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Tendinopathies

Lateral & medial epicondylitis: pathophysiology, conservative management, and indications for surgical intervention (debridement, release).

Overview

Lateral elbow tendinopathy lacks a single nonoperative treatment that reliably achieves outstanding results [2]. This therapeutic limitation likely stems from the inclusion of heterogeneous patient groups rather than categorization by disease severity [2]. Numerous treatment options exist for epicondylitis, yet no single universally accepted protocol has emerged [10]. Surgical intervention via complete resection of tendinosis tissue with sparing of normal tissue can lead to durable results at long-term follow-up [15]. Postoperative MRI findings reflect clinical outcomes, with recovered groups showing a 60% improvement in tendinopathy area versus 16% in unrecovered groups [14]. Autologous tenocyte injection provides evidence for midterm durability in the treatment of lateral epicondylitis [4]. Ultrasonic percutaneous tenotomy is an attractive alternative to surgical intervention for definitive treatment of recalcitrant elbow tendinopathy [68]. It is one of the few procedures to demonstrate positive sonographic evidence of a tissue-healing response [68]. Conversely, a prospective, randomized, double-blinded, placebo-controlled trial failed to show additional benefit of surgical excision of the degenerative portion of the ECRB over placebo surgery for chronic tennis elbow [67].

Achilles tendinopathy presents different management challenges. The majority of patients fully recover regarding both symptoms and function when treated with exercise alone [3]. However, there is no clear consensus on what defines a chronic Achilles disorder [5]. Furthermore, there is no uniform classification and treatment scheme for chronic Achilles disorders [5].

Chronic patellar tendinopathy responds well to operative management. Surgical treatment leads to substantial improvements in functional outcomes [6]. Fat pad debridement prolongs return-to-sport in surgical interventions for this condition [6]. Evidence on the efficacy of exercise therapy in patients with hand and wrist tendinopathies is limited [16]. In rotator cuff repair, the patients' characteristics and indications for surgery were not described in a majority of clinical outcome studies [23].

Anatomy & Pathophysiology

Elbow disorders, including tendinopathy, involve specific pathophysiology, diagnosis, and treatment strategies [12]. Lateral elbow tendinopathy is characterized by an adaptive motor pattern involving increased relative activation and coactivation of the anconeus muscle depending on grip force [78]. In patients with lateral epicondylitis, grip strength decreases as the elbow moves from a position of flexion to a position of extension [79]. Management of lateral epicondylalgia requires focusing on upper segments in addition to the elbow [65]. Significant differences in biomechanical parameters and clinical scores exist between tennis elbow patients and controls across manual, physical, and sports work groups [75].

Tenotomy of the long head of the biceps tendon results in increased fatigue of the biceps muscle [55]. Posterior rotator cuff cable tears lead to altered glenohumeral biomechanics and kinematics in a cadaveric model of the throwing shoulder [64]. Dynamic elongation of rotator cuff repair tissue during scapular-plane abduction exhibits distinct patterns that may suggest different patterns of supraspinatus mechanical and neuromuscular function [70]. Three-dimensional glenohumeral kinematics at the early phase of arm elevation may affect shoulder function in patients with massive rotator cuff tears [71]. Subscapularis tears influence three-dimensional glenohumeral kinematics in patients with massive rotator cuff tears [71].

Supraspinatus-to-glenoid contact occurs during standardized overhead reaching motion, with all participant models making contact by 150 degrees of humerothoracic elevation [82]. Anatomic factors influence the precise angle at which supraspinatus-to-glenoid contact occurs during overhead reaching [82]. Biomechanical analysis demonstrates that reverse shoulder arthroplasty (RSA) and superior capsular reconstruction (SCR) models produce moment arms that vary between muscles, with some contributing more to abduction and others less [86].

Elbow arthroscopy offers advantages such as decreased surgical morbidity and improved joint visualization due to improved instrumentation, advanced surgical technique, and better understanding of anatomy [77]. There is a high correlation between several dimensions of the radial head and the capitellum, allowing estimation of radial head size based on capitellum measurements [81]. There is a high correlation between the left and right elbow dimensions [81].

Classification

Clinical Diagnosis: Tendinopathies of the hand and wrist are diagnosed by history and examination [1]. The classification of midportion and insertional tendinopathy and retrocalcaneal bursitis in the Achilles tendon should strictly be used as a clinical diagnosis [35]. More specific pathologies in the Achilles tendon may be identified during surgical evaluations [35].

MRI Classification: A proposed MRI classification is one of the most reliable methods to define stages of chronic lateral epicondylitis [22]. Nonoperative treatment results for patellar tendinopathy were better in patients with stage 2 tendinopathy than in those with stage 3 [24].

Öhberg Score: The modified, 4-graded, Öhberg score is a reproducible instrument for assessment of tendon structure and neovascularisation [54].

Snyder Classification: The Snyder classification system is reproducible for the classification of partial-thickness rotator cuff tears [62].

Other Considerations: Lateral elbow tendinopathy treatment outcomes may be compromised by the inclusion of heterogeneous patient groups rather than categorization by disease severity [2]. There is no clear consensus on the definition of a chronic Achilles disorder [5]. There is no uniform classification and treatment scheme for chronic Achilles disorders [5]. The exact aetiology and pathophysiology of non-insertional Achilles tendinopathy are not fully known [11]. Patellar tendinopathy is a degenerative disorder (tendinosis) rather than an inflammatory one [21]. A comprehensive classification system integrating historical and newer descriptions of rotator cuff lesions may help to guide treatment [34].

Clinical Presentation

Tendinopathies of the hand and wrist are common conditions diagnosed by history and examination [1]. Lateral epicondylitis is a common, generally self-limiting tendinosis affecting patients aged 35 to 55 years [19]. However, the multifactorial etiology of lateral elbow tendinopathy makes finding one effective treatment intervention elusive [43]. Diagnostic accuracy is variable; nearly half (46.5%) of patients presenting with lateral elbow pain receive a diagnosis other than lateral elbow tendinopathy (LET) [36].

Rotator cuff tendinopathy is a common problem, though uncertainty remains regarding the true extent and risk factors associated with onset [41]. In patients with painful supraspinatus tendinopathy, clinical examination may reveal increased thickening with delayed return to baseline following loading [9]. Calcifying tendonitis appeared to be the most frequent pathologic condition associated with the onset of infraspinatus myotendinous junction tears [18].

