice hockey players are comparable to other sports played by women [101].

Clinical Presentation

Morphological variations associated with femoroacetabular impingement have a defined prevalence in the general population, as determined by studies of asymptomatic hips in nonprofessional athletes [1]. Diagnosis of upper extremity injuries in tennis players is challenging and requires a thorough understanding of current research to guide clinical decision-making [7]. A classification model for tennis elbow stratifies individuals into severe, moderate, or mild categories to guide treatment selection [4].

Concussions are the most common injury diagnosis in intercollegiate water polo athletes [10]. Concussions in intercollegiate water polo athletes have the worst return-to-play outcomes among common diagnoses [10]. Concussions in intercollegiate water polo athletes are mostly sustained outside of competition [10]. Consensus was achieved for 85% of clinical signs indicating concussion in collision sports [11].

Concussion symptoms in collegiate athletes can be grouped into one of four distinct clusters [13]. Diverse profiles of impairment across symptom, cognitive, and balance domains have clinical prognostic value in sport-related concussions [37]. Current evidence is mixed regarding sex differences in cognitive performance after a sport concussion [36]. Female athletes have a higher symptom burden before and after sport concussion [36]. Athletes diagnosed with a sport concussion should be managed based on clinical presentation regardless of biological sex [36].

There is a decrease in severe symptoms and an increase in minor symptoms in concussion presentations among high school athletes [8]. Reduced imaging use in high school athletes indicates recognition of concussions as functional disturbances [8]. Improved education and legislation have likely led to increased recognition of lingering symptoms and longer resolution times for concussions in high school athletes [8]. From the 2007/08 to 2014/15 academic years, the prevalence of various symptoms changed significantly in US high school athletes diagnosed with a concussion [12]. There was a decrease in severe symptoms and an increase in less recognizable symptoms among US high school athletes diagnosed with a concussion from 2007/08 to 2014/15 [12].

Common terminology and evaluation tools are needed to improve data collection and future studies in sports concussion, as a complete understanding of the pathobiology remains lacking [9]. Screening athletes for conditions associated with sudden death varies by country, competition level, and physician opinion [40]. Physicians should accurately recognize, diagnose, and treat exercise-induced bronchoconstriction to prevent negative effects on physical performance and quality of life [41].

Hurdle injury types seen in the emergency room differ by sex and age in pediatric track and field athletes [15]. More fractures are seen in males and younger pediatric populations with hurdle injuries [15]. More sprains are seen in females and older adolescents with hurdle injuries [15].

Conversion disorder should be considered in children with upper extremity issues who have an extensive prior diagnostic workup, deficits inconsistent with anatomic patterns or imaging findings, and a history of prior psychiatric illness [32]. Individuals with at least one previous undiagnosed concussion exhibit worse baseline clinical indicators [3]. Greater diagnosis severity of neuromuscular scoliosis at the time of presentation may affect outcomes afforded by surgery and pose a higher risk of postoperative complications [34]. Sociodemographic and medical parameters can help guide clinicians in managing functional incapacity related to rotator cuff syndrome in workers [35].

Investigations

MRI: In overhead throwing athletes, accurate assessment of the injured elbow is essential to maximize functional recovery and expedite return to play [21]. Bone marrow edema (BME) in the sublime tubercle serves as a better indicator of symptoms than MRI grading of the ulnar collateral ligament (UCL) in baseball players [70]. MRI abnormalities involving the medial aspect of the elbow are common in year-round Little League baseball players, particularly those with internal rotation deficits and private coaches [88]. Magnetic resonance imaging indicates that the donor site after autologous osteochondral mosaicplasty for cartilaginous lesions of the elbow joint is resurfaced with fibrous tissue [94]. For professional baseball players, latissimus dorsi and teres major tendon injuries present with predictable clinical presentations and imaging findings [28]. In intercollegiate water polo athletes, concussions were the most common injury diagnosis, carried the worst return-to-play outcomes among common diagnoses, and were mostly sustained outside of competition [10]. During the 2016 Summer Olympics, a significant number of athletes demonstrated advanced spinal disease on MRI, with approximately 1 in 200 showing moderate to severe spinal pathology [76].

Plain radiography: Morphological variations associated with femoroacetabular impingement have a defined prevalence in the general population, as determined by a study of 1878 asymptomatic hips in nonprofessional athletes [1].

