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Numbness and Tingling in the Hand and Arm

What causes numbness, tingling or 'pins and needles' in the hand and arm — from carpal tunnel and cubital tunnel to other nerve problems — when it matters, and what helps.

50 citationsUpdated Oct 2026
Illustration: Numbness and Tingling in the Hand and Arm

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Overview

Carpal tunnel syndrome (CTS) is the most frequent entrapment neuropathy of the upper limb [12], with incidence rising 43% between 1996 and 2005, driven largely by an aging population [27]. A significant discordance exists between the estimated prevalence of mild-to-moderate CTS based on clinical signs and symptoms (73%) versus electrodiagnostic studies and ultrasound (51%) [23]. Consequently, when clinical findings suggest mild-to-moderate median neuropathy and surgery is considered, additional testing such as electrodiagnostic studies or ultrasound is recommended to confirm the presence of median neuropathy amenable to surgical benefit [5]. Specific nerve conduction studies further aid in differentiating true compression symptoms from nonspecific polyneuropathies [6].

Diagnosis relies on identifying at least one of three major clinical signs: hypoesthesia restricted to the median distribution in the hand, a positive Tinel sign with light tapping over the median nerve at the wrist, and a positive wrist-flexion test [14]. Tinel’s sign demonstrates a sensitivity of 50% and specificity of 77%, while the carpal compression test shows a sensitivity of 64% and specificity of 83% [36]. Notably, Tinel's sign was present in 29% of subjects without CTS and 45% of those with the condition [8]. Systematic study of tingling caused by nerve pressure helps determine whether nerve interruption is complete or partial, localizes the injury, and detects early axonal regeneration [4]. The tingling response may be classified by its location and the magnitude threshold required to trigger it [2].

Patients with a history of ulnar nerve lesions face a significantly increased risk of developing CTS, particularly within the first two years [15]. Anomalous muscles invading the carpal canal are reported more frequently than any other cause of median nerve compression [26]. Upper-extremity neuropathy can also develop following non-upper extremity surgeries, particularly anterior cervical discectomy and fusion [7]. In neuropathy rehabilitation, assessment of position and tactile sensations is essential for determining participation in manual skills [11]. Evaluating a patient with a nerve injury in the hand requires consideration of four areas: type of injury, sensibility evaluation, motor function, and sudomotor function [28]. Normal two-point discrimination is usually 6 mm or less [28]; transected nerves result in an inability to feel light touch, appreciate sharp stimuli, or discriminate between one and two points [28], whereas closed or partial injuries may present with spotty appreciation of light touch and pain and markedly widened two-point discrimination [28].

Background & Causes

Entrapment Neuropathies

Radial tunnel syndrome is a relatively uncommon but important cause of lateral forearm pain [13]. In cubital tunnel syndrome, dislocation of the ulnar nerve is not an important factor among the causes; the tendinous arch is the important factor [56]. Upper-extremity neuropathy can develop following non-upper extremity surgeries, particularly anterior cervical discectomy and fusion (ACDF) [7].

Pathophysiology and Mechanisms

The histopathologic findings of chronic nerve compression span a spectrum beginning with breakdown of the blood-nerve barrier and progressing to axonal degeneration with continued compression [29]. Patient signs, symptoms, and sensory testing parallel the histopathologic changes occurring in the nerve [29]. Abnormal postures or positions can compress nerves or place them on tension, leading to chronic nerve compression [29]. These positions can also place muscles in shortened positions, leading to secondary effects [29], or weaken muscles in elongated or shortened positions, leading to underuse and compensatory overuse of other muscles [29]. A rise above a critical pressure brought about by vascular congestion would explain the clinical picture of predominantly nocturnal symptoms and no electro-physiological evidence with the wrist in a neutral resting position [63]. The authors were unable to confirm the association of bilateral disease with amyloid or the association with trigger digits in idiopathic carpal tunnel syndrome [58].

