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Diabetes and Upper-Limb Conditions

Why diabetes makes frozen shoulder, trigger finger, carpal tunnel syndrome and Dupuytren's more common, and how it affects healing and surgery.

36 citationsUpdated Aug 2026

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Overview

Assessment of upper limb locomotor disease in diabetes requires an estimate of glycaemic control and a search for other complications [1]. Examination of the hands and shoulders must be included in the evaluation of patients with diabetes [3]. Despite advances in medical management over the last two decades, the prevalence of musculoskeletal disorders in people with type 2 Diabetes mellitus remains high [4]. Musculoskeletal hand disorders were prevalent in type 2 diabetes mellitus patients in Jordan [36].

Diabetes exacerbates the burden of surgical upper-extremity infections, characterized by more proximal locations, deeper involved anatomy, broader pathogenic microbiology, increased need for repeat drainage, and higher risk for amputation [5]. The presence of diabetes mellitus rather than its severity was the most important factor for developing trigger digit [7]. The prevalence of frozen shoulder is less than previously reported but still greater in diabetic patients [14].

Shoulder involvement in periarthritis shows specific patterns in this population. Both shoulders were involved in 36 patients (4.5 per cent) with periarthritis of the shoulder, and there was a high incidence in insulin-dependent diabetics [2].

Background & Causes

Upper limb musculoskeletal abnormalities and poor metabolic control are associated in diabetes [1]. Assessment of upper limb locomotor disease in diabetes should include an estimate of glycaemic control [1]. Assessment of upper limb locomotor disease in diabetes should include a search for other complications [1] [1].

Limited joint mobility in diabetes shows continuing gradual deterioration with increasing duration of disease [6]. Finger joint contractures in diabetes are prevalent only in longstanding diabetics with a disease duration of nine years or more [6]. In adults with hand syndromes associated with diabetes, disability was related to impaired muscle function [16]. In adults with hand syndromes associated with diabetes, disability was related to carpal tunnel syndrome [16] [16]. Patients with painful shoulders, irrespective of having type 2 diabetes mellitus, seem to have abnormal shoulder muscles [15].

Infection: Diabetes exacerbates the burden of surgical upper-extremity infections, characterized by more proximal locations [5]. Diabetes exacerbates the burden of surgical upper-extremity infections, characterized by deeper involved anatomy [5]. Diabetes exacerbates the burden of surgical upper-extremity infections, characterized by broader pathogenic microbiology [5]. Diabetes exacerbates the burden of surgical upper-extremity infections, characterized by increased need for repeat drainage [5]. Diabetes exacerbates the burden of surgical upper-extremity infections, characterized by higher risk for amputation [5] [5].

Trigger Digit: The presence of diabetes mellitus rather than its severity was the most important factor for developing trigger digit after carpal tunnel release [7]. Corticosteroid injections in the hand transiently increase blood glucose levels in diabetic patients [10].

Frozen Shoulder: Type 2 diabetes may be a cause of frozen shoulder [20]. The effect of type 2 diabetes on frozen shoulder is not mediated by metabolic health [20]. Diabetes is a likely causal risk factor for frozen shoulder [29]. The causal pathway for diabetes as a risk factor for frozen shoulder likely involves long-term high blood glucose levels [29].

Carpal Tunnel Syndrome: Type 2 diabetes does not seem to be a risk factor for carpal tunnel syndrome [31]. Among patients with diabetes who had CTS, higher RAGE expression was observed in those with more severe disease [32]. RAGE-mediated pathways may play a role in the pathophysiology of CTS in patients with diabetes [32]. Molecular and pathological studies provide a potential basis for the predisposition of diabetic patients to the development of CTS [33].

Auricular Crepitus: Whole-transcriptome expression profiles demonstrate a fundamentally different underlying pathophysiology when comparing diabetic AC with idiopathic AC [34]. Diabetic AC and idiopathic AC are distinct clinical entities [34] [34].

Symptoms & Presentation

Diabetes mellitus is associated with a variety of hand manifestations, including stenosing tenosynovitis, Dupuytren's contracture, carpal tunnel syndrome, and limited joint mobility [19]. These conditions often present with multiple visits for hand conditions over time [19]. Limited joint mobility exhibits continuing gradual deterioration with increasing duration of disease [6]. Finger joint contractures are prevalent only in longstanding diabetics with a disease duration of nine years or more [6]. In adults with hand syndromes associated with diabetes, disability is related to impaired muscle function and carpal tunnel syndrome [16].