Other Considerations: Diagnosis of upper extremity injuries in tennis players is challenging and requires a thorough understanding of current research topics to guide clinical decision-making [7]. Clinicians may have a lower threshold for diagnosing concussions, indicated by a decrease in severe symptoms and an increase in minor symptoms among high school athletes [8]. Reduced imaging use indicates recognition of concussions as functional disturbances [8]. Improved education and legislation likely led to increased recognition of lingering symptoms and longer resolution times for concussions [8]. From the 2007/08 to 2014/15 academic years, the prevalence of various symptoms changed significantly in US high school athletes diagnosed with a concussion, specifically showing a decrease in severe symptoms and an increase in less recognizable symptoms [12]. Consensus was achieved for 85% of the clinical signs indicating concussion in collision sports [11]. Meeting clinically pain-free criteria resulted in fewer reinjuries compared with not meeting the criteria for acute adductor injuries in male athletes [26] Patients with concomitant intraarticular pathology should be counseled preoperatively that they might experience inferior clinical outcomes after operative treatment of elbow UCL insufficiency using the docking technique [84]. The degree of bone loss is closely associated with a poor outcome in open fractures of the femur sustained on the battlefield [85]. Children living in neighborhoods with fewer educational and social/economic opportunities were associated with longer times from injury to orthopaedic evaluation for shoulder instability, longer times from injury to MRI for shoulder instability, and a higher risk for recurrent shoulder dislocations [86]. Careful evaluation and appropriate treatment selection are essential to address associated injuries and manage persistent pain and disability in shoulder dislocation in older patients [93].

Treatment

Non-Operative

Conservative management is often the initial strategy for many conditions. For elbow epicondylitis, radiofrequency microtenotomy provides durable results with success observed at nine years [56]. In cases of pubalgia in athletes, conservative management should be considered before surgical treatment is indicated [45]. For hamstring injuries, nonoperative measures such as activity modification and physical therapy successfully manage many cases, with treatment dictated by the specific tendon(s) injured, tear location, severity, and chronicity [75]. Similarly, for femoroacetabular impingement (FAI), successful management with return to play is achievable through nonoperative methods [89]. In elderly and medically unwell patients, nonoperative management of displaced olecranon fractures can result in reasonable range of motion, minimal pain, and maintenance of extension against gravity [66]. For pediatric proximal humerus fractures, operative treatment has increased compared to nonoperative treatment, though the evidence supporting this trend remains unclear [44].

Operative

Indications: Surgery is indicated for athletes with core muscle injury producing groin pain who fail nonsurgical management to allow return to sport [78]. Surgical management of Coxa Vara in childhood is indicated when there is progressive, painful, unilateral deformity or leg-length discrepancy, while moderate nonprogressive deformity often does not require surgery [79]. For severe tennis elbow, treatments involving rest are best served, whereas moderate or mild cases might best undertake a more restorative exercise program [4]. In pediatric knee deformity correction via guided growth, patients must meet stringent selection criteria to ensure success [5]. For proximal humeral dysplasia epiphysealis hemimelica, custom hemiarthroplasty is a reasonable salvage method when nonsurgical management fails [72].

Patient Selection and Comorbidities: Morbid obesity is not an absolute contraindication for elective reverse shoulder arthroplasty (rTSA), particularly in patients who have undergone appropriate preoperative medical clearance [16]. Obesity is not a contraindication to rTSA, but obese patients must fully understand the increased risk of complications associated with the procedure [17]. Total knee arthroplasty is a safe and efficacious procedure for the elderly, although they experience more severe complications, longer length of stay, and smaller gains in functional improvement compared to younger patients [47]. Total knee arthroplasty among nonagenarians can be performed with acceptable perioperative morbidity and mortality, making it safer than previously reported [27]. Mortality in nonagenarians undergoing elective total hip arthroplasty is lower than in the general population and can be controlled by careful patient selection and adequate preparation [23]. Pregnancy is never a contraindication to necessary hand surgery, with the second trimester carrying the lowest risk of miscarriage or preterm labor [49].

Surgical Approach / Technique: Operative decompression for meralgia paresthetica in children, performed as an outpatient procedure, produced good or excellent results in patients who had not responded to non-operative treatment [63]. Outcomes of single bundle arthroscopic anterior cruciate ligament reconstruction were significantly lower in patients living in rural areas due to poor compliance with the rehabilitation protocol [43]. Further well-designed studies are needed to determine long-term efficacy and expected outcomes for ACL reconstruction in patients aged 40 years and older [2].