Patellar tendinopathy is a degenerative disorder (tendinosis) rather than an inflammatory one [21]. Bilateral changes in tendon structure occur in patients diagnosed with unilateral insertional or midportion Achilles tendinopathy or patellar tendinopathy [20]. Consequently, the asymptomatic side should not be used as a reference in clinical practice for patients with unilateral Achilles or patellar tendinopathy [20]. The exact aetiology and pathophysiology of non-insertional Achilles tendinopathy are not fully known [11].

Systemic factors also influence presentation. Tendinopathy usually occurs within the first year of statin use and improves after the drug therapy is stopped [7]. Overall, tendinopathy and acute muscle injuries are common yet difficult-to-treat conditions with large gaps in knowledge regarding etiology and management [8].

Investigations

Plain radiography: Tendinopathies of the hand and wrist are diagnosed by history and examination [1].

MRI: MRI-defined patellar tendinopathy is common in community-based adults and is associated with current and past history of obesity assessed by BMI or body weight [27]. MRI-defined patellar tendinopathy is not associated with fat mass [27]. Among patients with symptomatic rotator cuff tendinopathy that remained symptomatic at a minimum of 1 year and obtained a follow-up MRI, 39% progressed to a partial or full-thickness tear [30]. Continuous tendon recovery assessed by MRI was found during a 2-year period after platelet-rich plasma (PRP) treatment for lateral epicondylitis [32]. Postoperative MRI findings of tendinopathy area improvement reflect clinical outcomes in lateral epicondylitis [14]. A reproducible MRI-based assessment technique for lateral tendinopathy enhances diagnostic precision and treatment evaluation [44]. Magnetic resonance imaging is a reliable tool in determining the radiological severity of lateral epicondylitis [59]. Bilateral changes in tendon structure occur in patients with unilateral insertional or midportion Achilles or patellar tendinopathy [20]. The asymptomatic side should not be used as a reference for the symptomatic side in clinical practice for unilateral tendinopathy [20].

Ultrasound: Ultrasonography was more accurate than MRI in confirming clinically diagnosed patellar tendinopathy [50]. Elastography-ultrasound (EUS) can be used as the initial modality to screen for tendon pathology in athletes and non-athletes prior to advanced imaging such as MRI [60].

CT: Computed tomography arthrography (CTA) was a reliable and accurate diagnostic modality compared with MRI to detect capsular tears at the undersurface of the extensor carpi radialis brevis tendon in chronic tennis elbow [76].

Other Considerations: Patients with painful supraspinatus tendinopathy demonstrate increased tendon thickening with delayed return to baseline following loading [9]. No single nonoperative treatment reliably achieves outstanding results for lateral elbow tendinopathy [2] (Note: This bullet relates to treatment efficacy rather than investigation; however, as it is the only evidence provided for lateral elbow tendinopathy context, it is placed here as no other modality fits). The clinical use of MRI in the management of patients with enthesopathy of the extensor carpi radialis brevis (ECRB) origin merits further study [52]. Routine use of MRI for the diagnosis of lateral epicondylitis is low, although its use is associated with downstream effects [56]. MRI imaging has questionable diagnostic and prognostic value in lateral epicondylar tendinopathy, especially in older patients [57].

Treatment

Non-Operative Management

Tendinopathies of the hand and wrist are diagnosed by history and examination, with treatment advancing both nonsurgical and surgical management [1]. Nonsurgical treatment is the mainstay of management for lateral epicondylitis, involving options such as rest, physical therapy, and injections [49]. Most patients with lateral epicondylosis experience relief with non-operative management, though controversy remains regarding the optimal modality for quickest recovery and the role of surgical intervention for refractory cases [46]. While numerous treatment options exist for epicondylitis, no single universally accepted protocol has emerged [10]. There is little clear consensus on which modality works best for both conservative and operative options for lateral epicondylitis, indicating that the understanding of the disease process is currently incomplete [63]. No single nonoperative treatment reliably achieves outstanding results for lateral elbow tendinopathy, likely due to the inclusion of heterogeneous patient groups rather than categorization by disease severity [2].

For Achilles tendinopathy, the majority of patients fully recover in regard to both symptoms and function when treated with exercise alone [3]. Tendinopathy associated with statins usually occurs within the first year of use and improves after the drug therapy is stopped [7]. Evidence on the efficacy of exercise therapy in patients with hand and wrist tendinopathies is limited [16]. Topical glyceryl trinitrate should be included as part of nonsurgical management of chronic tendinopathies [51]. Multiple injections of platelet-rich plasma are a suitable nonsurgical option for chronic patellar tendinopathy, although the literature documents important limitations in terms of study quality [53]. The efficacy of iontophoresis in the management of lateral epicondylitis has not been proven due to methodological limitations, lack of a control group, and equivocal results from other trials [39]. Results of extracorporeal shock wave therapy have been mixed in the management of lateral epicondylitis, and this therapy has not been effective in managing noncalcific tendinosis of the supraspinatus [48]. When completed, a multi-center, blinded, randomized controlled trial will provide evidence on the effectiveness of injection therapy (autologous blood, dextrose, or perforation only) on pain, quality of life, and functional recovery in lateral epicondylitis [47].

Operative Management

Indications: Operative management is generally reserved for refractory cases where non-operative therapy fails. Arthroscopic debridement is reserved for cases of long head of the biceps tendon calcification where symptoms are not controlled by non-operative therapy, as conservative treatment remains the mainstay [42]. In patients with patellar tendinopathy treated nonoperatively, results were better in those with stage 2 tendinopathy than in those with stage 3 [24]. There is no clear consensus on what defines a chronic Achilles disorder or a uniform classification and treatment scheme [5]. The patients' characteristics and indications for surgery were not described in a majority of clinical outcome studies of rotator cuff repair [23]. Operative management of rotator cuff tears is increasingly cost-effective with time, given nonrepaired cuff tears are unlikely to heal and portend worse symptomatology [61].

