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Testosterone, Anabolic Steroids and Musculoskeletal Health

How testosterone, testosterone replacement therapy and anabolic steroids affect tendons, joints, bone and surgical outcomes — including the risks of TRT and the effects of anabolic-androgenic steroid use.

32 citationsUpdated Oct 2026
Illustration: Testosterone, Anabolic Steroids and Musculoskeletal Health

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Overview

Testosterone levels and anabolic steroid use exert a significant influence on musculoskeletal integrity, with hypogonadism and the use of anabolic androgenic steroids both demonstrating detrimental effects on the musculoskeletal system [15]. The relationship between androgen status and joint pathology is complex; a non-linear relationship exists between low testosterone levels and the risk of osteoarthritis [7], while bioavailable testosterone levels are identified as a risk factor for osteoarthritis supported by a causal relationship in a bidirectional Mendelian randomized study [10]. Maintaining optimal testosterone levels may be important for joint health regarding osteoarthritis risk [7]. Furthermore, testosterone levels and the risk of adhesive capsulitis demonstrate a threshold-dependent relationship [1].

Exogenous androgen exposure is associated with increased risks of tendon and soft tissue injuries. Testosterone users have a 2.9-fold increased risk of tendon rupture compared to nonusers [14], and testosterone replacement therapy is associated with increased odds of surgically treated tendon rupture [13]. Specific associations include an increased risk of rotator cuff tears, rotator cuff repairs, and subsequent rotator cuff repairs in patients prescribed testosterone [11]. Patients on testosterone therapy should be counseled about their increased risk for complications following distal biceps tendon repair [12], and preoperative risk stratification and optimization should be employed to minimize perioperative risk in these patients [12]. Anabolic steroid use may contribute to pectoralis major rupture in bodybuilders [3], and a patient presented with spontaneous rupture of the extensor pollicis longus tendon after taking anabolic steroids in doses twenty times the recommended dose for endocrine abnormalities and aplastic anaemia [16]. Selective androgen receptor modulator use is also associated with tendon damage [20].

In the context of total shoulder arthroplasty, patients prescribed supplemental testosterone have a higher risk of all-cause reoperation [2] and a higher risk of reoperation for infection [2]. Testosterone use is independently associated with a higher risk of infection-related reoperations [21] and all-cause reoperations [21] after total shoulder arthroplasty. Regarding ligamentous and extensor injuries, it is premature to imply causation between testosterone replacement therapy and ACL injuries based solely on existing results due to confounding variables [4]; clinicians should prescribe testosterone replacement therapy judiciously with a thorough assessment of each patient's unique risk profile regarding ACL injury [4]. Surgeons should be intentional about discussing endocrinologic history with patients regarding quadriceps tendon injury risk [6], as patients who filled a prescription for testosterone replacement therapy were much more likely to experience a quadriceps muscle or tendon injury within 1 year of filling their prescription [17] and were at increased risk of undergoing surgical repair of the quadriceps tendon [17]. Patients with testosterone deficiency should be counseled on the risks for quadriceps tendon injury or re-injury [6]. Four randomized controlled trials found that perioperative testosterone supplementation improved clinical outcomes, body composition, and bone mineral density in orthopaedic surgeries [5]. Data regarding the safety and association of testosterone supplementation with stroke in young adults remains limited and underexplored [9], and further studies are needed to determine the role of androgens in the male predominance of Dupuytren's contracture [8]. Current literature fails to present strong evidence for or against the use of anabolic androgenic steroids in orthopaedics [28].

How It Works

Tendon and Ligament Integrity

Anabolic steroid use contributes to pectoralis major rupture in bodybuilders [3] and is associated with a 2.9-fold increased risk of tendon rupture compared to nonusers [14]. Patients with prior prescription testosterone exposure demonstrate an increased rate of distal biceps tendon injury and subsequent biceps tendon repair compared with those without such exposure [23]. While ultrastructural analysis of ruptured tendons from anabolic steroid users found no collagen changes predisposing to rupture in humans [24], spontaneous rupture of the extensor pollicis longus tendon has been documented in patients taking anabolic steroids at doses twenty times the recommended therapeutic levels [16]. Selective androgen receptor modulators (SARMs) are also associated with tendon damage [20]. Androgen receptors are present in the cells of the anterior cruciate ligament, strongly suggesting that male sex hormones influence the structure and composition of this ligament in young men [29].