Shoulder pain and disability are common and persistent in adults with diabetes [8]. Patients with diabetes mellitus report shoulder pain and/or disability, with 63% (149/236) indicating such issues and a median SPADI score of 10.0 [13]. Diabetic patients experience more residual pain, reduced motion, and inferior function compared to idiopathic cases following arthroscopic capsular release for adhesive capsulitis [27]. However, patients with and without diabetes experience similar pain except during exertion in range of motion recovery of diabetic frozen shoulder [17].

The moderate correlations between upper and lower extremity range of motion, strength, and function suggest a concurrent development of musculoskeletal complications in people with DM [30].

Management

Assessment of upper limb locomotor disease in diabetes should include an estimate of glycaemic control and a search for other complications [1]. Examination of the hands and shoulders should be included in the evaluation of patients with diabetes [3].

Trigger Finger: Percutaneous release with or without simultaneous corticosteroid injection is equally effective and safe in diabetics and nondiabetics [22]. Excision of the ulnar slip of the flexor digitorum superficialis with or without A1 pulley release is a safe and effective treatment for stenosing flexor tenosynovitis in diabetic patients [24].

Adhesive Capsulitis: Platelet-rich plasma injection is a safe and well-tolerated method for adhesive capsulitis management in diabetic patients [23]. When shoulder mobilization was achievable with gentle manipulation under anesthesia, the outcome was satisfactory in both patients with IDDM and those with NIDDM [26]. Results of arthroscopic release for frozen shoulder in diabetics were significantly worse than those in non-diabetics six months post-operatively, with a tendency towards persistent limitation of movement two years after operation [18].

Corticosteroid Injections: Corticosteroid injections in the hand transiently increase blood glucose levels in diabetic patients [10]. Glycemic changes following steroid injection into the shoulder are short-lived, mostly limited to the 2-3 days after the injection, and none of the patients required any change in antidiabetic treatment [25].

The best current evidence supports the efficacy of surgical interventions for upper limb conditions in diabetic individuals, though additional research is required to determine whether treatment outcomes are equivalent to those of nondiabetic patients and whether diabetes is associated with an increased risk of complications [11].

Key Considerations

Diabetic patients exhibit specific musculoskeletal and surgical risk profiles that require careful preoperative assessment. Disease Progression: Limited joint mobility deteriorates gradually with increasing duration of disease [6]. Anatomic Predilection: Type II diabetes shows a predominance of hand involvement in musculoskeletal complications [12]. Surgical Risk Stratification: Insulin dependence is associated with an increased risk of complications after upper extremity surgery [9]. Conversely, non-insulin-dependent diabetes mellitus (NIDDM) patients do not have an increased rate of complications relative to nondiabetic patients [9].

Surgical interventions are supported by the best current evidence as efficacious for managing upper limb conditions in diabetic individuals [11]. However, outcomes vary by procedure. Arthroscopic Release for Frozen Shoulder: Results are significantly worse than in non-diabetics at six months post-operatively [18]. There is a tendency toward persistent limitation of movement two years after arthroscopic release in diabetic patients [18]. Carpal Tunnel Release: Long-term improvement remains to the same extent as for patients without diabetes [35]. Patients with diabetes experience more symptoms both before and after open carpal tunnel release, yet they can expect the same relative improvement as patients without diabetes [37].

Infection Epidemiology: More than one third of patients with diabetic hand infections are diabetic [38]. Future research is required to determine whether treatment outcomes for diabetic patients are equivalent to those of nondiabetic patients [11]. Additional research is also needed to determine whether diabetes is associated with an increased risk of complications [11]. Long-term prospective randomised controlled trials on the effects of exercise in preventing musculoskeletal complications and disability in diabetics are needed [12].