Surgical Approach / Technique: Surgical treatment for chronic patellar tendinopathy leads to substantial improvements in functional outcomes [6]. Fat pad debridement prolongs return-to-sport in surgical interventions for chronic patellar tendinopathy [6]. Arthroscopic debridement for refractory lateral epicondylitis results in substantial improvement in tendinosis scores and good clinical outcomes, with postoperative MRI findings reflecting clinical outcomes (60% improvement in tendinopathy area in recovered vs. 16% in unrecovered groups) [14]. Both the Nirschl procedure and arthroscopic extensor carpi radialis brevis débridement are comparable and highly effective for treating chronic recalcitrant lateral elbow tendinopathy [45].

Specific Interventions and Emerging Therapies

Autologous tenocyte injection (ATI) provides evidence for midterm durability in the treatment of chronic resistant lateral epicondylitis [4]. Percutaneous ultrasonic tenotomy is a safe and effective treatment for chronic medial and lateral elbow tendinosis, producing statistically significant improvements in pain and function over a 1-year follow-up period [13]. Injectable recombinant human collagen scaffold combined with autologous platelet-rich plasma (STR/PRP) is a safe treatment that effectively induces clinically significant improvements in elbow symptoms, general well-being, strength, and imaging of the common extensor tendon within 6 months for elbow tendinopathy recalcitrant to standard treatments [38]. Ultrasound-guided needling is considered safe and effective for calcific tendinopathy based on Level I evidence, although inclusion criteria in supporting studies were noted to be less strict than ideal [66].

Complications

Other Considerations: Tendinopathies of the hand and wrist are common conditions [1]. Tendinopathy and acute muscle injuries are common yet difficult-to-treat conditions with large gaps in knowledge regarding etiology and management [8]. Lateral epicondylitis is a common, generally self-limiting tendinosis affecting patients aged 35 to 55 years [19]. Enthesopathy of the extensor carpi radialis brevis origin is a benign, self-limiting disorder with a natural history of spontaneous resolution, for which no treatments have been proven to alter the course [28].

MRI-defined patellar tendinopathy is common in community-based adults and is associated with current and past history of obesity assessed by BMI or body weight, but not fat mass [27]. Calcifying tendonitis appeared to be the most frequent pathologic condition associated with infraspinatus myotendinous junction tear onset [18]. The short-term clinical influence of biceps complications on shoulder outcome after tenotomy associated with arthroscopic rotator cuff repair is very limited [58].

The exact aetiology and pathophysiology of non-insertional Achilles tendinopathy are not fully known and warrant further studies [11]. Additional research is required to improve our understanding of the causative factors in Achilles tendinopathy [83]. The absence of tendinopathic changes in the excised plantaris of 13 patients who clinically improved suggests plantaris involvement with Achilles tendinopathy may not yet be fully understood and supports the concept that this may be a compressive or a frictional phenomenon rather than purely tendinopathic [80]. Tendinopathy usually occurs within the first year of statin use and improves after the drug therapy is stopped [7].

Recovery

Light activity (weeks): Evidence does not provide specific week ranges for light activity or desk work return across the included tendinopathies.

Full activity (months): Evidence does not provide specific month ranges for full activity, manual work, or sport return across the included tendinopathies.

Complete recovery / outcome plateau (months): The majority of patients with Achilles tendinopathy fully recover in regard to both symptoms and function when treated with exercise alone [3]. Pain sensitization during the early stages of lateral epicondylitis correlated with initial symptom severity and duration and was associated with persistently increasing disability after 1 year of nonsurgical treatment [87]. The transient symptoms of tennis elbow reflect the natural course of a self-limiting condition [88]. Tendinopathy associated with statins usually occurs within the first year of use and improves after the drug therapy is stopped [7].

Rehabilitation protocol: Evidence does not provide specific rehabilitation protocols, immobilisation durations, or weight-bearing progressions for the included tendinopathies.

Functional milestones: Autologous tenocyte injection (ATI) provides evidence for midterm durability in the treatment of lateral epicondylitis (LE) tendinopathy [4]. Surgical treatment for chronic patellar tendinopathy leads to substantial improvements in functional outcomes [6]. Percutaneous ultrasonic tenotomy is a safe and effective treatment for chronic medial and lateral elbow tendinosis, producing statistically significant improvements in pain and function over a 1-year follow-up period [13]. Surgical treatment for lateral epicondylitis via complete resection of tendinosis tissue with sparing of normal tissue leads to durable results at long-term follow-up [15]. Arthroscopic isolated subscapularis tendon repair (AISR) results in improved clinical outcomes and an overall high rate of tendon healing at midterm follow-up [25]. Favorable short-term outcomes, including reduction of pain and increase in function, are maintained over long-term follow-up after arthroscopic treatment of lateral epicondylitis [26]. Results for arthroscopic transosseous repair of rotator cuff tears are satisfactory in the early period, but long follow-up is needed to evaluate bone-tendon healing [29]. Among patients with symptomatic rotator cuff tendinopathy that remained symptomatic at a minimum of 1 year and obtained a follow-up MRI, 39% progressed to a partial or full-thickness tear [30]. Ultrasound-guided percutaneous tenotomy demonstrates good sustainability of pain relief and functional recovery, accompanied by sonographic evidence of tissue healing, at 7.5 years follow-up for recalcitrant lateral elbow tendinopathy [31]. Continuous tendon recovery assessed by MRI was found during a 2-year period after platelet-rich plasma (PRP) treatment for lateral epicondylitis [32]. A patient with an isolated traumatic full-thickness supraspinatus tear demonstrated good clinical evolution with a Subjective Shoulder Value of 85% and no retear at 6 months follow-up [33]. At 90 months follow-up, ultrasonic percutaneous tenotomy demonstrated good durability of pain relief and functional recovery, accompanied by sustained sonographic tissue healing with no significant deterioration, for recalcitrant lateral elbow tendinopathy [69].

Other Considerations: Fat pad debridement prolongs return-to-sport in the context of surgical interventions for chronic patellar tendinopathy [6]. Patients diagnosed with painful supraspinatus tendinopathy demonstrate increased tendon thickening with delayed return to baseline following fatigue loading [9]. Enthesopathy of the extensor carpi radialis brevis origin is a benign, self-limiting disorder with a natural history of spontaneous resolution, for which no treatments have been proven to alter the course [28]. Chronic and acute calcific tendinitis are two phases of the same disease, with surgery preferably performed during the formative phase if conservative management fails [89]. Distal biceps short head tears present acutely, have a poor natural history akin to complete tears, and have good outcomes with acute and delayed reconstruction [90].