Clinical Presentation and Signs

Numbness or tingling indicates a neurologic problem rather than a mechanical one [47]. Systematic study of tingling caused by pressure on the nerve enables determination of whether nerve interruption is complete or partial, determination of exact location and extent of injury, and detection of axon regeneration at an early stage [4]. Tinel's sign may be present only in certain stages of carpal tunnel syndrome, but when present is quite specific [32]. The surgeon should observe one or more of three major clinical signs of carpal tunnel syndrome: * Hypoesthesia: restricted to the median distribution in the hand * Tinel sign: positive with light tapping over the median nerve at the wrist * Wrist-flexion test: positive [14]

Clinical tests for carpal tunnel syndrome have poorer specificity (more false-positive results) when evaluated among symptomatic CTS-free subjects than among asymptomatic CTS-free subjects [60]. As the severity of ulnar neuropathy at the elbow increases, the cross-sectional area (CSA) of the ulnar nerve correspondingly increases at the elbow [20].

Diagnostic Considerations

A careful history suggests the correct diagnosis in approximately 90% of patients with hand problems [47]. Radial tunnel syndrome diagnosis relies crucially on clinical examination [13]. When signs and symptoms suggest mild-to-moderate median neuropathy and surgery is being considered, patients and clinicians might consider additional testing, such as electrodiagnostic studies (EDS) or ultrasound (US), to increase the probability of actual median neuropathy that can benefit from surgery [5].

Symptoms & Presentation

The primary clinical indicators of carpal tunnel syndrome include hypoesthesia restricted to the median distribution in the hand, a positive Tinel sign elicited by light tapping over the median nerve at the wrist, and a positive wrist-flexion test [14]. While Tinel's sign may be present only in certain stages of the condition, it is considered quite specific when detected [32]. Diagnostic performance varies between these maneuvers; Tinel's sign demonstrates an estimated sensitivity of 50% and specificity of 77% for detecting carpal tunnel syndrome [36], whereas carpal compression shows an estimated sensitivity of 64% and specificity of 83% [36]. Surgeons are encouraged to bear anatomic anomalies in mind when assessing patients with symptoms of median nerve compression [31].

Radial tunnel syndrome represents an important cause of lateral forearm pain, where clinical examination is a crucial part of the diagnosis [13]. Neuropathy symptoms following shoulder surgery were often refractory to conservative management [18]. In cases where double crush syndrome is suspected but symptoms are mild, they may respond to conservative treatment [25].

Management

Diagnostic and Preoperative Assessment

Systematic study of tingling caused by nerve pressure determines whether nerve interruption is complete or partial, identifies the exact location and extent of injury, and detects early axon regeneration [4]. The tingling response is classified by its location and the magnitude threshold triggering the response [2]. Clinical examination remains crucial for diagnosing radial tunnel syndrome [13]. For carpal tunnel syndrome, the surgeon must observe one or more of three major signs: hypoesthesia restricted to the median distribution in the hand, a positive Tinel sign with light tapping over the median nerve at the wrist, and a positive wrist-flexion test [14]. When signs suggest mild-to-moderate median neuropathy and surgery is considered, electrodiagnostic studies or ultrasound may increase the probability of actual median neuropathy benefiting from surgery [5]. Specific nerve conduction studies differentiate true compression symptoms from nonspecific polyneuropathies [6].

Evaluation of hand nerve injury requires consideration of four areas: type of injury, sensibility evaluation, motor function, and sudomotor function [28]. Normal two-point discrimination is usually 6 mm or less [28]. Pain evaluation questionnaires incorporating body diagrams, subjective questions, and visual analog scales are useful for evaluating nerve compression or diffuse symptoms [29]. Several validated instruments assess specific domains: * Carpal Tunnel Syndrome Questionnaire: Assesses symptom severity (11 items) and functional status (8 items); reliable, valid, and sensitive to change [29]. * Disabilities of Arm, Shoulder, and Hand (DASH): A generic upper extremity disability measure allowing comparison across conditions [29]. * Michigan Hand Outcomes Questionnaire (MHQ): A 67-item instrument addressing overall hand function, physical function, cosmesis, and satisfaction [29]. * Patient-Specific Functional Scale (PSFS): Assesses patient-identified activities or tasks that are difficult or impossible to perform [29].

Electrodiagnostic studies by an experienced examiner are critical for differential diagnosis and localization of compression in failed cubital tunnel syndrome [45]. High-resolution nerve-specific magnetic resonance imaging helps identify swelling or signal changes in the axillary nerve at the compression site [50].