Joint Pathology and Arthritis

A threshold-dependent relationship exists between testosterone and shoulder pathology, with testosterone levels correlated with the risk of adhesive capsulitis [1]. A causal relationship exists between bioavailable testosterone levels and osteoarthritis, identifying bioavailable testosterone as a risk factor for the condition [10]. Consequently, maintaining optimal testosterone levels may be important for joint health [7].

Perioperative and Surgical Outcomes

Patients prescribed supplemental testosterone face a higher risk of all-cause reoperation and reoperation for infection after total shoulder arthroplasty [2]. There is an increased risk of rotator cuff tears, rotator cuff repairs, and subsequent rotator cuff repairs in patients prescribed testosterone [11]. Conversely, testosterone deficiency is associated with poorer postoperative outcomes in total joint arthroplasty, with distinct patterns of poorer outcomes observed in total hip arthroplasty and total knee arthroplasty [22]. In the context of lower extremity fracture fixation, testosterone replacement therapy increases the risk of nonunion after surgical fixation [19], although thromboembolic events and wound complications were not associated with testosterone supplementation [19]. Four randomized controlled trials found that perioperative testosterone supplementation improved clinical outcomes, body composition, and bone mineral density in orthopaedic surgeries [5].

Cellular and Molecular Mechanisms

The use of anabolic steroids has a detrimental effect on the musculoskeletal system [15]. Dupuytren's myofibroblasts are highly responsive to 5a-di-hydrotestosterone, a responsiveness mediated by androgen receptors that strongly suggests a hormonal influence in the pathogenesis of the disease [25]. The palmar fascia is a target tissue for androgen action via androgen receptors [30], and androgen receptors are present in Dupuytren's contracture tissue [8]. In bone healing, targeted activation of androgen receptor signaling in the periosteum improves bone fracture repair, suggesting that targeting the androgen/AR axis in the periosteum may provide a novel therapy approach to improve fracture healing [26].

Systemic and Other Associations

SARM use is associated with increased muscle mass [20]. However, SARM use is also associated with hepatotoxicity [20], cardiotoxicity [20], and androgenic side effects throughout the body [20].

What the Evidence Shows

Tendon Injury and Rupture Risk

Supplemental testosterone prescription is associated with a higher risk of all-cause reoperation and reoperation for infection following total shoulder arthroplasty [2]. This association extends to both infection-related and all-cause reoperations in the same population [21]. In the upper extremity, patients prescribed testosterone demonstrate an increased risk of rotator cuff tears, rotator cuff repairs, and subsequent rotator cuff repairs [11]. Furthermore, prior prescription testosterone exposure correlates with an increased rate of distal biceps tendon injury and biceps tendon repair compared with patients without such exposure [23]. Testosterone replacement therapy (TRT) is linked to increased tendon rupture risk in men but not women, a disparity potentially attributable to sex-specific differences in dosing [27].

Anabolic steroids may contribute to pectoralis major rupture injury [3]. In one case report, the patient was taking anabolic steroids in doses twenty times the dose recommended by physicians to treat endocrine abnormalities and aplastic anaemia [16]. However, other authors conclude that anabolic steroids did not induce ultrastructural collagen changes that might predispose to tendon rupture in humans [24].

Joint Pathology and Osteoarthritis

Findings suggest a threshold-dependent relationship between testosterone and shoulder pathology [1]. The observed non-linear relationship implies that maintaining optimal testosterone levels may be important for joint health [7]. A bidirectional Mendelian randomized study supported a causal relationship between bioavailable testosterone levels and osteoarthritis, identifying bioavailable testosterone levels as a risk factor for osteoarthritis [10]. Additionally, testosterone deficiency is associated with poorer postoperative outcomes in total joint arthroplasty, with distinct patterns observed in total hip arthroplasty and total knee arthroplasty [22].

Ligament Injury and Revision

Injectable TRT use within 1 year of primary ACLR is associated with a 3.3-fold increase in ACLR revision rates with 2 years of follow-up [33].

Perioperative Outcomes and Complications

Thromboembolic events as well as wound complications were not associated with testosterone supplementation [19]. Patients on testosterone therapy should be counseled about their increased risk for complications, and both preoperative risk stratification and optimization should be employed to minimize perioperative risk [12]. Cessation of TRT prior to rotator cuff repair should be considered on a patient-specific basis [32].

