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Vitamin D and Musculoskeletal Health

How vitamin D affects bone, muscle strength, falls, fracture and tendon healing, and surgical outcomes — including who benefits from supplementation.

34 citationsUpdated Oct 2026
Illustration: Vitamin D and Musculoskeletal Health

For patients: a plain-language version of this topic is available. See the patient guide.

Overview

Vitamin D status is a modifiable risk factor across the spectrum of orthopaedic care, influencing outcomes in both surgical and nonsurgical management. In high-risk populations, assessing vitamin D levels guides preventive strategies for stress fracture risk [3] and identifies patients with deficiency who face increased rates of anterior cruciate ligament tears and reconstruction failure [2]. For patients with Charcot arthropathy, optimizing vitamin D represents a potentially modifiable risk factor during both surgical and nonsurgical management [5]. In the adolescent population, targeted interventions are required to optimize musculoskeletal and metabolic health in those with vitamin D deficiency and adverse body composition [9].

Preoperative assessment and supplementation are critical for specific surgical cohorts. Determining vitamin D levels preoperatively and providing supplementation if deficiency is present may prevent delayed wound healing after open carpal tunnel release surgery [7]. For patients undergoing hip fracture surgery under general anesthesia, preoperative screening and potential supplementation are important for those with vitamin D levels below 20 ng/mL [10]. Regular supplementation significantly reduces the likelihood of deficiency among arthroplasty patients presenting in winter [6], and administering an oral 300,000 U single-dose regimen to correct deficiency can positively impact outcomes following primary total joint arthroplasty [12]. In total shoulder arthroplasty, surgeons should recognize vitamin D deficiency as a potential modifiable risk factor for postoperative complications [14].

Current evidence regarding universal supplementation remains inconsistent. For total knee arthroplasty, evidence is insufficient to support universal vitamin D supplementation for outcomes [17]. Similarly, findings do not justify routine testing and supplementation in patients undergoing rotator cuff repair, despite an association between preoperative serum vitamin D deficiency and increased rotator cuff fatty degeneration [28]. However, nonselective preoperative vitamin D supplementation appears more cost-effective than selective supplementation in arthroscopic rotator cuff repair, likely due to the lower cost of 25(OH)D supplementation compared to serum assays [11]. While evidence suggests vitamin D may support tendon healing, particularly in rotator cuff repair, studies remain low quality and limited to a single tendon group [8]. Peptide supplements should not currently be recommended as a replacement or adjunct for existing orthopaedic standard of care due to the lack of robust efficacy and safety data [13]. More research is needed to determine the effect of vitamin D supplementation on bone health and injury risk in elite athletes [1]. Educational initiatives and revised guidelines may have improved vitamin D prescription rates after fragility fracture, but there is a need to raise awareness about the importance of vitamin D for bone health, particularly in older adults [4]. Hand grip strength, vitamin D status, and diets might be considered diagnostic non-invasive predictors of bone health for clinical use in epidemiological contexts in 6–12 years old school children [29].

How It Works

Mechanisms of Action

Vitamin D3 stimulation induces an osteoblastic phenotype in human dermal fibroblasts via BMP signaling [30]. In the growth plate, retinoic acid and vitamin D likely act as antagonists of thyroid hormone signaling [33]. Immunomodulatory effects require optimized serum levels; supplementation with 10,000 IU/day for 8 weeks can increase vitamin D levels >50 ng/dl to achieve this state [15]. Active vitamin D3 treatment promotes fracture healing by modulating immune factor levels [19]. Regarding oncologic safety, apoptosis is evident at higher concentrations only in human osteosarcoma cell lines treated with 1 a,25(OH)2D3 [32].

Bone and Fracture Healing

In elderly rats, administering 25-OH-vitamin D after experimental fracture production improves the mechanical strength of the healing callus [18]. Clinical data indicate a correlation between vitamin D status and radiographic fracture healing outcomes in distal humeral fractures [20]. For osteoporotic bone density, sixteen weeks of HIIT combined with vitamin D consumption yields greater benefits for BMD levels in women with osteoporosis than either vitamin D consumption or HIIT training alone [16].

Tendon and Soft Tissue Healing

In a rabbit rotator cuff tear model, combining systemic and localized vitamin D delivery significantly enhances tendon-to-bone healing, muscle regeneration, and biomechanical strength compared to other treatment groups [21]. While evidence suggests vitamin D may support tendon healing, particularly in rotator cuff repair, current studies remain low quality and are limited to a single tendon group [8]. Lower preoperative serum vitamin D levels strongly correlate with lower tissue vitamin D levels and lower serum vitamin D levels at 1 year after rotator cuff surgery [25].