Key Evidence

  • [L5] No single nonoperative treatment reliably achieves outstanding results for lateral elbow tendinopathy, likely due to the inclusion of heterogeneous patient groups rather than categorization by disease severity. (10.1177/2325967116670635)
  • [L4] The majority of patients with Achilles tendinopathy fully recovered in regard to both symptoms and function when treated with exercise alone. (10.1177/0363546510384789)
  • [L4] This study provides evidence for the midterm durability of ATI for treatment of LE tendinopathy. (10.1177/0363546515579185)
  • [L5] There is no clear consensus on what defines a chronic Achilles disorder or a uniform classification and treatment scheme. (10.5435/00124635-200901000-00002)
  • [L1] Surgical treatment for chronic patellar tendinopathy leads to substantial improvements in functional outcomes. (10.1002/ksa.70284)
  • [L4] Tendinopathy usually occurs within the first year of statin use and improves after the drug therapy is stopped. (10.2106/jbjs.rvw.15.00072)
  • [L3] Those diagnosed with painful supraspinatus tendinopathy demonstrated increased thickening with delayed return to baseline following loading. (10.1136/bmjsem-2017-000279)
  • [L5] This article is a review of recently published information on elbow tendinopathy and tendon ruptures intended to assist clinicians in diagnosis and management, noting that while numerous treatment options exist for epicondylitis, no single universally accepted protocol has emerged. (10.1016/j.jhsa.2009.01.022)
  • [L5] The exact aetiology and pathophysiology of non-insertional Achilles tendinopathy are not fully known and warrant further studies. (10.1136/jisakos-2017-000164)
  • [L4] Percutaneous ultrasonic tenotomy is a safe and effective treatment for chronic medial and lateral elbow tendinosis, producing statistically significant improvements in pain and function over a 1-year follow-up period. (10.1016/j.jse.2014.07.017)
  • [L4] In the recovered and unrecovered groups, improvement of tendinopathy area was 60% versus 16%, indicating that postoperative MRI findings reflect clinical outcomes. (10.1016/j.arthro.2022.07.019)
  • [L4] Surgical treatment for lateral epicondylitis by complete resection of the tendinosis tissue with the sparing of normal tissue can lead to durable results at long-term follow-up. (10.1177/0363546507308932)
  • [L1] Evidence on the efficacy of exercise therapy in patients with hand and wrist tendinopathies is limited. (10.1016/j.jht.2023.08.016)
  • [L4] Calcifying tendonitis appeared to be the most frequent pathologic condition associated with the lesion onset. (10.1016/j.jse.2022.01.092)
  • [L5] Lateral epicondylitis is a common, generally self-limiting tendinosis affecting patients aged 35 to 55 years. (10.1302/0301-620x.95b9.29285)
  • [L3] These results stress the importance of monitoring both symptomatic and asymptomatic tendon structures and in addition highlight that the asymptomatic side should not be used as reference in clinical practice. (10.1007/s00167-019-05495-2)
  • [L5] Patellar tendinopathy is a degenerative disorder (tendinosis) rather than an inflammatory one. (10.5435/jaaos-d-15-00703)
  • [L4] The proposed MRI classification has emerged as one of the most reliable methods to define stages of chronic lateral epicondylitis. (10.1186/s12891-022-05758-z)
  • [L3] The patients' characteristics and indications for surgery were not described in a majority of clinical outcome studies of rotator cuff repair. (10.1007/s11999-008-0585-9)
  • [L3] In the group treated nonoperatively, results were better in the patients who had stage 2 tendinopathy than in those with stage 3. (10.1177/03635465000280031901)
  • [L4] Improved clinical outcomes and an overall high rate of tendon healing were seen at the midterm follow-up after AISR. (10.1177/23259671241229429)
  • [L3] MRI defined patellar tendinopathy is common in community-based adults and is associated with current and past history of obesity assessed by BMI or body weight, but not fat mass. (10.1186/1471-2474-15-266)
  • [L5] Enthesopathy of the extensor carpi radialis brevis origin is a benign, self-limiting disorder with a natural history of spontaneous resolution, for which no treatments have been proven to alter the course. (10.5435/jaaos-d-15-00233)
  • [L4] Results were satisfactory in the early period, but long follow-up is needed to evaluate bone-tendon healing. (10.1177/2325967117s00060)
  • [L3] Among patients with symptomatic rotator cuff tendinopathy that remained symptomatic at a minimum of 1 year and obtained a follow-up MRI, 39% progressed to a partial or full-thickness tear. (10.1016/j.asmr.2022.05.004)
  • [L4] At long term follow up, ultrasound-guided percutaneous tenotomy demonstrates good sustainability of pain relief and functional recovery that was previously achieved, accompanied with sonographic evidence of tissue healing at 7.5 years. (10.1177/2325967120s00420)
  • [L4] Continuous tendon recovery assessed by MRI was found during a 2-year period after PRP treatment. (10.1016/j.jse.2022.01.147)
  • [Case_report] The patient demonstrated good clinical evolution with a Subjective Shoulder Value of 85% and no retear at 6 months follow-up. (10.1016/j.xrrt.2023.10.005)
  • [L4] A comprehensive classification system integrating historical and newer descriptions of rotator cuff lesions may help to guide treatment further. (10.1302/2058-5241.1.160005)
  • [L4] The classification of midportion and insertional tendinopathy and retrocalcaneal bursitis in AT should strictly be used as a clinical diagnosis, as more specific pathologies may be identified during surgical evaluations. (10.1177/2325967114562371)
  • [L3] Nearly half (46.5%) of patients presenting with lateral elbow pain receive a diagnosis other than lateral elbow tendinopathy (LET). (10.1016/j.jse.2025.10.006)
  • [L4] STR/PRP is a safe treatment that effectively induces clinically significant improvements in elbow symptoms and general well-being as well as objective measures of strength and imaging of the common extensor tendon within 6 months of treatment of elbow tendinopathy recalcitrant to standard treatments. (10.1016/j.jse.2018.09.007)
  • [Commentary] The efficacy of iontophoresis in the management of lateral epicondylitis has not been proven due to methodological limitations, lack of a control group, and equivocal results from other trials. (10.1016/j.jhsa.2011.10.029)
  • [L1] Rotator cuff tendinopathy is a common problem but uncertainty remains regarding the true extent and risk factors associated with onset. (10.1111/sae.12028)
  • [L4] Conservative treatment remains the mainstay, with arthroscopic debridement reserved for cases where symptoms are not controlled by non-operative therapy. (10.1177/1758573214567559)
  • [L5] The multifactorial etiology of lateral elbow tendinopathy makes finding one effective treatment intervention elusive; a multifaceted treatment method addressing tendon pathology, the pain system, and proprioception may be the answer to resolving symptoms and eliminating recurrence. (10.1016/j.jht.2018.04.002)
  • [L1] This study presents a reproducible MRI-based assessment technique for lateral tendinopathy, enhancing diagnostic precision and treatment evaluation. (10.1016/j.jse.2026.03.020)
  • [L3] Both techniques are comparable and highly effective for treating chronic recalcitrant lateral elbow tendinopathy. (10.1016/j.jse.2016.09.022)
  • [L5] This article serves to provide an updated review of the various treatment options and management for lateral epicondylosis, noting that while most patients experience relief with non-operative management, controversy remains regarding the optimal modality for quickest recovery and the role of surgical intervention for refractory cases. (10.1016/j.jhsa.2024.07.003)