Biological Mechanisms and General Effects

Hypogonadism and the use of anabolic steroids seem to have a detrimental effect on the musculoskeletal system [15]. The high responsiveness of Dupuytren's myofibroblasts to 5a-di-hydrotestosterone, mediated by androgen receptors, strongly suggests an hormonal influence in the pathogenesis of the disease [25]. Further studies will need to determine the role of androgens in the male predominance of Dupuytren's contracture [8]. Targeting androgen/AR axis in the periosteum may provide a novel therapy approach to improve fracture healing [26].

Although evidence regarding orthopaedic perioperative use of testosterone replacement therapy is heterogeneous, 4 randomized controlled trials reviewed found that testosterone supplementation improved clinical outcomes, body composition, and BMD [5]. SARM use is associated with increased muscle mass, hepatotoxicity, cardiotoxicity, and androgenic side effects throughout the body [20]. Continuation of anabolic steroids during recovery does not seem to have a negative effect on functional recovery [3]. Current literature fails to present strong evidence for or against the use of AASs in orthopaedics [28].

Practical Considerations

Tendon and Ligament Injury Risk

Testosterone replacement therapy is associated with an increased risk of rotator cuff tears, initial repairs, and subsequent revisions in patients prescribed the hormone [11]. This association extends to a general increase in tendon rupture risk in men, though this effect is not observed in women, potentially due to sex-specific differences in dosing [27]. The risk is exacerbated by supraphysiologic dosing; a patient presenting with spontaneous rupture of the extensor pollicis longus tendon had been taking anabolic steroids at doses twenty times the recommended physician dose for endocrine abnormalities and aplastic anaemia [16]. Additionally, selective androgen receptor modulator (SARM) use is independently associated with tendon damage [20].

Joint Pathology and Arthroplasty Outcomes

A causal relationship exists between bioavailable testosterone levels and osteoarthritis, identifying these levels as a risk factor for the condition [10]. A non-linear relationship between low testosterone levels and osteoarthritis risk suggests that maintaining optimal testosterone levels may be important for joint health [7]. Furthermore, a threshold-dependent relationship exists between testosterone levels and shoulder pathology, highlighting the need to consider hormonal status in musculoskeletal risk assessment [1]. In the context of surgical intervention, testosterone deficiency is associated with poorer postoperative outcomes in total joint arthroplasty, with distinct patterns observed in total hip arthroplasty and total knee arthroplasty [22]. Regarding specific pathologies, androgen receptors are present in Dupuytren's contracture tissue, and further studies are needed to determine the role of androgens in the male predominance of the condition [8].

Perioperative Management and Counseling

Surgeons are advised to be more intentional about discussing endocrinologic history with patients and counseling those with testosterone deficiency on the risks for injury or re-injury [6]. Patients on testosterone therapy should be counseled about their increased risk for distal biceps tendon repair complications, and both preoperative risk stratification and optimization should be employed to minimize perioperative risk [12]. Clinicians should prescribe testosterone replacement therapy judiciously with a thorough assessment of each patient's unique risk profile [4]. While hypogonadism and the use of anabolic steroids seem to have a detrimental effect on the musculoskeletal system [15], thromboembolic events and wound complications were not associated with testosterone supplementation in the context of lower extremity fracture fixation [19]. Selective androgen receptor modulator (SARM) use is associated with increased muscle mass, hepatotoxicity, cardiotoxicity, and androgenic side effects throughout the body [20]. Future areas of investigation are needed to provide guidance on how surgeons can mitigate adverse risks while optimizing benefits of testosterone replacement therapy in the orthopaedic patient [31].