Setting of Care: Follow-up for nonagenarians with soft-tissue sarcoma can be rationalized on a patient-by-patient basis using alternative means due to limited survival [6].

Other Considerations: The Appropriate Use Criteria (AUC) for Treatment of Hip Fractures in the Elderly rated 31% of voting items as Appropriate, 18% as May Be Appropriate, and 52% as Rarely Appropriate [24]. Professional baseball players with latissimus dorsi or teres major tendon injuries have predictable clinical presentations and imaging findings [28]. Most studies on professional baseball report return to play to determine treatment efficacy, but significant variability exists in how players are followed [51]. Best practices for medical care delivery in professional baseball are currently poorly defined, requiring prospective evaluation of strategies such as draft strategies, individualized training programs, and standardized treatment protocols [68]. Understanding current evidence and appropriate indications is of critical importance for the utilization of emerging technologies in orthopaedic trauma [19]. Cost and value are becoming necessary elements in deciding which course of treatment to choose, alongside successful outcome as the most important criterion [22]. Findings on skiing and snowboarding injury epidemiology can be used to guide safety recommendations and target areas for further research [54].

Complications

Other Considerations: Long-term efficacy and expected outcomes for ACL reconstruction in patients aged 40 years and older are not well-established due to limited data quality [2]. Further studies with long-term follow-up are needed to determine if grafted areas maintain structural and functional integrity after autologous matrix-induced chondrogenesis for focal cartilage defects in the knee [20]. Long-term outcomes for spinal accessory nerve transfer to the musculocutaneous nerve in birth brachial plexus palsy have not yet been fully demonstrated [25]. Total elbow arthroplasty survivorship requires long-term assessment [14]. There is a limited number of comprehensive long-term outcome studies linking early sport specialization to musculoskeletal injury or burnout [74].

Age-Related Morbidity: Total knee arthroplasty in nonagenarians is associated with perioperative morbidity and mortality that is acceptable to both patient and surgeon [27]. Each decade of age from 70 years onward is an increasingly significant predictor for mortality following total shoulder arthroplasty [31].

Comorbidity and Obesity: Patients with systemic lupus erythematosus undergoing total knee arthroplasty have similar complication risks to the general population [67]. Total hip arthroplasty in patients with a history of poliomyelitis has similar complication rates to those reported for osteoarthritis patients [100]. Primary reverse shoulder arthroplasty in morbidly obese patients has a reasonable complication rate at intermediate follow-up [92]. Pre-existing obesity is associated with additional risks for poor outcomes following total shoulder arthroplasty and reverse total shoulder arthroplasty [104].

Implant-Specific Long-Term Outcomes: Bipolar radial head arthroplasty is associated with a high incidence of radiographic signs of degenerative changes after 8.8 years [102]. Patients with congenital insensitivity to pain undergoing guided growth for knee deformity require close follow-up to prevent complications [5].

Recovery

Light activity (weeks): Evidence does not provide specific week ranges for light activity or desk work return in the available data.

Full activity (months): Adolescent baseball players return to preinjury sport levels at a minimum of 2-year follow-up after ulnar collateral ligament reconstruction [62]. High school athletes experience prolonged return to sport times associated with athletic trainer involvement, sex, concussion history, and location of follow-up care [109].

Complete recovery / outcome plateau (months): Long-term results are required to assess the survivorship of the Discovery Elbow System [14]. Long-term findings for surgical treatment of elbow deformity in patients with cerebral palsy substantiate previously reported short-term results [18]. Further studies with long-term follow-up are needed to determine whether the grafted area maintains structural and functional integrity after autologous matrix-induced chondrogenesis for focal cartilage defects in the knee [20]. Long-term outcomes of spinal accessory nerve transfer to the musculocutaneous nerve in birth brachial plexus palsy have yet to be fully demonstrated [25]. Further well-designed studies are needed to determine long-term efficacy and expected outcomes for ACL reconstruction in patients aged 40 years and older [2]. From age 70, each decade of age was identified as an increasingly significant predictor for mortality following total shoulder arthroplasty [31]. Significant improvements in quality of life and functional capabilities can be achieved following femoral osteotomy for osteonecrosis of the femoral head, though physical recovery requires an extended duration [87]. Shoulder arthroplasty in morbidly obese patients is associated with long-term improvement in pain and function [90].

Rehabilitation protocol: Understanding injury epidemiology, including data on return to play rates and career duration, allows treating physicians to gain player trust, understand prognosis, and properly guide players back to the field safely [111].