Key Evidence

  • [L3] Assessment of upper limb locomotor disease in diabetes should include an estimate of glycaemic control and a search for other complications. [1] (10.1016/j.ejim.2009.08.001)
  • [L4] In 36 patients (4.5 per cent.), both shoulders were involved and there was a high incidence in insulin-dependent diabetics. [2] (10.1136/ard.31.1.69)
  • [L3] Examination of the hands and shoulders should be included in the evaluation of patients with diabetes. [3] (10.1016/s0002-9343(02)01045-8)
  • [L3] The prevalence of musculoskeletal disorders in people with type 2 Diabetes mellitus remains high despite advances in medical management over the last two decades. [4] (10.1016/j.jht.2021.04.013)
  • [L2] Diabetes exacerbates the burden of surgical upper-extremity infections, characterized by more proximal locations, deeper involved anatomy, broader pathogenic microbiology, increased need for repeat drainage, and higher risk for amputation. [5] (10.1016/j.jhsa.2017.11.003)
  • [L3] There is continuing gradual deterioration with increasing duration of disease, though finger joint contractures are prevalent only in longstanding diabetics with a disease duration of nine years or more. [6] (10.1136/ard.44.2.93)
  • [L4] The presence of diabetes mellitus rather than its severity was the most important factor for developing trigger digit. [7] (10.1016/j.jhsa.2013.10.023)
  • [L4] Shoulder pain and disability are common, and persistent in adults with diabetes. [8] (10.1093/rheumatology/ken333)
  • [L2] The NIDDM patients did not have an increased rate of complications relative to nondiabetic patients. [9] (10.1016/j.jhsa.2018.06.006)
  • [L3] Corticosteroid injections in the hand transiently increase blood glucose levels in diabetic patients. [10] (10.1016/j.jhsa.2014.01.014)
  • [L4] The best current evidence supports the efficacy of surgical interventions for the management of these conditions in diabetic individuals; however, additional research is required to determine whether the treatment outcomes are equivalent to those of nondiabetic patients, and whether diabetes is associated with an increased risk of complications. [11] (10.1016/j.jhsa.2011.10.002)
  • [L3] Long-term prospective randomised controlled trials on the effects of exercise in preventing musculoskeletal complications and disability in diabetics are needed. [12] (10.1007/s10067-003-0704-7)
  • [L3] Patients with diabetes mellitus reported shoulder pain and/or disability, with 63% (149/236) indicating such issues and a median SPADI score of 10.0. [13] (10.1016/j.physio.2014.07.003)
  • [L3] The prevalence of frozen shoulder is less than previously reported but still greater in diabetic patients. [14] (10.1016/j.jse.2007.02.133)
  • [L3] Patients with painful shoulders, irrespective of having type 2 diabetes mellitus, seem to have abnormal shoulder muscles. [15] (10.1186/s12891-022-05627-9)
  • [L4] In adults with hand syndromes associated with diabetes, disability was related to impaired muscle function and carpal tunnel syndrome. [16] (10.3899/jrheum.090239)
  • [L3] Patients with and without diabetes experienced similar pain except during exertion. [17] (10.1177/0300060516675112)
  • [L3] The results in diabetics were significantly worse than those in non-diabetics six months post-operatively with a tendency towards persistent limitation of movement two years after operation. [18] (10.1302/0301-620x.96b10.34476)
  • [L4] Diabetes mellitus is associated with a variety of hand manifestations including stenosing tenosynovitis, Dupuytren's contracture, carpal tunnel syndrome, and limited joint mobility, which often present with multiple visits for hand conditions over time. [19] (10.1016/j.jhsa.2008.01.038)
  • [L2] This study suggests that type 2 diabetes may be a cause of frozen shoulder but does not support the hypothesis that the effect is mediated by metabolic health. [20] (10.1186/s12891-025-08672-2)
  • [L4] Percutaneous release with or without simultaneous corticosteroid injection has shown promising results and is equally effective and safe in diabetics and nondiabetics. [22] (10.1016/j.jhsa.2018.03.045)
  • [L3] Additionally, it is a safe and well-tolerated method for AC management for diabetic patients. [23] (10.5397/cise.2021.00381)
  • [L4] This procedure is a safe and effective treatment for the often-difficult problem of stenosing flexor tenosynovitis in the diabetic patient. [24] (10.1007/s11552-007-9065-z)
  • [L2] These glycemic changes are short-lived, mostly limited to the 2-3 days after the injection, and none of the patients required any change in antidiabetic treatment. [25] (10.1016/j.jseint.2022.05.016)
  • [L3] When shoulder mobilization was achievable with gentle manipulation under anesthesia, the outcome was satisfactory in both patients with IDDM and those with NIDDM. [26] (10.1067/mse.2002.127301)
  • [L4] However, diabetic patients are reported to have more residual pain, reduced motion and inferior function compared to idiopathic cases. [27] (10.1016/j.otsr.2019.02.014)
  • [L1] Diabetes is a likely causal risk factor for frozen shoulder, likely through a pathway involving long-term high blood glucose levels. [29] (10.1371/journal.pgen.1009577)
  • [L4] The moderate correlations between upper and lower extremity range of motion, strength, and function suggest a concurrent development of musculoskeletal complications in people with DM. [30] (10.1016/j.foot.2020.101680)
  • [L3] Type 2 diabetes does not seem to be a risk factor for carpal tunnel syndrome. [31] (10.1186/1471-2474-15-346)
  • [L2] Among patients with diabetes who had CTS, higher RAGE expression was observed in those with more severe disease, suggesting that RAGE-mediated pathways may play a role in the pathophysiology of CTS in patients with diabetes. [32] (10.1097/corr.0000000000003800)
  • [L4] It therefore provides a potential molecular and pathological basis for the predisposition of diabetic patients to the development of CTS. [33] (10.1007/s00125-014-3271-3)
  • [L5] Whole-transcriptome expression profiles demonstrate a fundamentally different underlying pathophysiology when comparing diabetic AC with idiopathic AC, suggesting that these conditions are distinct clinical entities. [34] (10.1016/j.jse.2021.06.016)
  • [L2] Long-term improvement in patients with diabetes remained after carpal tunnel release to the same extent as for patients without diabetes. [35] (10.1016/j.jhsa.2014.01.012)
  • [L4] In the present study, musculoskeletal hand disorders were prevalent in T2DM patients in Jordan. [36] (10.1111/1756-185x.12617)
  • [L3] Patients with diabetes experience more symptoms both before and after open carpal tunnel release, but can expect the same relative improvement from surgery as patients without diabetes. [37] (10.1136/bmjopen-2019-030179)
  • [L4] Analysis of the authors' clinical series demonstrates that more than one third of the patients are diabetic. [38] (10.1016/s0749-0712(21)00424-8)