Key Evidence

  • [L3] These findings suggest a threshold-dependent relationship between testosterone and shoulder pathology and highlight the need to consider hormonal status in musculoskeletal risk assessment. [1] (10.1016/j.jse.2026.01.012)
  • [L3] Patients prescribed supplemental testosterone had a higher risk of all cause reoperation and reoperation for infection after TSA. [2] (10.1177/2325967124s00118)
  • [L4] Anabolic steroids use may contribute to the injury, but continuation during recovery does not seem to have a negative effect on functional recovery. [3] (10.1186/s12891-023-06382-1)
  • [L5] It is premature to imply causation between testosterone replacement therapy and ACL injuries based solely on existing results due to confounding variables; clinicians should remain vigilant and prescribe TRT judiciously with a thorough assessment of each patient's unique risk profile. [4] (10.1016/j.arthro.2024.11.086)
  • [L2] Although evidence regarding orthopaedic perioperative use of testosterone replacement therapy is heterogeneous, 4 randomized controlled trials reviewed here found that testosterone supplementation improved clinical outcomes, body composition, and BMD. [5] (10.1016/j.arthro.2024.12.026)
  • [L5] The author advises surgeons to be more intentional about discussing endocrinologic history with patients and counseling those with testosterone deficiency on the risks for injury or re-injury. [6] (10.1097/corr.0000000000002835)
  • [L3] The observed non-linear relationship suggests that maintaining optimal testosterone levels may be important for joint health. [7] (10.1186/s12891-024-08272-6)
  • [L4] Further studies will need to determine the role of androgens in the male predominance of Dupuytren's contracture. [8] (10.1016/s0736-0266(01)00072-9)
  • [L4] The review highlights that while testosterone supplementation is increasing, data regarding its safety and association with stroke in young adults remains limited and underexplored. [9] (10.3389/fneur.2024.1422931)
  • [L1] The results of our study supported a causal relationship between bioavailable testosterone levels and OA, identifying bioavailable testosterone levels as a risk factor for OA. [10] (10.1186/s12891-025-08626-8)
  • [L3] There is increased risk of RCTs, RCRs, and subsequent RCRs in patients prescribed testosterone. [11] (10.5435/jaaos-d-22-00554)
  • [L3] Patients on testosterone therapy should be counseled about their increased risk for these complications, and both preoperative risk stratification and optimization should be employed to minimize perioperative risk. [12] (10.1177/2325967126s00288)
  • [L3] Testosterone replacement therapy is associated with increased odds of surgically treated tendon rupture. [13] (10.1177/2325967125s00009)
  • [L3] Testosterone users had a 2.9-fold increased risk of tendon rupture compared to nonusers. [14] (10.1177/2325967124s00339)
  • [Paper] Hypogonadism and the use of AASs seem to have a detrimental effect on the musculoskeletal system. [15] (10.2106/jbjs.rvw.24.00061)
  • [L5] The patient presented had been taking anabolic steroids in doses twenty times the dose recommended by physicians to treat endocrine abnormalities and aplastic anaemia. [16] (10.1016/0266-7681(86)90022-7)
  • [L3] Patients who filled a prescription for testosterone replacement therapy were much more likely to experience a quadriceps muscle or tendon injury within 1 year of filling their prescription and were at increased risk of undergoing surgical repair of the quadriceps tendon. [17] (10.1097/corr.0000000000002744)
  • [L3] However, thromboembolic events as well as wound complications were not associated with testosterone supplementation. [19] (10.1016/j.injury.2026.113445)
  • [L4] SARM use is associated with increased muscle mass, hepatotoxicity, cardiotoxicity, tendon damage, and androgenic side effects throughout the body. [20] (10.1177/03635465241252435)
  • [L2] Testosterone use is associated with a higher risk of both infection-related and all-cause reoperations after total shoulder arthroplasty. [21] (10.1016/j.jseint.2026.101634)
  • [L3] Testosterone deficiency is associated with poorer postoperative outcomes in total joint arthroplasty, with distinct patterns observed in THA and TKA. [22] (10.5435/jaaos-d-25-00190)
  • [L3] Patients with prior prescription testosterone exposure have an increased rate of distal biceps tendon injury and biceps tendon repair compared with patients without such exposure. [23] (10.1016/j.jse.2023.02.122)
  • [L4] The authors conclude that anabolic steroids did not induce ultrastructural collagen changes that might predispose to tendon rupture in humans. [24] (10.1016/s0020-1383(98)00183-1)
  • [L5] The high responsiveness of Dupuytren's myofibroblasts to 5a-di-hydrotestosterone, mediated by androgen receptors, strongly suggest an hormonal influence in the pathogenesis of the disease. [25] (10.1016/s0363-5023(03)80322-2)
  • [L5] Targeting androgen/AR axis in the periosteum may provide a novel therapy approach to improve fracture healing. [26] (10.1038/s41419-022-04595-1)
  • [L3] TRT is associated with increased tendon rupture risk in men but not women, potentially due to sex-specific differences in dosing. [27] (10.1177/23259671261430731)
  • [L4] Current literature fails to present strong evidence for or against the use of AASs in orthopaedics, but there is continuous research on this topic. [28] (10.5435/jaaosglobal-d-21-00156)
  • [L4] The demonstration of androgen receptors in the cells of the anterior cruciate ligament strongly suggests that male sex hormones may have an effect on the structure and composition of this ligament in young men. [29] (10.1002/jor.1100150505)
  • [L5] The palmar fascia is a target tissue for androgen action via androgen receptors. [30] (10.1016/s0363-5023(03)00429-5)
  • [L5] The authors suggest future areas of investigation that may provide guidance on how surgeons can mitigate adverse risks while optimizing benefits of TRT in the orthopaedic patient. [31] (10.5435/jaaos-d-23-00348)
  • [L3] Cessation of TRT prior to rotator cuff repair should be considered on a patient-specific basis. [32] (10.1016/j.jseint.2025.10.002)
  • [L3] Injectable TRT use within 1 year of primary ACLR is associated with a 3.3-fold increase in ACLR revision rates with 2 years of follow-up. [33] (10.1177/23259671251399845)