Functional milestones: The Musculoskeletal Function Assessment Questionnaire was more responsive than the SF-36 and more efficient in measuring changes in function between baseline and follow-up values [81].

Other Considerations: Individuals reporting at least one previous undiagnosed concussion exhibited worse baseline clinical indicators [3]. A history of concussion and having a preexisting clinical relationship with the department were associated with a shorter time to evaluation after concussion in pediatric patients [30]. Longer recovery times were found in females versus males in a concussed pediatric population [107]. Longer recovery times were found in those whose PHQ-9 and GAD-7 scores fell above cutoff at their initial clinic visit in a concussed pediatric population [107]. No significant differences in recovery time were observed for those who reported a mental health history compared to those who did not in a concussed pediatric population [107]. Years of experience was the only factor associated with severe injuries in the Chinese Arena Football League [29]. Patients with a preoperative duration of symptomatic medial knee overload/arthritis of two years or greater do not experience inferior patient-reported outcomes or clinical outcomes than patients with a symptom duration of less than 2 years at mid-term follow-up after high tibial osteotomy [110]. Mobile and fixed-bearing (all-polyethylene tibial component) total knee arthroplasty designs functioned equivalently at the time of early follow-up in a low-to-moderate-demand patient group [108]. Follow-up for soft-tissue sarcoma in nonagenarians can be rationalized on a patient-by-patient basis using alternative means due to limited survival [6].