Non-Operative Management

Conservative treatments, specifically manual therapies such as massage and mobilization, are recommended as first-line treatments for carpal tunnel syndrome [52]. Sensory interventions for upper limb conditions are inexpensive, noninvasive, and easy to perform, allowing implementation into conventional therapy practice in any setting [53]. For ulnar nerve entrapment at the elbow, 24% of patients treated with the drop-out splint demonstrated complete resolution of symptoms [10].

In thoracic outlet syndrome, tricyclic antidepressants, neurotropics, or low doses of benzodiazepines may help patients sleep [39]. Narcotics should rarely be prescribed preoperatively for this condition [39]. Regarding vascular malformations, a fitted compression glove can effectively treat lesions that swell when dependent or with activity [40]. Asymptomatic vascular malformations in the hand can usually be left alone [40].

Operative Management

Surgical decompression of neuropathy symptoms following shoulder surgery led to nearly 90% symptom resolution [18]. For severe chronic ulnar nerve compression, anterior interosseous nerve transfer along with cubital and ulnar tunnel release results in sustained clinical and electrophysiological improvements [55]. Hand abduction tracings serve as a quantitative outcome measure to follow recovery of intrinsic hand function over time in these patients [22].

Radial sensory nerve release is performed at the point of compression between the tendons of the extensor carpi radialis longus and brachioradialis [41]. A full tenotomy of the brachioradialis tendon is performed, with a portion resected to completely decompress the nerve [41]. A bioresorbable adhesion barrier may be placed over the nerve to decrease scarring [41]. For recurrent carpal tunnel syndrome, a minimally invasive surgical option using a synovial flap is part of the therapeutic arsenal [33]. Endoscopic management requires rigorous patient selection, specifically for true recurrences without obvious etiology or trophic disorders [19]. The most common intraoperative findings in recurrent carpal tunnel surgery are incomplete release of the flexor retinaculum and median nerve adherence to surrounding tissue [50]. Electrodiagnostic studies for recurrent carpal tunnel syndrome may not be particularly helpful due to persistent electrical changes after successful surgery, but should be performed as a baseline [50].

Upper-extremity neuropathy can develop following nonupper extremity surgeries, particularly anterior cervical discectomy and fusion [7]. In patients with a history of ulnar nerve lesions, there is a significantly increased risk of developing carpal tunnel syndrome, especially within the first 2 years [15]. More than 50% of patients who did not undergo carpal tunnel release at the initial surgery for perilunate injuries required a release within the follow-up period [35]. Invasive treatments for double crush syndrome should be initiated preferentially at sites with greater clinical suspicion [25].

If a second surgery is considered for advanced nerve damage, the probability that it will address pathophysiology is low, as 11 to 17 of 28 reviewed patients had signs of advanced and likely permanent nerve damage [9]. If a patient has undergone more than two surgical attempts to correct a nerve compression problem, it is less likely that a third operation will be helpful [50]. For injury to the superficial branch of the radial nerve complicated by complex regional pain syndrome, treatment options include proximal transection of the nerve in normal tissue, exploration with neurolysis, or repair [42]. When repairing an injured superficial radial nerve with complex regional pain syndrome, a sural nerve is preferred for interposition grafting to avoid a potential nociceptive focus in the same extremity [42]. Postoperative reactivation of the dystrophic process in complex regional pain syndrome can be minimized by maintaining a continuous autonomic blockade for 3 to 5 days after surgery [42].

Surgery on contracted joints secondary to complex regional pain syndrome should not be performed until maximal nonoperative improvement has been achieved, with a waiting period of a minimum of 3 to 6 months after successful elimination of active dystrophic pain [37]. Indications for surgical release of metacarpophalangeal or proximal interphalangeal joints in complex regional pain syndrome include joint pain without diffuse dystrophic symptoms and arthrofibrosis that interferes with function [37]. Restoration of full flexion or extension is an unreasonable goal for surgical correction of chronic deformities after complex regional pain syndrome [37].