See Also

  • Osteoarthritis

References

[1] Testosterone levels and risk of adhesive capsulitis: a 1:1 propensity matched analysis. Journal of Shoulder and Elbow Surgery. 2026. DOI: 10.1016/j.jse.2026.01.012

[2] Poster 149: Supplemental Testosterone Increases Risk of Reoperation after Total Shoulder Arthroplasty. Orthopaedic Journal of Sports Medicine. 2024. DOI: 10.1177/2325967124s00118

[3] Pectoralis major rupture in body builders: a case series including anabolic steroid use. BMC Musculoskeletal Disorders. 2023. DOI: 10.1186/s12891-023-06382-1

[4] Editorial Commentary: Testosterone Replacement Therapy and Anterior Cruciate Ligament Injury Risk: Insights and Cautions for Clinical Application. Arthroscopy. 2024. DOI: 10.1016/j.arthro.2024.11.086

[5] Perioperative Testosterone Supplementation Improves Outcomes of Orthopaedic Surgeries: A Systematic Review of Heterogeneous Studies. Arthroscopy. 2024. DOI: 10.1016/j.arthro.2024.12.026

[6] CORR Insights®: Testosterone Therapy Is Associated With Increased Odds of Quadriceps Tendon Injury. Clinical Orthopaedics & Related Research. 2023. DOI: 10.1097/corr.0000000000002835

[7] Correlation between low testosterone levels and the risk of osteoarthritis: a cross-sectional analysis of NHANES data (2011–2016). BMC Musculoskeletal Disorders. 2025. DOI: 10.1186/s12891-024-08272-6

[8] Androgen receptors in Dupuytren's contracture. Journal of Orthopaedic Research. 2002. DOI: 10.1016/s0736-0266(01)00072-9

[9] Testosterone supplementation and stroke in young adults: a review of the literature. Frontiers in Neurology. 2024. DOI: 10.3389/fneur.2024.1422931

[10] The causal impact of bioavailable testosterone levels on osteoarthritis: a bidirectional Mendelian randomized study. BMC Musculoskeletal Disorders. 2025. DOI: 10.1186/s12891-025-08626-8

[11] The Relationship Between Testosterone Therapy and Rotator Cuff Tears, Repairs, and Revision Repairs. Journal of the American Academy of Orthopaedic Surgeons. 2023. DOI: 10.5435/jaaos-d-22-00554

[12] Paper 30. Comparative Outcomes of Distal Biceps Tendon Repair in Patients With and Without Testosterone Therapy. Orthopaedic Journal of Sports Medicine. 2026. DOI: 10.1177/2325967126s00288

[13] Testosterone Replacement Therapy Increases Odds of Tendon Ruptures Treated Surgically. Orthopaedic Journal of Sports Medicine. 2025. DOI: 10.1177/2325967125s00009