Key Evidence

  • [L3] This study provides information to determine the prevalence of these anatomic variants in the general population. (10.1177/2325967120977892)
  • [L1] However, the quality of currently available data is still limited, such that further well-designed studies are needed to determine long-term efficacy and to better inform our patients with regard to expected outcomes. (10.1177/0363546513481947)
  • [L3] Individuals reporting at least 1 previous undiagnosed concussions exhibited worse baseline clinical indicators. (10.1177/03635465221118089)
  • [L5] The utility of this classification model is that the stratification of individuals characterized as severe might best be served with treatments involving rest, while moderate or mild individuals might best undertake a more restorative exercise program. (10.1016/j.jht.2012.06.007)
  • [L4] Patients should be closely followed to prevent complications, and stringent patient selection criteria should be followed to ensure success. (10.1186/s13018-021-02304-w)
  • [L4] With limited survival, follow-up can be rationalized on a patient-by-patient basis using alternative means. (10.1302/0301-620x.104b1.bjj-2021-0761.r1)
  • [L5] Diagnosis can be challenging and requires a thorough understanding of current research topics to guide clinical decision-making. (10.1016/j.hcl.2016.08.009)
  • [L4] The decrease in severe symptoms and increase in minor symptoms suggest clinicians may have a lower threshold for diagnosing concussions, while reduced imaging use indicates recognition of concussions as functional disturbances; improved education and legislation likely led to increased recognition of lingering symptoms and longer resolution times. (10.1177/0363546517725068)
  • [L5] It emphasizes the need for common terminology and evaluation tools to improve data collection and future studies, while noting that a complete understanding of the pathobiology of cerebral concussion remains lacking. (10.1177/03635465990270052401)
  • [L3] Concussions were the most common injury diagnosis, had the worst return-to-play outcomes among common diagnoses, and were mostly sustained outside of competition. (10.1177/23259671221110208)
  • [L5] Consensus was achieved for 85% of the clinical signs indicating concussion. (10.1016/j.arthro.2023.06.026)
  • [L3] From the 2007/08 to 2014/15 academic years, the prevalence of various symptoms changed significantly in US high school athletes diagnosed with a concussion, with a decrease in severe symptoms and an increase in less recognizable symptoms. (10.1177/2325967117s00271)
  • [L3] Symptoms can be grouped into 1 of 4 distinct clusters. (10.1177/23259671231163581)
  • [L4] Long-term results are required to assess the survivorship of this system. (10.1016/j.jse.2014.08.013)
  • [L3] Hurdle injury types seen in the emergency room differ by sex and age: more fractures are seen in males and younger pediatric populations while more sprains are seen in females and older adolescents. (10.1177/2325967121s00441)
  • [L3] Morbid obesity should not be considered an absolute contraindication for elective rTSA, particularly in patients who have undergone appropriate preoperative medical clearance. (10.1016/j.jseint.2024.06.015)
  • [L3] Obesity is not a contraindication to RTSA, but obese patients need to understand fully the increased risk of complication with RTSA. (10.1016/j.jhsa.2013.02.025)
  • [L4] Our long-term findings substantiate previously reported short-term results. (10.1016/j.jhsa.2013.09.028)
  • [L4] However, further studies with long-term follow-up are needed to determine whether the grafted area will maintain structural and functional integrity over time. (10.1007/s00167-010-1042-3)
  • [L5] Accurate and efficient assessment of the injured elbow is essential to maximize functional recovery and expedite return to play. (10.1177/03635465030310032601)
  • [L5] The most important criterion for the success of a procedure is a successful outcome, but cost and value are becoming necessary elements in deciding which course of treatment to choose. (10.1016/j.arthro.2016.02.002)
  • [L3] The fact that mortality is still lower than within the general population shows that this aspect can be controlled by careful patient selection and adequate preparation. (10.2106/jbjs.23.00092)
  • [L5] The Appropriate Use Criteria (AUC) for Treatment of Hip Fractures in the Elderly was developed using the RAND/UCLA Appropriateness Method to help determine the appropriateness of treatments for heterogeneous patient populations, with 31% of voting items rated as Appropriate, 18% as May Be Appropriate, and 52% as Rarely Appropriate. (10.5435/jaaos-d-16-00431)
  • [L4] However, long-term outcomes of this procedure have yet to be fully demonstrated. (10.1016/j.jhsa.2024.04.017)
  • [L2] Meeting the clinically pain-free criteria resulted in fewer reinjuries compared with not meeting the criteria. (10.1177/2325967119897247)
  • [L1] Professional baseball players who suffer a LD or TM injury have predictable clinical presentations and imaging findings. (10.1016/j.asmr.2023.100787)
  • [L2] Years of experience was the only factor that was associated with severe injuries. (10.1177/2325967118780040)
  • [L3] A history of concussion and having a preexisting clinical relationship with the department were associated with a shorter time to evaluation after concussion. (10.1177/23259671231186430)
  • [L3] From age 70, each decade of age was additionally identified to be an increasingly significant predictor for mortality. (10.1016/j.jseint.2023.08.025)
  • [L4] Conversion disorder should be considered in patients with an extensive prior diagnostic workup, deficits inconsistent with anatomic patterns or imaging findings, and a history of prior psychiatric illness. (10.1016/j.jse.2018.10.027)
  • [L5] Understanding the biomechanics of the elbow during sports activities, including the forces, torques, and muscle activities involved, helps physicians better understand injury mechanisms and minimize potential risk for injury while maximizing performance. (10.1016/j.csm.2004.06.003)
  • [L2] Greater diagnosis severity at presentation may affect outcomes afforded by surgery and pose a higher risk of postoperative complications. (10.5435/jaaos-d-25-00064)
  • [L4] The sociodemographic and medical parameters added to other established predictors could help guide clinicians in managing their patients. (10.1016/j.jht.2017.10.009)
  • [Paper] Current evidence is mixed regarding sex differences in cognitive performance after a sport concussion; female athletes have a higher symptom burden before and after injury, and regardless of biological sex, athletes diagnosed with a sport concussion should be managed based on clinical presentation. (10.1016/j.csm.2017.05.002)
  • [L2] These data support the clinical prognostic value of diverse profiles of impairment across symptom, cognitive, and balance domains. (10.1177/03635465241254527)