References

[1] Upper limb musculoskeletal abnormalities and poor metabolic control in diabetes. European Journal of Internal Medicine. 2009. DOI: 10.1016/j.ejim.2009.08.001

[2] Periarthritis of the shoulder and diabetes mellitus.. Annals of the Rheumatic Diseases. 1972. DOI: 10.1136/ard.31.1.69

[3] Musculoskeletal disorders of the hand and shoulder in patients with diabetes mellitus. The American Journal of Medicine. 2002. DOI: 10.1016/s0002-9343(02)01045-8

[4] Proportion and distribution of upper extremity musculoskeletal disorders and its association with disability in type 2 diabetes mellitus. Journal of Hand Therapy. 2022. DOI: 10.1016/j.jht.2021.04.013

[5] Quantifying the Effect of Diabetes on Surgical Hand and Forearm Infections. The Journal of Hand Surgery. 2018. DOI: 10.1016/j.jhsa.2017.11.003

[6] Limited joint mobility in diabetes mellitus.. Annals of the Rheumatic Diseases. 1985. DOI: 10.1136/ard.44.2.93

[7] The Incidence of Trigger Digit After Carpal Tunnel Release in Diabetic and Nondiabetic Patients. The Journal of Hand Surgery. 2014. DOI: 10.1016/j.jhsa.2013.10.023

[8] Predictors of shoulder pain and shoulder disability after one year in diabetic outpatients. Rheumatology. 2008. DOI: 10.1093/rheumatology/ken333

[9] Insulin Dependence Is Associated With Increased Risk of Complications After Upper Extremity Surgery in Diabetic Patients. The Journal of Hand Surgery. 2018. DOI: 10.1016/j.jhsa.2018.06.006

[10] Blood Glucose Levels in Diabetic Patients Following Corticosteroid Injections Into the Hand and Wrist. The Journal of Hand Surgery. 2014. DOI: 10.1016/j.jhsa.2014.01.014

[11] Impact of Diabetes on Outcomes in Hand Surgery. The Journal of Hand Surgery. 2011. DOI: 10.1016/j.jhsa.2011.10.002

[12] The musculoskeletal complications seen in type II diabetics: predominance of hand involvement. Clinical Rheumatology. 2003. DOI: 10.1007/s10067-003-0704-7

[13] Upper extremity impairments, pain and disability in patients with diabetes mellitus. Physiotherapy. 2015. DOI: 10.1016/j.physio.2014.07.003

[14] Prevalence of symptoms and signs of shoulder problems in people with diabetes mellitus. Journal of Shoulder and Elbow Surgery. 2007. DOI: 10.1016/j.jse.2007.02.133

[15] Shoulder muscle changes in patients with type 2 diabetes mellitus who have a painful shoulder: a quantitative muscle ultrasound study. BMC Musculoskeletal Disorders. 2022. DOI: 10.1186/s12891-022-05627-9