Clinical Outcomes and Complications

Following a fragility fracture, there is a need to raise awareness about the importance of vitamin D for bone health, particularly in older adults [4].

What the Evidence Shows

Fracture Healing and Bone Health

Administration of 25-OH-vitamin D following experimental fracture production improves the mechanical strength of the callus in healing bone [18]. In osteoporotic fracture patients, active vitamin D3 treatment promotes fracture healing by modulating immune factor levels [19]. Furthermore, vitamin D status correlates with radiographic fracture healing outcomes in distal humeral fractures [20]. Regarding bone density management, sixteen weeks of high-intensity interval training combined with vitamin D consumption yields greater benefits for bone mineral density in women with osteoporosis than either intervention alone [16]. Combined calcium and vitamin D supplementation may improve pelvic bone mineral density and correct serum 25OHD deficiencies in postmenopausal women with osteoporosis [35]; however, this combined supplementation does not reduce clinical fracture risk in this population [35]. Additionally, regular sling core stabilization training based on calcium and vitamin D supplementation can improve bone mineral density and prevent low back pain in patients with primary osteoporosis over a six-year period [37]. Vitamin D deficiency is also associated with adverse body composition in adolescents [9].

Injury Risk and Prevalence

Vitamin D deficiency is highly prevalent in patients with knee osteoarthritis [24]. The severity of this deficiency is associated with bilateral knee osteoarthritis and polyarthralgia, but not with inflammatory markers [24]. Among arthroplasty patients, a higher prevalence of vitamin D deficiency is observed in those presenting in winter [6]. Regular vitamin D supplementation significantly reduces the likelihood of deficiency [6].

Arthroplasty and Postoperative Outcomes

Preoperative vitamin D screening and potential supplementation strategies are important for patients with vitamin D levels below 20 ng/mL receiving hip fracture surgery under general anesthesia [10]. While vitamin D status alone may not influence immediate recovery, maintaining adequate levels may improve longer-term survival after proximal femoral fracture surgery [34]. In total knee arthroplasty, low-dose vitamin D supplementation benefits vitamin D–sufficient patients by achieving higher levels and maintaining sufficiency [26]. Deficient total knee arthroplasty patients benefit from medium-to-high dose vitamin D supplementation, although only 33.7% achieve repletion [26]. Supplementation with 50,000 international units of vitamin D3 on the day of surgery fails to demonstrate statistically significant differences in functional Knee Society Score, Timed Up and Go Test times, or complications in the early postoperative period compared to placebo for total knee arthroplasty [36].

Tendon and Soft Tissue Healing

Lower preoperative serum vitamin D levels strongly correlate with lower tissue vitamin D levels and lower serum vitamin D levels at one year after rotator cuff repair [25]. Preoperative serum vitamin D deficiency is associated with increased rotator cuff fatty degeneration but is unlikely to influence post-repair outcomes [28]. Consequently, the findings of systematic reviews and meta-analyses do not justify routine testing and supplementation of vitamin D in patients undergoing rotator cuff repair [28]. Further research is necessary to elucidate the direct role of vitamin D in the pathogenesis of rotator cuff tears and its impact on clinical outcomes after rotator cuff surgery and total shoulder arthroplasty [22].

Immunology and Other Clinical Considerations

Supplementation with vitamin D at 10,000 IU/day for eight weeks can increase vitamin D levels above 50 ng/dl to optimally act as an immunomodulator in tuberculosis spondylitis patients [15]. Nonselective vitamin D supplementation appears more cost-effective than selective supplementation for arthroscopic rotator cuff repair, likely due to the lower cost of 25(OH)D supplementation compared to serum assays [11].

Practical Considerations

Screening and Assessment

Vitamin D status should be assessed in high-risk populations to guide preventive strategies focused on maintaining optimal levels [3]. Preoperative screening is particularly important for patients with vitamin D levels below 20 ng/mL [10]. In the context of open carpal tunnel release surgery, determining vitamin D levels preoperatively may be beneficial for preventing delayed wound healing [7]. For patients with knee osteoarthritis, the severity of vitamin D deficiency is associated with bilateral osteoarthritis and polyarthralgia [24], but it is not associated with inflammatory markers [24]. Furthermore, vitamin D deficiency is associated with adverse medical outcomes following total shoulder arthroplasty [14].