Postoperative management following median nerve compression surgery involves removing the dressing 2 to 3 days after surgery and starting general range-of-motion exercises [50]. A sling can be used at night for comfort for 3 weeks [50]. Patients are referred for therapy postoperatively to assist with restoration of range of motion and strength [50]. In patients with a motor deficit following failed nerve compression surgery, nerve graft, nerve transfer, or tendon transfers are considered [50]. If pain is the primary problem following failed nerve compression surgery, a peripheral nerve stimulator or dorsal column stimulator can be considered [50].

Decompressing known areas of compression can enhance nerve regeneration in patients with incomplete nerve injuries [50]. Proximal nerve decompression may be needed in cases of macrodactyly with concurrent compressive neuropathy [51]. Resection of a digital nerve for macrodactyly may result in a sensory deficit that is often less than expected, as the remaining nerve is adequate to supply the entire skin envelope [51]. Caution is advised for resection of digital nerves on the radial side of the index and the ulnar side of the thumb, as loss of sensibility would interfere with pinch [51].

Transfer of a neurovascular island graft is useful for restoring sensibility to critical areas of a digit in cases of permanent nerve damage [43]. Sensibility in a neurovascular island graft is never normal after transfer, and more than half of patients have persistently hyperesthetic skin [43]. Surgical excision of symptomatic venous malformations in the hand usually reduces pain and improves function for a significant period of time [40]. An aggressive surgical approach in symptomatic vascular lesions in the hand leads to acceptable outcomes with low complication rates, except in the worst high-flow lesions [40].

Key Considerations

Diagnosis and Clinical Assessment

Surgeons should bear bifid median nerve anomalies in mind when assessing patients with symptoms of median nerve compression [31].

Etiology and Risk Factors

No specific etiological risk factors are detailed in the provided evidence for this section.

Surgical Management and Outcomes

Refractory Neuropathy: Neuropathy symptoms were often refractory to conservative management, while surgical decompression led to nearly 90% symptom resolution following shoulder surgery [18].

Ulnar Nerve Interventions: Decompressing the deep motor branch of the ulnar nerve caused by heterotopic ossification allowed for spontaneous nerve recovery and reinnervation of ulnar nerve innervated intrinsic muscles [57]. At 6 months, EMG analysis showed no residual compression and good release of the ulnar nerve in all cases following endoscopic neurolysis [61].

Recurrent Carpal Tunnel Syndrome: Treatment requires rigorous patient selection, specifically for true recurrences without obvious etiology or trophic disorders [19]. A minimally invasive surgical option using a synovial flap should be part of the therapeutic arsenal for recurrent carpal tunnel syndromes [33]. In a review of 28 patients with advanced nerve damage, the probability that a second surgery will address pathophysiology is low [9].

Diagnostic Exclusion: In 250 patients with carpal tunnel syndrome over 6 years, no patient had a late diagnosis of distal ulnar nerve compression after prior carpal tunnel release [62].

Conservative Management and Rehabilitation

Complete recovery of shoulder function and relief of symptoms was achieved in both cases of long thoracic nerve paralysis associated with thoracic outlet syndrome at 8 and 13 months, respectively, after application of the orthosis [24].

Outcome Measurement

Hand abduction tracings are a quantitative outcome measure to follow recovery over time for intrinsic hand function and can be used in patients with severe ulnar neuropathy following surgical intervention [22].