[16] Hand Syndromes Associated with Diabetes: Impairments and Obesity Predict Disability. The Journal of Rheumatology. 2009. DOI: 10.3899/jrheum.090239

[17] Range of motion of diabetic frozen shoulder recovers to the contralateral level. Journal of International Medical Research. 2016. DOI: 10.1177/0300060516675112

[18] Comparative outcome of arthroscopic release for frozen shoulder in patients with and without diabetes. The Bone & Joint Journal. 2014. DOI: 10.1302/0301-620x.96b10.34476

[19] Hand Manifestations of Diabetes Mellitus. The Journal of Hand Surgery. 2008. DOI: 10.1016/j.jhsa.2008.01.038

[20] Type 2 diabetes, metabolic health, and the development of frozen shoulder: a cohort study in UK electronic health records. BMC Musculoskeletal Disorders. 2025. DOI: 10.1186/s12891-025-08672-2

[22] Management of Diabetic Trigger Finger. The Journal of Hand Surgery. 2019. DOI: 10.1016/j.jhsa.2018.03.045

[23] The benefit of platelet-rich plasma injection over institution-based physical therapy program in adhesive capsulitis patients with diabetes mellitus: prospective observational cohort study. Clinics in Shoulder and Elbow. 2021. DOI: 10.5397/cise.2021.00381

[24] Treating Trigger Finger in Diabetics Using Excision of the Ulnar Slip of the Flexor Digitorum Superficialis with or without A1 Pulley Release. HAND. 2007. DOI: 10.1007/s11552-007-9065-z

[25] The effect of steroid injection into the shoulder on glycemia in patients with type 2 diabetes. JSES International. 2022. DOI: 10.1016/j.jseint.2022.05.016

[26] Operative management of the frozen shoulder in patients with diabetes. Journal of Shoulder and Elbow Surgery. 2002. DOI: 10.1067/mse.2002.127301

[27] Comparison of outcomes following arthroscopic capsular release for idiopathic, diabetic and secondary shoulder adhesive capsulitis: A Systematic Review. Orthopaedics & Traumatology: Surgery & Research. 2019. DOI: 10.1016/j.otsr.2019.02.014

[29] A genome-wide association study identifies 5 loci associated with frozen shoulder and implicates diabetes as a causal risk factor. PLOS Genetics. 2021. DOI: 10.1371/journal.pgen.1009577

[30] Relationships within and between lower and upper extremity dysfunction in people with diabetes. The Foot. 2020. DOI: 10.1016/j.foot.2020.101680

[31] Type 2 diabetes seems not to be a risk factor for the carpal tunnel syndrome: a case control study. BMC Musculoskeletal Disorders. 2014. DOI: 10.1186/1471-2474-15-346

[32] Is RAGE Expression in Flexor Tendon Synovium Associated With Carpal Tunnel Syndrome in Patients With Diabetes?. Clinical Orthopaedics & Related Research. 2025. DOI: 10.1097/corr.0000000000003800

[33] Molecular and pathological studies in the posterior interosseous nerve of diabetic and non-diabetic patients with carpal tunnel syndrome. Diabetologia. 2014. DOI: 10.1007/s00125-014-3271-3

[34] Evaluating whole-genome expression differences in idiopathic and diabetic adhesive capsulitis. Journal of Shoulder and Elbow Surgery. 2022. DOI: 10.1016/j.jse.2021.06.016

[35] Carpal Tunnel Release in Patients With Diabetes: A 5-Year Follow-Up With Matched Controls. The Journal of Hand Surgery. 2014. DOI: 10.1016/j.jhsa.2014.01.012

[36] Musculoskeletal disorders of the hand in type 2 diabetes mellitus: prevalence and its associated factors. International Journal of Rheumatic Diseases. 2015. DOI: 10.1111/1756-185x.12617

[37] Open carpal tunnel release and diabetes: a retrospective study using PROMs and national quality registries. BMJ Open. 2019. DOI: 10.1136/bmjopen-2019-030179

[38] DIABETIC HAND INFECTIONS. Hand Clinics. 1998. DOI: 10.1016/s0749-0712(21)00424-8