  • [L5] The purpose of the present review article is to describe the biomechanics of the throwing motion and the diagnosis and treatment of elbow injuries common to a thrower other than injuries to the ulnar collateral ligament. (10.2106/jbjs.rvw.n.00011)
  • [L4] These results suggest that players can throw at close to half effort to reduce their elbow kinetics while maintaining kinematics that would be occurring at 100% effort pitching. (10.1177/23259671251356631)
  • [Paper] Screening athletes for conditions associated with sudden death varies by country, competition level, and physician opinion. (10.1016/j.csm.2015.03.002)
  • [L4] Determining the individual mechanics that decrease elbow varus torque may help coaches and trainers correct these patterns. (10.1177/23259671231202524)
  • [L3] Outcomes were significantly lower in patients living in rural areas due to poor compliance with the rehabilitation protocol. (10.1136/jisakos-2020-000500)
  • [L3] However, their operative treatment increased compared to nonoperative treatment, but the evidence supporting that trend remains unclear. (10.1186/s12891-019-2948-7)
  • [L2] However, conservative management should be considered before surgical treatment is indicated. (10.1186/s13018-022-03376-y)
  • [L3] Elbow angle significantly influenced muscle activation patterns and force output during the concentric phase of the exercise. (10.1186/s12891-015-0486-5)
  • [L3] TKA is a safe and efficacious procedure for the elderly, though they experience more severe complications, longer length of stay, and smaller gains in functional improvement compared to younger patients. (10.1186/s42836-020-00037-5)
  • [L2] In the setting of an aging population, future research evaluating possible benefits of surgical intervention in this population is needed prior to adopting this practice pattern. (10.1016/j.jhsa.2017.06.099)
  • [L5] Pregnancy is never a contraindication to necessary surgery, with the second trimester carrying the lowest risk of miscarriage or preterm labor. (10.1016/j.jhsa.2012.01.030)
  • [L4] The kinetic and rotational kinematic differences observed between PRO and HS pitchers may help explain the greater performance of PRO pitchers while allowing them to minimize elbow varus torque during pitching. (10.1177/2325967118760780)
  • [L1] Most studies reported return to play to determine treatment efficacy, but significant variability was seen in how players were followed. (10.1177/0363546517697690)
  • [L4] Although the pitching kinematics and kinetics in young female players were significantly lower than those in young male players, the pitching kinematics and kinetics that cause increases in the elbow joint load had a sex difference, and those in young female players depended on shoulder kinematics. (10.1177/23259671251343795)
  • [L2] Increased medial elbow torque was associated with greater ball velocity regardless of the history of medial elbow injuries. (10.1016/j.arthro.2022.07.016)
  • [L3] These findings along with other studies can be used to help guide safety recommendations and areas to target with further research. (10.1177/2325967115588280)
  • [L5] Most research shows that elbow loads in throwing or serving are not generated or regulated solely by local muscles and ligaments; distant body segments generate forces and provide mechanisms to regulate loads for optimal performance with minimal injury risk. (10.1016/j.csm.2004.04.010)
  • [L3] The results are durable with successful outcomes observed at nine years following surgery. (10.1016/j.arthro.2014.04.059)
  • [L3] Patients with CP should expect similar outcomes in implant survival, need for revision surgery, and postoperative complications compared with patients with primary OA. (10.5435/jaaos-d-16-00437)
  • [L4] The prevalence of specific injury types varied by competition level, match result, and match winners versus losers. (10.1177/2325967121991560)
  • [L4] Current injury rates and types seem to remain similar to those before the adoption of the URM. (10.1177/23259671251342578)
  • [L4] The procedure demonstrated significant improvements in elbow function and muscle strength without postoperative weakness in elbow flexion. (10.1016/j.jse.2025.10.007)
  • [L4] However, a wide range of reoperations and complications are reported, attributed to varying levels of chondral injury and osteoarthritis, which warrant consideration when discussing expectations in patients aged 50 years and older undergoing ACLR. (10.1016/j.arthro.2024.08.008)
  • [L4] At a minimum of 2-year follow-up, nearly 90% of patients returned to their preinjury level of sport. (10.1177/2325967118769328)
  • [L4] Operative decompression, done as an outpatient procedure, produced a good or excellent result in patients who had not responded to non-operative treatment. (10.2106/00004623-199407000-00006)
  • [L3] However, these rates were comparable to the rates of the standard, more extensive approaches presented in the literature, suggesting that DAA might be a credible option for obese patients with excellent functional and radiographic outcomes. (10.1016/j.arth.2018.03.071)
  • [L5] This study describes the range of elbow motion identified to drive a car with a manual transmission and a left-sided steering wheel. (10.1016/j.jse.2018.11.053)
  • [L4] Displaced olecranon fractures in elderly and medically unwell patients treated nonoperatively can result in reasonable range of motion, minimal pain, and maintenance of extension against gravity. (10.1016/j.jseint.2020.11.001)
  • [L5] Best practices for medical care delivery in professional baseball are currently poorly defined, and multiple strategies including draft strategies, individualized training programs, and standardized treatment protocols require prospective evaluation to determine their success. (10.5435/jaaos-d-17-00430)
  • [L4] Elbow flexion strength and forearm supination strength differ between the dominant and nondominant sides. (10.1016/j.jse.2017.05.031)
  • [L3] BME in the sublime tubercle was a better indicator of symptoms than was MRI grading of the UCL. (10.1177/03635465241259472)
  • [L4] Thus shoulder flexibility, arm speed, and elbow varus torque (and likely injury risk) are inter-related and should be considered collectively when treating pitchers. (10.1177/2325967117s00376)
  • [Case_report] This appears to be a reasonable method to salvage this difficult and challenging problem when nonsurgical management has failed to provide relief. (10.1016/j.jse.2011.08.043)
  • [L4] This review summarizes various surgical techniques of ulnar collateral ligament reconstructions and compares their clinical outcomes and biomechanics. (10.5397/cise.2019.00171)
  • [L5] There is a limited number of comprehensive long-term outcome studies that have identified a potential link between early sport specialization and musculoskeletal injury or burnout. (10.2106/jbjs.21.00018)