  • [L2] When completed, this trial will provide evidence on the effectiveness of injection therapy in the treatment of lateral epicondylitis on pain, quality of life and functional recovery. (10.1186/s12891-019-2711-0)
  • [L5] Results have been mixed in the management of lateral epicondylitis, and this therapy has not been effective in managing noncalcific tendinosis of the supraspinatus. (10.5435/00124635-200604000-00001)
  • [L5] Nonsurgical treatment is the mainstay of management for lateral epicondylitis, involving options such as rest, physical therapy, and injections. (10.5435/00124635-200801000-00004)
  • [L2] Ultrasonography was more accurate than MRI in confirming clinically diagnosed patellar tendinopathy. (10.1177/0363546506294858)
  • [L1] Topical glyceryl trinitrate should be included as part of nonsurgical management of chronic tendinopathies. (10.1177/0363546504270998)
  • [L3] The clinical use of MRI in the management of patients with enthesopathy of the ECRB origin merits further study. (10.1016/j.jhsa.2009.02.023)
  • [L1] The literature documents several nonsurgical approaches for the treatment of chronic patellar tendinopathy with important limitations in terms of study quality. (10.1177/0363546518759674)
  • [L4] The modified, 4-graded, Öhberg score was found to be a reproducible instrument for assessment of tendon structure and neovascularisation. (10.1007/s00167-014-3270-4)
  • [L3] An improvement in isometric contraction in flexion of the elbow was observed, but this did not reach the flexion power of the contralateral healthy arm. (10.1007/s00167-018-5007-2)
  • [L3] Although there is variation in the use of MRI for lateral epicondylitis and its use is associated with downstream effects, the routine use of MRI for the diagnosis of lateral epicondylitis is low. (10.1016/j.jhsa.2023.03.025)
  • [L4] This draws into question the diagnostic and prognostic value of MRI imaging in lateral epicondylar tendinopathy, especially in older patients. (10.1177/17585732221146731)
  • [L3] Nevertheless, the short-term clinical influence of biceps complications on shoulder outcome is very limited. (10.1177/2325967121s00362)
  • [L2] Magnetic resonance imaging is a reliable tool in determining radiological severity of lateral epicondylitis. (10.1016/j.jhsa.2010.11.040)
  • [L4] EUS can be used as the initial modality to screen any tendon pathology both in athlete and non-athlete, prior to advance imaging such as magnetic resonance imaging (MRI). (10.1177/2325967119s00483)
  • [L3] Operative management of cuff tears is increasingly cost-effective with time, given nonrepaired cuff tears are unlikely to heal and portend worse symptomatology. (10.1016/j.jseint.2025.04.038)
  • [L2] The Snyder classification system is reproducible and can be used in future research studies in analyzing the treatment options of partial rotator cuff tears. (10.1177/2325967116667058)
  • [L4] Although many treatments have been advocated for lateral epicondylitis, there is little clear consensus on which modality works best for both conservative and operative options, indicating that the understanding of the disease process is currently incomplete. (10.1016/j.jhsa.2007.07.019)
  • [L5] In this cadaveric shoulder model of the throwing shoulder, tears of the posterior rotator cuff cable lead to altered glenohumeral biomechanics and kinematics. (10.1177/2325967117s00373)
  • [L3] In addition to the elbow, focusing on the upper segments is essential in the management of LE. (10.1016/j.jse.2018.12.010)
  • [L5] The authors appreciate the Level I evidence provided by Kim et al. regarding the safety and effectiveness of ultrasound-guided needling for calcific tendinopathy, while noting that the inclusion criteria were less strict than ideal. (10.1016/j.jse.2014.12.006)
  • [L2] With the number of available participants, this study failed to show additional benefit of the surgical excision of the degenerative portion of the ECRB over placebo surgery for the management of chronic tennis elbow. (10.1177/0363546517753385)
  • [L4] It is one of the few procedures to demonstrate positive sonographic evidence of tissue-healing response and is an attractive alternative to surgical intervention for definitive treatment of recalcitrant elbow tendinopathy. (10.1177/0363546515612758)
  • [L4] At the long-term follow-up of 90 months, ultrasonic percutaneous tenotomy demonstrated good durability of pain relief and functional recovery that was previously achieved, accompanied by sustained sonographic tissue healing with no significant deterioration. (10.1177/03635465211010158)
  • [L4] Dynamic elongation of repair tissue during scapular-plane abduction exhibited 1 of 2 distinct patterns, which may suggest different patterns of supraspinatus mechanical and neuromuscular function. (10.1177/23259671221084294)
  • [Abstract] The 3D glenohumeral kinematics at the early phase of arm elevation may affect the shoulder function in patients with massive rotator cuff tears. (10.1016/j.jse.2020.01.004)
  • [L4] Significant differences were observed between tennis elbow patients and the control group regarding biomechanical parameters and clinical scores across manual, physical, and sports work groups. (10.1016/j.jse.2021.03.113)
  • [L2] CTA was a reliable and accurate diagnostic modality compared with MRI to detect the capsular tear in patients with chronic tennis elbow. (10.1016/j.jse.2010.12.002)
  • [L3] This study presents novel evidence of an adaptive motor pattern in lateral elbow tendinopathy, characterized by increased relative activation and coactivation of the anconeus muscle depending on grip force. (10.1016/j.jse.2024.11.001)
  • [L3] In patients with lateral epicondylitis, the grip strength decreases as one moves from a position of flexion to a position of extension. (10.1016/j.jhsa.2007.04.010)
  • [L4] The absence of tendinopathic changes in the excised plantaris of 13 patients who clinically improved suggests plantaris involvement with Achilles tendinopathy may not yet be fully understood and supports the concept that this may be a compressive or a frictional phenomenon rather than purely tendinopathic. (10.1177/2325967116673978)
  • [Abstract] There is a high correlation between several dimensions of the radial head and the capitellum, and there is also a high correlation between the left and right elbow, allowing estimation of radial head size based on capitellum measurements. (10.1016/j.jse.2015.05.018)
  • [L4] Additionally, all participant models eventually made contact with the glenoid by 150 of humerothoracic elevation, although anatomic factors influenced the precise angle at which contact occurred. (10.1177/23259671211036908)
  • [L3] Additional research is required to improve our understanding of the causative factors in Achilles tendinopathy. (10.1177/0363546509332250)
  • [L5] Biomechanical analysis demonstrated that RSA and SCR models produce moment arms that vary between muscles, with some contributing more to abduction and some contributing less. (10.1177/2325967121s00333)
  • [L3] Pain sensitization during the early stages of lateral epicondylitis correlated with initial symptom severity and duration and was associated with persistently increasing disability after 1 year of nonsurgical treatment. (10.1016/j.jhsa.2018.06.013)
  • [L4] The transient symptoms of tennis elbow seen in these two cases reflect the natural course of a self-limiting condition. (10.1007/s00167-012-1939-0)
  • [L5] Chronic and acute calcific tendinitis are two phases of the same disease; optimal treatment requires determining the disease stage, with surgery preferably performed during the formative phase if conservative management fails. (10.5435/00124635-199707000-00001)
  • [L4] They present acutely, have a poor natural history akin to complete tears, and have good outcomes with acute and delayed reconstruction. (10.1016/j.jse.2020.04.038)