Key Evidence

  • [L5] The tingling response may then be classified according to its location and to the magnitude threshold at which the response is triggered. [2] (10.1016/s0894-1130(99)80068-4)
  • [L5] The authors emphasize the need for clear definitions of recurrence versus persistent compression neuropathy, agreements on supplementary diagnostics, and standardized outcome measurements to enable comparing results from different techniques and clinics. [3] (10.1177/17531934241311822)
  • [L5] The systematic study of tingling caused by pressure on the nerve very often enables us to find out if the interruption to the nerve is complete or partial, determine the exact location and the extent of the injury, and detect regeneration of the axons at an early stage. [4] (10.1016/j.jhsb.2004.10.007)
  • [L3] When signs and symptoms suggest mild-to-moderate median neuropathy and surgery is being considered, patients and clinicians might consider additional testing, such as EDS or US, to increase the probability of actual median neuropathy that can benefit from surgery. [5] (10.1097/corr.0000000000002751)
  • [L4] Specific nerve conduction studies helped differentiate true compression symptoms from nonspecific polyneuropathies. [6] (10.1016/s0363-5023(81)80059-7)
  • [L3] Upper-extremity neuropathy can develop following nonupper extremity surgeries, particularly ACDF. [7] (10.1016/j.jhsg.2026.100972)
  • [L5] They note that Tinel's sign was present in 29% of subjects who did not have carpal tunnel syndrome and in 45% of those with carpal tunnel syndrome. [8] (10.1016/j.jhsa.2004.02.009)
  • [L4] Of these patients, 24% demonstrated complete resolution of their symptoms, whereas another 24% of the patients subsequently required surgical decompression of the nerve. [10] (10.1016/s0894-1130(12)80378-4)
  • [L3] In neuropathy rehabilitation, the assessment of position and tactile sensations should not be ignored in determining participation in manual skills. [11] (10.1016/j.jht.2024.12.005)
  • [Paper] Carpal tunnel syndrome is the most frequent among entrapment neuropathies at the upper limb. [12] (10.1016/j.main.2004.10.016)
  • [L5] Radial tunnel syndrome is relatively uncommon but is an important cause of lateral forearm pain, with clinical examination being a crucial part of the diagnosis. [13] (10.1197/j.jht.2006.02.005)
  • [L5] The surgeon should observe one or more of the three major clinical signs of CTS: (1) hypoesthesia restricted to the median distribution in the hand, (2) a positive Tinel sign with light tapping over the median nerve at the wrist; and (3) a positive wrist-flexion test. [14] (10.1016/s0363-5023(81)80163-3)
  • [L2] Patients with a history of ulnar nerve lesions are at a significantly increased risk of developing carpal tunnel syndrome, especially within the first 2 years. [15] (10.1016/j.jhsg.2026.100970)
  • [L4] Neuropathy symptoms were often refractory to conservative management, while surgical decompression led to nearly 90% symptom resolution. [18] (10.1016/j.jseint.2024.05.011)
  • [L4] It requires rigorous patient selection, specifically for true recurrences without obvious etiology or trophic disorders. [19] (10.1016/j.main.2015.10.029)
  • [L2] As the severity of ulnar neuropathy at the elbow increases, the CSA of the ulnar nerve correspondingly increases at the elbow. [20] (10.1016/j.jhsa.2024.12.004)
  • [L4] Hand abduction tracings are a quantitative outcome measure to follow recovery over time for intrinsic hand function and can be used in patients with severe ulnar neuropathy following surgical intervention. [22] (10.1016/j.jht.2023.09.005)
  • [L5] There is a severe discordance between the estimated prevalence of mild-to-moderate carpal tunnel syndrome based on clinical signs and symptoms (73%) versus electrodiagnostic studies and ultrasound (51%), calling into question whether clinicians can confidently diagnose patients with mild-to-moderate CTS. [23] (10.1097/corr.0000000000002822)
  • [L4] Complete recovery of shoulder function and relief of the symptoms was achieved in both cases at 8 and 13 months, respectively, after application of the orthosis. [24] (10.1016/s1058-2746(09)80005-0)
  • [L4] If double crush syndrome is suspected but symptoms are mild, they may respond to conservative treatment, while invasive treatments should be initiated preferentially at sites with greater clinical suspicion. [25] (10.1186/s12891-024-07574-z)
  • [L4] An anomalous muscle invading the carpal canal has been reported more frequently than any other as a cause of median nerve compression. [26] (10.1097/00130911-199906000-00005)
  • [L5] We encourage surgeons to bear such anomalies in mind when assessing patients with symptoms of median nerve compression. [31] (10.1177/17531934251401431)
  • [L5] Tinel's sign may be present only in certain stages of CTS, but when present is quite specific. [32] (10.1016/s0894-1130(12)80090-1)
  • [L4] This minimally invasive surgical option is interesting and should be part of the therapeutic arsenal for recurrent carpal tunnel syndromes. [33] (10.1016/j.hansur.2017.10.066)
  • [L3] More than 50% of patients who did not undergo carpal tunnel release at the initial surgery required a release within the follow-up period. [35] (10.1016/j.jhsg.2023.09.003)
  • [L1] Next was Tinel’s, with estimates of 50% and 77%, and then carpal compression, with estimates of 64% and 83% for sensitivity and specificity, respectively. [36] (10.1197/j.jht.2004.02.015)
  • [Paper] The paper argues that conservative treatments, specifically manual therapies like massage and mobilization, are recommended as first-line treatments for carpal tunnel syndrome (SCC). [52] (10.1016/j.hansur.2017.10.229)
  • [L2] These interventions are inexpensive, noninvasive, and easy to perform, so can be easily implemented into conventional therapy practice in any setting. [53] (10.1016/j.jht.2024.08.051)
  • [L4] Anterior interosseous nerve transfer, along with cubital and ulnar tunnel release, results in sustained clinical and electrophysiological improvements in patients with severe chronic ulnar nerve compression, which encourages its adoption as a standard treatment for severe chronic ulnar nerve compression. [55] (10.1177/17531934251381023)
  • [Paper] The author states that dislocation of the ulnar nerve is not an important factor among the causes of cubital tunnel syndrome, and that the important factor is the tendinous arch. [56] (10.1016/s0363-5023(89)80109-1)
  • [L4] Decompressing the patient's deep motor branch of the ulnar nerve allowed for spontaneous nerve recovery and reinnervation of his ulnar nerve innervated intrinsic muscles. [57] (10.1016/j.jhsg.2024.02.001)
  • [L4] The authors were unable to confirm the association of bilateral disease with amyloid or the association with trigger digits. [58] (10.1177/17531934221085542)
  • [L5] They demonstrate empirically that tests for carpal tunnel syndrome have poorer specificity (more false-positive results) when evaluated among symptomatic CTS-free subjects than among asymptomatic CTS-free subjects. [60] (10.1053/jhsu.2000.9420)
  • [L4] At 6 months, EMG analysis showed no residual compression and good release of the ulnar nerve in all cases. [61] (10.1016/j.main.2014.10.075)
  • [L5] Gelberman further notes that in 250 patients with carpal tunnel syndrome over 6 years, no patient had a late diagnosis of distal ulnar nerve compression after prior carpal tunnel release. [62] (10.1016/s0363-5023(86)80167-8)
  • [L4] A rise above a critical pressure brought about by congestion would explain the clinical picture of predominantly nocturnal symptoms and no electro-physiological evidence with the wrist in a neutral (resting) position. [63] (10.1016/0266-7681(88)90164-7)