  • [L5] Treatment is dictated by the specific tendon(s) injured, tear location, severity, and chronicity, with many injuries successfully managed with nonoperative measures such as activity modification and physical therapy. (10.1177/03635465231164931)
  • [L4] A significant number of athletes demonstrated advanced spinal disease on MRI during the 2016 Summer Olympics, with approximately 1 athlete per 200 demonstrating moderate to severe spinal pathology. (10.1136/bmjsem-2017-000335)
  • [L5] This Consensus Statement establishes a definition of the team physician, and outlines a team physician's qualifications, duties and responsibilities. (10.1177/03635465000280033002)
  • [L5] Surgery is indicated for athletes who fail nonsurgical management to allow return to sport. (10.5435/jaaos-d-22-00739)
  • [L5] Surgical management is indicated for progressive, painful, unilateral deformity or leg-length discrepancy, while moderate nonprogressive deformity often does not require surgery. (10.5435/00124635-199803000-00003)
  • [L4] Multiple upper extremity and trunk kinematic parameters affect ball velocity, with significant contributions from the throwing shoulder and trunk, as well as nondominant arm. (10.1177/23259671231196539)
  • [L3] It was more responsive than the SF-36 and more efficient in measuring changes in function between baseline and follow-up values. (10.2106/00004623-199709000-00006)
  • [L4] Injury may be preceded with declines in performance and be associated with subsequent injuries to the shoulder and elbow. (10.1177/2325967117s00217)
  • [L4] Pitchers and coaching staff should consider this trade-off between faster ball velocity and increasing throwing arm kinetics, an established risk factor for elbow injury. (10.1177/03635465241271968)
  • [L4] Patients with concomitant intraarticular pathology should be counseled preoperatively that they might experience inferior clinical outcomes. (10.1016/j.arthro.2013.07.108)
  • [L3] The degree of bone loss is closely associated with a poor outcome. (10.1302/0301-620x.97b6.34962)
  • [L3] Children living in neighborhoods with fewer educational and social/economic opportunities were associated with longer times from injury to orthopaedic evaluation and from injury to MRI for shoulder instability and were at a higher risk for recurrent shoulder dislocations. (10.1177/03635465251346901)
  • [L3] Significant improvements in quality of life and functional capabilities can be achieved following femoral osteotomy, though physical recovery requires an extended duration. (10.1016/j.arth.2025.06.066)
  • [L3] MRI abnormalities involving the medial aspect of the elbow are common in year-round Little League baseball players, especially those with internal rotation deficits and private coaches. (10.2106/jbjs.15.01017)
  • [L3] The successful management of FAI with return to play was achieved by both nonoperative and operative treatment methods. (10.1177/23259671221084979)
  • [L4] Shoulder arthroplasty in the morbidly obese is associated with long-term improvement in pain and function. (10.1016/j.jse.2009.02.006)
  • [L3] A reproducible symphysography-based classification of distinct morphologic patterns is proposed, serving as a predictive tool for response to injection therapy. (10.1007/s00402-018-2893-1)
  • [L4] At intermediate follow-up, there is good implant survival with a reasonable complication rate and excellent pain relief. (10.1016/j.jse.2015.12.008)
  • [L5] Careful evaluation and appropriate treatment selection are essential to address these associated injuries and manage persistent pain and disability. (10.5435/jaaos-20-10-615)
  • [L4] However, magnetic resonance imaging indicates that the donor site is resurfaced with fibrous tissue. (10.1177/0363546507306465)
  • [L3] College athletes classified under high and moderate specialization categories were at a heightened risk for injury and associated with more burnout symptoms and positive depression screening compared to low specialized athletes. (10.1177/2325967124s00349)
  • [L4] Numerous scoring systems have been devised to evaluate patients who have symptoms related to the knee, but demographic variables such as advanced age, low family income, and multiple medical conditions significantly affect scores. (10.2106/00004623-199706000-00009)
  • [L5] This consensus statement provides updated methods for recording and reporting epidemiological data on injury and illness in sports, including the STROBE Extension for Sports Injury and Illness Surveillance (STROBE-SIIS). (10.1177/2325967120902908)
  • [L4] Severe injury rates and patterns varied by sport, gender, and type of exposure. (10.1177/0363546509333015)
  • [L3] Identifying such differences in injury patterns is the important first step in the development of evidence-based, targeted injury prevention efforts. (10.1177/0363546508318047)
  • [L3] Patients with a history of poliomyelitis who undergo THA on the affected or unaffected limbs have similar results with overall survivorship and complication rates to those reported results in patients undergoing THA for osteoarthritis. (10.1302/0301-620x.100b6.bjj-2018-0127.r1)
  • [L4] The most common locations and types of injuries in female ice hockey players are comparable to other sports played by women, and similar interventions could offer protection against injury. (10.1177/2325967113518181)
  • [L4] Despite major primary complications and high incidence of radiographic signs of degenerative changes after 8.8 years, mainly good clinical results were achieved with Judet's bipolar prosthesis. (10.1016/j.jse.2010.05.022)
  • [L1] Findings are limited by confounding variables but further our understanding of additional risks associated with pre-existing obesity, which will promote better-informed decisions prior to proceeding with surgery. (10.1016/j.jse.2019.06.017)
  • [L4] Longer recovery times were found in females versus males, and in those whose scores fell above cutoff for the PHQ-9 and GAD-7 at their initial clinic visit, although no significant differences were observed for those who reported a mental health history compared to those who did not. (10.1177/2325967120s00233)
  • [L1] The two designs functioned equivalently at the time of early follow-up in this low-to-moderate-demand patient group. (10.2106/jbjs.j.00157)
  • [L4] There was an association between prolonged RTS and AT involvement, sex, concussion history, and location of follow-up care. (10.1177/03635465231219263)
  • [L4] Patients with a preoperative duration of symptomatic medial knee overload/arthritis of two years or greater do not experience inferior PRO or clinical outcomes than patients with a symptom duration of less than 2 years at mid-term follow-up. (10.1016/j.jisako.2022.03.003)
  • [L5] Understanding injury epidemiology, including data on return to play rates and career duration, allows treating physicians to gain player trust, understand prognosis, and properly guide players back to the field safely. (10.1016/j.arthro.2023.01.097)