See Also

  • Tennis Elbow

References

[1] Chapter 32 Tendon Injuries and Tendinopathies of the Hand and Wrist. 2020.

[2] Lateral Elbow Tendinopathy. Orthopaedic Journal of Sports Medicine. 2016. DOI: 10.1177/2325967116670635

[3] The Majority of Patients With Achilles Tendinopathy Recover Fully When Treated With Exercise Alone. The American Journal of Sports Medicine. 2010. DOI: 10.1177/0363546510384789

[4] Evidence for the Durability of Autologous Tenocyte Injection for Treatment of Chronic Resistant Lateral Epicondylitis. The American Journal of Sports Medicine. 2015. DOI: 10.1177/0363546515579185

[5] Surgical Treatment for Chronic Disease and Disorders of the Achilles Tendon. Journal of the American Academy of Orthopaedic Surgeons. 2009. DOI: 10.5435/00124635-200901000-00002

[6] Fat pad debridement prolongs return‐to‐sport: A meta‐analysis and meta‐regression of surgical interventions for chronic patellar tendinopathy. Knee Surgery, Sports Traumatology, Arthroscopy. 2026. DOI: 10.1002/ksa.70284

[7] Tendinopathy and Tendon Rupture Associated with Statins. JBJS Reviews. 2016. DOI: 10.2106/jbjs.rvw.15.00072

[8] Chapter 38 Current Concepts in Tendinopathy and Acute Muscle Injury. 2019.

[9] Increased supraspinatus tendon thickness following fatigue loading in rotator cuff tendinopathy: potential implications for exercise therapy. BMJ Open Sport & Exercise Medicine. 2017. DOI: 10.1136/bmjsem-2017-000279

[10] Elbow Tendinopathy and Tendon Ruptures: Epicondylitis, Biceps and Triceps Ruptures. The Journal of Hand Surgery. 2009. DOI: 10.1016/j.jhsa.2009.01.022

[11] Achilles tendinopathy – pathophysiology: state of the art. Journal of ISAKOS. 2018. DOI: 10.1136/jisakos-2017-000164

[12] Chapter 28 Tendinopathy, Elbow Ligament Reconstruction, and Throwing Injuries. 2020.

[13] Percutaneous ultrasonic tenotomy for chronic elbow tendinosis: a prospective study. Journal of Shoulder and Elbow Surgery. 2015. DOI: 10.1016/j.jse.2014.07.017

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[15] Ten- to 14-Year Follow-up of the Nirschl Surgical Technique for Lateral Epicondylitis. The American Journal of Sports Medicine. 2007. DOI: 10.1177/0363546507308932

[16] Evidence for exercise therapy in patients with hand and wrist tendinopathy is limited: A systematic review. Journal of Hand Therapy. 2023. DOI: 10.1016/j.jht.2023.08.016

[18] Infraspinatus Myotendinous Junction Tears: Analysis Of A Consecutive Series And Their Relationship With Calcifying Tendonitis. Journal of Shoulder and Elbow Surgery. 2022. DOI: 10.1016/j.jse.2022.01.092

[19] Lateral epicondylitis. The Bone & Joint Journal. 2013. DOI: 10.1302/0301-620x.95b9.29285

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[21] Patellar Tendinopathy: Diagnosis and Treatment. Journal of the American Academy of Orthopaedic Surgeons. 2016. DOI: 10.5435/jaaos-d-15-00703

[22] Validation of a novel magnetic resonance imaging classification and recommended treatment for lateral elbow tendinopathy. BMC Musculoskeletal Disorders. 2022. DOI: 10.1186/s12891-022-05758-z

[23] Indications for Surgery in Clinical Outcome Studies of Rotator Cuff Repair. Clinical Orthopaedics & Related Research. 2009. DOI: 10.1007/s11999-008-0585-9

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[25] Clinical Outcomes and Tendon Healing After Arthroscopic Isolated Subscapularis Tendon Repair: Results at Midterm Follow-up. Orthopaedic Journal of Sports Medicine. 2024. DOI: 10.1177/23259671241229429

[26] Long-term_Follow-up_of_Arthroscopic_Treatment_of_Lateral_Epicondylitis_S0894113008000707. n.d..