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a. UNLESS OTHERWISE SEPARATELY UNDERTAKEN BY THE LICENSOR, TO THE EXTENT POSSIBLE, THE LICENSOR OFFERS THE LICENSED MATERIAL AS-IS AND AS-AVAILABLE, AND MAKES NO REPRESENTATIONS OR WARRANTIES OF ANY KIND CONCERNING THE LICENSED MATERIAL, WHETHER EXPRESS, IMPLIED, STATUTORY, OR OTHER. THIS INCLUDES, WITHOUT LIMITATION, WARRANTIES OF TITLE, MERCHANTABILITY, FITNESS FOR A PARTICULAR PURPOSE, NON-INFRINGEMENT, ABSENCE OF LATENT OR OTHER DEFECTS, ACCURACY, OR THE PRESENCE OR ABSENCE OF ERRORS, WHETHER OR NOT KNOWN OR DISCOVERABLE. WHERE DISCLAIMERS OF WARRANTIES ARE NOT ALLOWED IN FULL OR IN PART, THIS DISCLAIMER MAY NOT APPLY TO YOU.

b. TO THE EXTENT POSSIBLE, IN NO EVENT WILL THE LICENSOR BE LIABLE TO YOU ON ANY LEGAL THEORY (INCLUDING, WITHOUT LIMITATION, NEGLIGENCE) OR OTHERWISE FOR ANY DIRECT, SPECIAL, INDIRECT, INCIDENTAL, CONSEQUENTIAL, PUNITIVE, EXEMPLARY, OR OTHER LOSSES, COSTS, EXPENSES, OR DAMAGES ARISING OUT OF THIS PUBLIC LICENSE OR USE OF THE LICENSED MATERIAL, EVEN IF THE LICENSOR HAS BEEN ADVISED OF THE POSSIBILITY OF SUCH LOSSES, COSTS, EXPENSES, OR DAMAGES. WHERE A LIMITATION OF LIABILITY IS NOT ALLOWED IN FULL OR IN PART, THIS LIMITATION MAY NOT APPLY TO YOU.

c. The disclaimer of warranties and limitation of liability provided above shall be interpreted in a manner that, to the extent possible, most closely approximates an absolute disclaimer and waiver of all liability.

Section 6 -- Term and Termination.

a. This Public License applies for the term of the Copyright and Similar Rights licensed here. However, if You fail to comply with this Public License, then Your rights under this Public License terminate automatically.

b. Where Your right to use the Licensed Material has terminated under Section 6(a), it reinstates:

1. automatically as of the date the violation is cured, provided it is cured within 30 days of Your discovery of the violation; or

2. upon express reinstatement by the Licensor.

For the avoidance of doubt, this Section 6(b) does not affect any right the Licensor may have to seek remedies for Your violations of this Public License.

c. For the avoidance of doubt, the Licensor may also offer the Licensed Material under separate terms or conditions or stop distributing the Licensed Material at any time; however, doing so will not terminate this Public License.

d. Sections 1, 5, 6, 7, and 8 survive termination of this Public License.

Section 7 -- Other Terms and Conditions.

a. The Licensor shall not be bound by any additional or different terms or conditions communicated by You unless expressly agreed.

b. Any arrangements, understandings, or agreements regarding the Licensed Material not stated herein are separate from and independent of the terms and conditions of this Public License.

Section 8 -- Interpretation.

a. For the avoidance of doubt, this Public License does not, and shall not be interpreted to, reduce, limit, restrict, or impose conditions on any use of the Licensed Material that could lawfully be made without permission under this Public License.

b. To the extent possible, if any provision of this Public License is deemed unenforceable, it shall be automatically reformed to the minimum extent necessary to make it enforceable. If the provision cannot be reformed, it shall be severed from this Public License without affecting the enforceability of the remaining terms and conditions.

c. No term or condition of this Public License will be waived and no failure to comply consented to unless expressly agreed to by the Licensor.

d. Nothing in this Public License constitutes or may be interpreted as a limitation upon, or waiver of, any privileges and immunities that apply to the Licensor or You, including from the legal processes of any jurisdiction or authority.

Creative Commons is not a party to its public licenses. Notwithstanding, Creative Commons may elect to apply one of its public licenses to material it publishes and in those instances will be considered the “Licensor.” The text of the Creative Commons public licenses is dedicated to the public domain under the CC0 Public Domain Dedication. Except for the limited purpose of indicating that material is shared under a Creative Commons public license or as otherwise permitted by the Creative Commons policies published at creativecommons.org/policies, Creative Commons does not authorize the use of the trademark "Creative Commons" or any other trademark or logo of Creative Commons without its prior written consent including, without limitation, in connection with any unauthorized modifications to any of its public licenses or any other arrangements, understandings, or agreements concerning use of licensed material. For the avoidance of doubt, this paragraph does not form part of the public licenses.

Creative Commons may be contacted at creativecommons.org.