[14] Poster 374: Tendon Tears Among Patients Treated with Exogenous Therapeutic Anabolic Steroids: An Eight Year Retrospective Analysis in a Single Institution. Orthopaedic Journal of Sports Medicine. 2024. DOI: 10.1177/2325967124s00339

[15] Testosterone. JBJS Reviews. 2024. DOI: 10.2106/jbjs.rvw.24.00061

[16] Spontaneous rupture of the extensor pollicis longus tendon after anabolic steroids. The Journal of Hand Surgery: Journal of the British Society for Surgery of the Hand. 1986. DOI: 10.1016/0266-7681(86)90022-7

[17] Testosterone Therapy Is Associated With Increased Odds of Quadriceps Tendon Injury. Clinical Orthopaedics & Related Research. 2023. DOI: 10.1097/corr.0000000000002744

[19] Testosterone replacement therapy increases the risk of nonunion after surgical fixation of lower extremity fractures. Injury. 2026. DOI: 10.1016/j.injury.2026.113445

[20] Athlete Selective Androgen Receptor Modulators Abuse: A Systematic Review. The American Journal of Sports Medicine. 2025. DOI: 10.1177/03635465241252435

[21] Prescription testosterone is associated with increased risk of infection-related and all-cause reoperations after primary total shoulder arthroplasty in male patients. JSES International. 2026. DOI: 10.1016/j.jseint.2026.101634

[22] Testosterone Deficiency and Total Joint Arthroplasty Outcomes—A Large Claims Database Study. Journal of the American Academy of Orthopaedic Surgeons. 2025. DOI: 10.5435/jaaos-d-25-00190

[23] The use of prescription testosterone is associated with an increased likelihood of experiencing a distal biceps tendon injury and subsequently requiring surgical repair. Journal of Shoulder and Elbow Surgery. 2023. DOI: 10.1016/j.jse.2023.02.122

[24] Ultrastructural analysis of ruptured tendon from anabolic steroid users. Injury. 1998. DOI: 10.1016/s0020-1383(98)00183-1

[25] Responsiveness of dupuytren's myofibroblasts to di-hydrotestosterone. The Journal of Hand Surgery. 2003. DOI: 10.1016/s0363-5023(03)80322-2

[26] Targeted activation of androgen receptor signaling in the periosteum improves bone fracture repair. Cell Death & Disease. 2022. DOI: 10.1038/s41419-022-04595-1

[27] Testosterone Therapy and Associated Rates of Tendon Tear and Surgical Repair: A Retrospective Analysis. Orthopaedic Journal of Sports Medicine. 2026. DOI: 10.1177/23259671261430731

[28] Anabolic Androgenic Steroids in Orthopaedic Surgery: Current Concepts and Clinical Applications. JAAOS: Global Research and Reviews. 2022. DOI: 10.5435/jaaosglobal-d-21-00156

[29] Primary immunolocalization of androgen target cells in the human anterior cruciate ligament. Journal of Orthopaedic Research. 1997. DOI: 10.1002/jor.1100150505

[30] Responsiveness of Dupuytren’s disease fibroblasts to 5α-dihydrotestosterone. The Journal of Hand Surgery. 2003. DOI: 10.1016/s0363-5023(03)00429-5

[31] Testosterone Replacement Therapy in Orthopaedic Surgery. Journal of the American Academy of Orthopaedic Surgeons. 2024. DOI: 10.5435/jaaos-d-23-00348

[32] Preoperative testosterone replacement therapy: a potential risk-factor for complications and reoperation after rotator cuff repair. JSES International. 2026. DOI: 10.1016/j.jseint.2025.10.002

[33] Injectable Testosterone Replacement Therapy Within 1 Year Before ACL Reconstruction Is Associated With Increased Revision Rates. Orthopaedic Journal of Sports Medicine. 2026. DOI: 10.1177/23259671251399845

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

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

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

ii. a copyright notice;

iii. a notice that refers to this Public License;

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

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

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

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

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

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

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

Section 4 -- Sui Generis Database Rights.

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

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

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

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

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

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

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

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

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

Section 6 -- Term and Termination.

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

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

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

2. upon express reinstatement by the Licensor.

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

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

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

Section 7 -- Other Terms and Conditions.

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

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

Section 8 -- Interpretation.

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

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

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

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

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

Creative Commons may be contacted at creativecommons.org.