[27] Association between obesity and magnetic resonance imaging defined patellar tendinopathy in community-based adults: a cross-sectional study. BMC Musculoskeletal Disorders. 2014. DOI: 10.1186/1471-2474-15-266

[28] Enthesopathy of the Extensor Carpi Radialis Brevis Origin. Journal of the American Academy of Orthopaedic Surgeons. 2016. DOI: 10.5435/jaaos-d-15-00233

[29] Treatment of rotator cuff tears with arthroscopic transosseous technique: results of the first twenty cases. Orthopaedic Journal of Sports Medicine. 2017. DOI: 10.1177/2325967117s00060

[30] Conservatively Treated Symptomatic Rotator Cuff Tendinopathy May Progress to a Tear. Arthroscopy, Sports Medicine, and Rehabilitation. 2022. DOI: 10.1016/j.asmr.2022.05.004

[31] Ultrasound-guided Percutaneous Tenotomy Shows Sustained Clinical and Sonographic Outcomes for Recalcitrant Lateral Elbow Tendinopathy at 7.5 Years. Orthopaedic Journal of Sports Medicine. 2020. DOI: 10.1177/2325967120s00420

[32] Repeated magnetic resonance imaging at 6 follow-up visits over a 2-year period after platelet-rich plasma injection in patients with lateral epicondylitis. Journal of Shoulder and Elbow Surgery. 2022. DOI: 10.1016/j.jse.2022.01.147

[33] Isolated traumatic full-thickness supraspinatus tear with intact glenohumeral capsule: a case report. JSES Reviews, Reports, and Techniques. 2024. DOI: 10.1016/j.xrrt.2023.10.005

[34] Classification of full-thickness rotator cuff lesions: a review. EFORT Open Reviews. 2016. DOI: 10.1302/2058-5241.1.160005

[35] Macroscopic Anomalies and Pathological Findings in and Around the Achilles Tendon. Orthopaedic Journal of Sports Medicine. 2014. DOI: 10.1177/2325967114562371

[36] Clinical diagnosis of lateral-sided elbow pain: predictors for recognizing a diagnosis other than tennis elbow. Journal of Shoulder and Elbow Surgery. 2026. DOI: 10.1016/j.jse.2025.10.006

[38] First clinical experience with a new injectable recombinant human collagen scaffold combined with autologous platelet-rich plasma for the treatment of lateral epicondylar tendinopathy (tennis elbow). Journal of Shoulder and Elbow Surgery. 2019. DOI: 10.1016/j.jse.2018.09.007

[39] Commentary on “Iontophoresis for the Treatment of Lateral Epicondylitis of the Elbow”. The Journal of Hand Surgery. 2012. DOI: 10.1016/j.jhsa.2011.10.029

[41] Epidemiology of Rotator Cuff Tendinopathy: A Systematic Review. Shoulder & Elbow. 2013. DOI: 10.1111/sae.12028

[42] Spontaneous resorption of calcification at the long head of the biceps tendon. Shoulder & Elbow. 2015. DOI: 10.1177/1758573214567559

[43] Response letter to the role of proprioception of lateral elbow tendinopathy. Journal of Hand Therapy. 2019. DOI: 10.1016/j.jht.2018.04.002

[44] Morphological changes in tennis elbow after PRP injection: a novel MRI-based assessment in a randomized controlled study. Journal of Shoulder and Elbow Surgery. 2026. DOI: 10.1016/j.jse.2026.03.020

[45] The Nirschl procedure versus arthroscopic extensor carpi radialis brevis débridement for lateral epicondylitis. Journal of Shoulder and Elbow Surgery. 2017. DOI: 10.1016/j.jse.2016.09.022

[46] Management of Lateral Epicondylosis. The Journal of Hand Surgery. 2024. DOI: 10.1016/j.jhsa.2024.07.003

[47] Effectiveness of standardized ultrasound guided percutaneous treatment of lateral epicondylitis with application of autologous blood, dextrose or perforation only on pain: a study protocol for a multi-center, blinded, randomized controlled trial with a 1 year follow up. BMC Musculoskeletal Disorders. 2019. DOI: 10.1186/s12891-019-2711-0

[48] Extracorporeal Shock Wave Therapy in the Treatment of Chronic Tendinopathies. Journal of the American Academy of Orthopaedic Surgeons. 2006. DOI: 10.5435/00124635-200604000-00001

[49] Management of Lateral Epicondylitis: Current Concepts. Journal of the American Academy of Orthopaedic Surgeons. 2008. DOI: 10.5435/00124635-200801000-00004

[50] Comparative Accuracy of Magnetic Resonance Imaging and Ultrasonography in Confirming Clinically Diagnosed Patellar Tendinopathy. The American Journal of Sports Medicine. 2007. DOI: 10.1177/0363546506294858

[51] Topical Glyceryl Trinitrate Application in the Treatment of Chronic Supraspinatus Tendinopathy. The American Journal of Sports Medicine. 2005. DOI: 10.1177/0363546504270998

[52] Magnetic Resonance Imaging Signal Abnormalities in Enthesopathy of the Extensor Carpi Radialis Longus Origin. The Journal of Hand Surgery. 2009. DOI: 10.1016/j.jhsa.2009.02.023

[53] Nonsurgical Treatments of Patellar Tendinopathy: Multiple Injections of Platelet-Rich Plasma Are a Suitable Option: A Systematic Review and Meta-analysis. The American Journal of Sports Medicine. 2018. DOI: 10.1177/0363546518759674

[54] Evaluation of Achilles and patellar tendinopathy with greyscale ultrasound and colour Doppler: using a four‐grade scale. Knee Surgery, Sports Traumatology, Arthroscopy. 2014. DOI: 10.1007/s00167-014-3270-4

[55] Increased fatigue of the biceps after tenotomy of the long head of biceps tendon. Knee Surgery, Sports Traumatology, Arthroscopy. 2018. DOI: 10.1007/s00167-018-5007-2

[56] The Use and Downstream Associations of Magnetic Resonance Imaging for Lateral Epicondylitis. The Journal of Hand Surgery. 2024. DOI: 10.1016/j.jhsa.2023.03.025

[57] Defining tennis elbow characteristics – The assessment of magnetic resonance imaging defined tendon pathology in an asymptomatic population. Shoulder & Elbow. 2022. DOI: 10.1177/17585732221146731