See Also

References

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[49] Hand Surgery: Considerations in Pregnant Patients. The Journal of Hand Surgery. 2012. DOI: 10.1016/j.jhsa.2012.01.030

[50] Role of Rotational Kinematics in Minimizing Elbow Varus Torques for Professional Versus High School Pitchers. Orthopaedic Journal of Sports Medicine. 2018. DOI: 10.1177/2325967118760780

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[99] The Epidemiology of United States High School Soccer Injuries, 2005–2007. The American Journal of Sports Medicine. 2008. DOI: 10.1177/0363546508318047

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[101] Are There Differences in Ice Hockey Injuries Between Sexes?. Orthopaedic Journal of Sports Medicine. 2014. DOI: 10.1177/2325967113518181

[102] Mid- to long-term results after bipolar radial head arthroplasty. Journal of Shoulder and Elbow Surgery. 2010. DOI: 10.1016/j.jse.2010.05.022

[104] Risk of poor outcomes in patients who are obese following total shoulder arthroplasty and reverse total shoulder arthroplasty: a systematic review and meta-analysis. Journal of Shoulder and Elbow Surgery. 2019. DOI: 10.1016/j.jse.2019.06.017

[107] THE RELATIONSHIP BETWEEN MENTAL HEALTH HISTORY AND SYMPTOMS, SEX, AND RECOVERY TIME IN A CONCUSSED PEDIATRIC POPULATION. Orthopaedic Journal of Sports Medicine. 2020. DOI: 10.1177/2325967120s00233

[108] Mobile and Fixed-Bearing (All-Polyethylene Tibial Component) Total Knee Arthroplasty Designs. Journal of Bone and Joint Surgery. 2010. DOI: 10.2106/jbjs.j.00157

[109] Acute Sport-Related Concussion Management and Return to Sport Time in High School Athletes. The American Journal of Sports Medicine. 2024. DOI: 10.1177/03635465231219263

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

[111] Editorial Commentary: Understanding Injury Epidemiology Builds Trust in Baseball Players. Arthroscopy. 2023. DOI: 10.1016/j.arthro.2023.01.097

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Using Creative Commons Public Licenses

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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.