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Creative Commons Corporation ("Creative Commons") is not a law firm and does not provide legal services or legal advice. Distribution of Creative Commons public licenses does not create a lawyer-client or other relationship. Creative Commons makes its licenses and related information available on an "as-is" basis. Creative Commons gives no warranties regarding its licenses, any material licensed under their terms and conditions, or any related information. Creative Commons disclaims all liability for damages resulting from their use to the fullest extent possible.

Using Creative Commons Public Licenses

Creative Commons public licenses provide a standard set of terms and conditions that creators and other rights holders may use to share original works of authorship and other material subject to copyright and certain other rights specified in the public license below. The following considerations are for informational purposes only, are not exhaustive, and do not form part of our licenses.

Considerations for licensors: Our public licenses are intended for use by those authorized to give the public permission to use material in ways otherwise restricted by copyright and certain other rights. Our licenses are irrevocable. Licensors should read and understand the terms and conditions of the license they choose before applying it. Licensors should also secure all rights necessary before applying our licenses so that the public can reuse the material as expected. Licensors should clearly mark any material not subject to the license. This includes other CC- licensed material, or material used under an exception or limitation to copyright. More considerations for licensors: wiki.creativecommons.org/Considerations_for_licensors

Considerations for the public: By using one of our public licenses, a licensor grants the public permission to use the licensed material under specified terms and conditions. If the licensor's permission is not necessary for any reason--for example, because of any applicable exception or limitation to copyright--then that use is not regulated by the license. Our licenses grant only permissions under copyright and certain other rights that a licensor has authority to grant. Use of the licensed material may still be restricted for other reasons, including because others have copyright or other rights in the material. A licensor may make special requests, such as asking that all changes be marked or described. Although not required by our licenses, you are encouraged to respect those requests where reasonable. More considerations for the public: wiki.creativecommons.org/Considerations_for_licensees