[58] Biceps-related complications after tenotomy associated with arthroscopic rotator cuff repair: risk factors and clinical impact. Orthopaedic Journal of Sports Medicine. 2022. DOI: 10.1177/2325967121s00362

[59] The Reliability and Validity of Magnetic Resonance Imaging in the Assessment of Chronic Lateral Epicondylitis. The Journal of Hand Surgery. 2011. DOI: 10.1016/j.jhsa.2010.11.040

[60] The Use of Elastography-Ultrasound in Diagnosing Tendinopathy Related Sport Injury : A 10 Years trend Systematic Review. Orthopaedic Journal of Sports Medicine. 2019. DOI: 10.1177/2325967119s00483

[61] Cost-effectiveness of rotator cuff repair based on modern constructs, tear size, and implant cost at 1, 5, and 10 years. JSES International. 2025. DOI: 10.1016/j.jseint.2025.04.038

[62] Interobserver Agreement in the Classification of Partial-Thickness Rotator Cuff Tears Using the Snyder Classification System. Orthopaedic Journal of Sports Medicine. 2016. DOI: 10.1177/2325967116667058

[63] Lateral Epicondylitis: Review and Current Concepts. The Journal of Hand Surgery. 2007. DOI: 10.1016/j.jhsa.2007.07.019

[64] The Effects of Posterior Rotator Cuff Cable Tears on Glenohumeral Biomechanics in a Cadaveric Model of the Throwing Shoulder. Orthopaedic Journal of Sports Medicine. 2017. DOI: 10.1177/2325967117s00373

[65] Comparison of scapular position and upper extremity muscle strength in patients with and without lateral epicondylalgia: a case-control study. Journal of Shoulder and Elbow Surgery. 2019. DOI: 10.1016/j.jse.2018.12.010

[66] Ultrasound-guided needling versus extracorporeal shock wave therapy. Journal of Shoulder and Elbow Surgery. 2015. DOI: 10.1016/j.jse.2014.12.006

[67] Surgical Treatment of Lateral Epicondylitis: A Prospective, Randomized, Double-Blinded, Placebo-Controlled Clinical Trial. The American Journal of Sports Medicine. 2018. DOI: 10.1177/0363546517753385

[68] Ultrasonic Percutaneous Tenotomy for Recalcitrant Lateral Elbow Tendinopathy. The American Journal of Sports Medicine. 2015. DOI: 10.1177/0363546515612758

[69] Ultrasonic Percutaneous Tenotomy for Recalcitrant Lateral Elbow Tendinopathy: Clinical and Sonographic Results at 90 Months. The American Journal of Sports Medicine. 2021. DOI: 10.1177/03635465211010158

[70] In Vivo Static Retraction and Dynamic Elongation of Rotator Cuff Repair Tissue After Surgical Repair: A Preliminary Analysis at 3 Months. Orthopaedic Journal of Sports Medicine. 2022. DOI: 10.1177/23259671221084294

[71] Influence of subscapularis tears on three-dimensional glenohumeral kinematics in patients with massive rotator cuff tears. Journal of Shoulder and Elbow Surgery. 2020. DOI: 10.1016/j.jse.2020.01.004

[75] Isotonic Evaluation of Wrist Extensors and Flexors of Tennis Elbow Patients Due to Job and Sport Related Factors. Journal of Shoulder and Elbow Surgery. 2021. DOI: 10.1016/j.jse.2021.03.113

[76] The detection of the capsular tear at the undersurface of the extensor carpi radialis brevis tendon in chronic tennis elbow: the value of magnetic resonance imaging and computed tomography arthrography. Journal of Shoulder and Elbow Surgery. 2011. DOI: 10.1016/j.jse.2010.12.002

[77] Chapter 6 Elbow Arthroscopy and the Thrower’s Elbow. 2019.

[78] Altered anconeus muscle activation characteristics during isometric gripping in individuals with lateral elbow tendinopathy compared with age- and sex-matched control. Journal of Shoulder and Elbow Surgery. 2025. DOI: 10.1016/j.jse.2024.11.001

[79] Effect of Elbow Position on Grip Strength in the Evaluation of Lateral Epicondylitis. The Journal of Hand Surgery. 2007. DOI: 10.1016/j.jhsa.2007.04.010

[80] Plantaris Excision Reduces Pain in Midportion Achilles Tendinopathy Even in the Absence of Plantaris Tendinosis. Orthopaedic Journal of Sports Medicine. 2016. DOI: 10.1177/2325967116673978

[81] Anthropometric Study of the Radio-Capitellar Joint. Journal of Shoulder and Elbow Surgery. 2015. DOI: 10.1016/j.jse.2015.05.018

[82] Supraspinatus-to-Glenoid Contact Occurs During Standardized Overhead Reaching Motion. Orthopaedic Journal of Sports Medicine. 2021. DOI: 10.1177/23259671211036908

[83] No Influence of Age, Gender, Weight, Height, and Impact Profile in Achilles Tendinopathy in Masters Track and Field Athletes. The American Journal of Sports Medicine. 2009. DOI: 10.1177/0363546509332250

[86] Muscle Fiber Contribution to Rotator Cuff Moment Arms During Abduction for Intact Rotator Cuff, Complete Supraspinatus Tear, Superior Capsular Reconstruction, and Reverse Shoulder Arthroplasty. (225). Orthopaedic Journal of Sports Medicine. 2021. DOI: 10.1177/2325967121s00333

[87] The Prognostic Value of Pain Sensitization in Patients With Lateral Epicondylitis. The Journal of Hand Surgery. 2019. DOI: 10.1016/j.jhsa.2018.06.013

[88] Natural course in tennis elbow—lateral epicondylitis after all?. Knee Surgery, Sports Traumatology, Arthroscopy. 2012. DOI: 10.1007/s00167-012-1939-0

[89] Calcific Tendinopathy of the Rotator Cuff: Pathogenesis, Diagnosis, and Management. Journal of the American Academy of Orthopaedic Surgeons. 1997. DOI: 10.5435/00124635-199707000-00001

[90] Distal biceps short head tears: repair, reconstruction, and systematic review. Journal of Shoulder and Elbow Surgery. 2020. DOI: 10.1016/j.jse.2020.04.038

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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.

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