Creative Commons Attribution-NonCommercial 4.0 International Public License

By exercising the Licensed Rights (defined below), You accept and agree to be bound by the terms and conditions of this Creative Commons Attribution-NonCommercial 4.0 International Public License ("Public License"). To the extent this Public License may be interpreted as a contract, You are granted the Licensed Rights in consideration of Your acceptance of these terms and conditions, and the Licensor grants You such rights in consideration of benefits the Licensor receives from making the Licensed Material available under these terms and conditions.

Section 1 -- Definitions.

a. Adapted Material means material subject to Copyright and Similar Rights that is derived from or based upon the Licensed Material and in which the Licensed Material is translated, altered, arranged, transformed, or otherwise modified in a manner requiring permission under the Copyright and Similar Rights held by the Licensor. For purposes of this Public License, where the Licensed Material is a musical work, performance, or sound recording, Adapted Material is always produced where the Licensed Material is synched in timed relation with a moving image.

b. Adapter's License means the license You apply to Your Copyright and Similar Rights in Your contributions to Adapted Material in accordance with the terms and conditions of this Public License.

c. Copyright and Similar Rights means copyright and/or similar rights closely related to copyright including, without limitation, performance, broadcast, sound recording, and Sui Generis Database Rights, without regard to how the rights are labeled or categorized. For purposes of this Public License, the rights specified in Section 2(b)(1)-(2) are not Copyright and Similar Rights.

d. Effective Technological Measures means those measures that, in the absence of proper authority, may not be circumvented under laws fulfilling obligations under Article 11 of the WIPO Copyright Treaty adopted on December 20, 1996, and/or similar international agreements.

e. Exceptions and Limitations means fair use, fair dealing, and/or any other exception or limitation to Copyright and Similar Rights that applies to Your use of the Licensed Material.

f. Licensed Material means the artistic or literary work, database, or other material to which the Licensor applied this Public License.

g. Licensed Rights means the rights granted to You subject to the terms and conditions of this Public License, which are limited to all Copyright and Similar Rights that apply to Your use of the Licensed Material and that the Licensor has authority to license.

h. Licensor means the individual(s) or entity(ies) granting rights under this Public License.

i. NonCommercial means not primarily intended for or directed towards commercial advantage or monetary compensation. For purposes of this Public License, the exchange of the Licensed Material for other material subject to Copyright and Similar Rights by digital file-sharing or similar means is NonCommercial provided there is no payment of monetary compensation in connection with the exchange.

j. Share means to provide material to the public by any means or process that requires permission under the Licensed Rights, such as reproduction, public display, public performance, distribution, dissemination, communication, or importation, and to make material available to the public including in ways that members of the public may access the material from a place and at a time individually chosen by them.

k. Sui Generis Database Rights means rights other than copyright resulting from Directive 96/9/EC of the European Parliament and of the Council of 11 March 1996 on the legal protection of databases, as amended and/or succeeded, as well as other essentially equivalent rights anywhere in the world.

l. You means the individual or entity exercising the Licensed Rights under this Public License. Your has a corresponding meaning.

Section 2 -- Scope.

a. License grant.

1. Subject to the terms and conditions of this Public License, the Licensor hereby grants You a worldwide, royalty-free, non-sublicensable, non-exclusive, irrevocable license to exercise the Licensed Rights in the Licensed Material to:

a. reproduce and Share the Licensed Material, in whole or in part, for NonCommercial purposes only; and

b. produce, reproduce, and Share Adapted Material for NonCommercial purposes only.

2. Exceptions and Limitations. For the avoidance of doubt, where Exceptions and Limitations apply to Your use, this Public License does not apply, and You do not need to comply with its terms and conditions.

3. Term. The term of this Public License is specified in Section 6(a).

4. Media and formats; technical modifications allowed. The Licensor authorizes You to exercise the Licensed Rights in all media and formats whether now known or hereafter created, and to make technical modifications necessary to do so. The Licensor waives and/or agrees not to assert any right or authority to forbid You from making technical modifications necessary to exercise the Licensed Rights, including technical modifications necessary to circumvent Effective Technological Measures. For purposes of this Public License, simply making modifications authorized by this Section 2(a) (4) never produces Adapted Material.

5. Downstream recipients.

a. Offer from the Licensor -- Licensed Material. Every recipient of the Licensed Material automatically receives an offer from the Licensor to exercise the Licensed Rights under the terms and conditions of this Public License.

b. No downstream restrictions. You may not offer or impose any additional or different terms or conditions on, or apply any Effective Technological Measures to, the Licensed Material if doing so restricts exercise of the Licensed Rights by any recipient of the Licensed Material.

6. No endorsement. Nothing in this Public License constitutes or may be construed as permission to assert or imply that You are, or that Your use of the Licensed Material is, connected with, or sponsored, endorsed, or granted official status by, the Licensor or others designated to receive attribution as provided in Section 3(a)(1)(A)(i).

b. Other rights.

1. Moral rights, such as the right of integrity, are not licensed under this Public License, nor are publicity, privacy, and/or other similar personality rights; however, to the extent possible, the Licensor waives and/or agrees not to assert any such rights held by the Licensor to the limited extent necessary to allow You to exercise the Licensed Rights, but not otherwise.

2. Patent and trademark rights are not licensed under this Public License.

3. To the extent possible, the Licensor waives any right to collect royalties from You for the exercise of the Licensed Rights, whether directly or through a collecting society under any voluntary or waivable statutory or compulsory licensing scheme. In all other cases the Licensor expressly reserves any right to collect such royalties, including when the Licensed Material is used other than for NonCommercial purposes.

Section 3 -- License Conditions.

Your exercise of the Licensed Rights is expressly made subject to the following conditions.

a. Attribution.

1. If You Share the Licensed Material (including in modified form), You must:

a. retain the following if it is supplied by the Licensor with the Licensed Material:

i. identification of the creator(s) of the Licensed Material and any others designated to receive attribution, in any reasonable manner requested by the Licensor (including by pseudonym if designated);

ii. a copyright notice;

iii. a notice that refers to this Public License;

iv. a notice that refers to the disclaimer of warranties;

v. a URI or hyperlink to the Licensed Material to the extent reasonably practicable;

b. indicate if You modified the Licensed Material and retain an indication of any previous modifications; and

c. indicate the Licensed Material is licensed under this Public License, and include the text of, or the URI or hyperlink to, this Public License.

2. You may satisfy the conditions in Section 3(a)(1) in any reasonable manner based on the medium, means, and context in which You Share the Licensed Material. For example, it may be reasonable to satisfy the conditions by providing a URI or hyperlink to a resource that includes the required information.

3. If requested by the Licensor, You must remove any of the information required by Section 3(a)(1)(A) to the extent reasonably practicable.

4. If You Share Adapted Material You produce, the Adapter's License You apply must not prevent recipients of the Adapted Material from complying with this Public License.

Section 4 -- Sui Generis Database Rights.

Where the Licensed Rights include Sui Generis Database Rights that apply to Your use of the Licensed Material:

a. for the avoidance of doubt, Section 2(a)(1) grants You the right to extract, reuse, reproduce, and Share all or a substantial portion of the contents of the database for NonCommercial purposes only;

b. if You include all or a substantial portion of the database contents in a database in which You have Sui Generis Database Rights, then the database in which You have Sui Generis Database Rights (but not its individual contents) is Adapted Material; and

c. You must comply with the conditions in Section 3(a) if You Share all or a substantial portion of the contents of the database.

For the avoidance of doubt, this Section 4 supplements and does not replace Your obligations under this Public License where the Licensed Rights include other Copyright and Similar Rights.

Section 5 -- Disclaimer of Warranties and Limitation of Liability.

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

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

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

Section 6 -- Term and Termination.

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

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

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

2. upon express reinstatement by the Licensor.

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

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

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

Section 7 -- Other Terms and Conditions.

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

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

Section 8 -- Interpretation.

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

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

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

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

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

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