Supplementation and Management

Providing supplementation if vitamin D deficiency is present preoperatively may be beneficial for preventing delayed wound healing after open carpal tunnel release surgery [7]. In deficient total knee arthroplasty patients, medium-to-high dose vitamin D supplementation provided benefit [26]; however, only 33.7% of these patients achieved repletion with this regimen [26]. Regarding arthroscopic rotator cuff repair, nonselective vitamin D supplementation appears to be more cost-effective than selective supplementation [11]. This cost-effectiveness is likely driven by the lower cost of 25(OH)D supplementation compared to serum assays [11].

Evidence Limitations and Gaps

Although evidence suggests vitamin D may support tendon healing, particularly in rotator cuff repair, studies remain low quality and limited to a single tendon group [8]. Current evidence regarding the effect of vitamin D supplementation on total knee arthroplasty outcomes is inconsistent and insufficient to support universal supplementation [17]. Targeted interventions are needed to optimize musculoskeletal and metabolic health in adolescents with vitamin D deficiency [9].

Key Evidence

  • [L1] More research is needed to determine the effect of vitamin D supplementation on bone health and injury risk in this population. [1] (10.1177/23259671231220371)
  • [L3] These results identify a population with increased odds of injury and provide valuable knowledge as we expand our understanding of the relationship between vitamin D and musculoskeletal health. [2] (10.1016/j.arthro.2023.04.011)
  • [L3] These findings suggest that vitamin D status should be assessed in high-risk populations to guide preventive strategies focused on maintaining optimal levels. [3] (10.1177/03635465261441254)
  • [L3] Educational initiatives and revised guidelines may have improved prescription rates, but there is a need to raise awareness about the importance of vitamin D for bone health, particularly in older adults. [4] (10.5435/jaaos-d-23-00932)
  • [L4] Vitamin D represents a potentially modifiable risk factor that could be optimized during both surgical and nonsurgical management of patients with Charcot arthropathy. [5] (10.5435/jaaosglobal-d-22-00162)
  • [L3] Regular vitamin D supplementation significantly reduces the likelihood of deficiency. [6] (10.1186/s13018-025-06482-9)
  • [L3] Determining vitamin D levels preoperatively and providing supplementation if deficiency is present may be beneficial for preventing delayed wound healing. [7] (10.5435/jaaos-d-25-00410)
  • [L4] Although evidence suggests vitamin D may support tendon healing, particularly in rotator cuff repair, studies remain low quality and limited to a single tendon group. [8] (10.1177/23259671251371300)
  • [L3] These findings highlight the need for targeted interventions to optimize musculoskeletal and metabolic health during this developmental window. [9] (10.1186/s13018-025-06091-6)
  • [L2] These findings highlight the importance of preoperative vitamin D screening and potential supplementation strategies for patients who have vitamin D levels below 20 ng/mL. [10] (10.1016/j.arth.2025.04.080)
  • [L4] Nonselective supplementation appears to be more cost-effective than selective supplementation, likely due to the lower cost of 25(OH)D supplementation compared to serum assays. [11] (10.1016/j.jse.2023.05.007)
  • [L3] Administering an oral 300,000 U single-dose vitamin D regimen to correct vitamin D deficiency can positively impact outcomes following primary TJA. [12] (10.1016/j.arth.2024.05.012)
  • [L5] Because of the lack of robust efficacy and safety data, peptide supplements should not currently be recommended as a replacement or adjunct for existing orthopaedic standard of care. [13] (10.1177/03635465261464420)
  • [L3] Orthopedic surgeons should recognize vitamin D deficiency as a potential modifiable risk factor for postoperative complications in TSA. [14] (10.1016/j.jseint.2025.01.010)
  • [L1] Supplementation with vitamin D 10,000 IU/day for 8 weeks can increase vitamin D levels >50 ng/dl to optimally act as an immunomodulator. [15] (10.1186/s13018-023-04445-6)
  • [L1] Sixteen weeks of HIIT and vitamin D consumption showed greater benefits for BMD levels in women with osteoporosis than either vitamin D consumption or HIIT training alone. [16] (10.1186/s12891-025-08275-x)
  • [L2] However, current evidence is inconsistent and insufficient to support universal supplementation. [17] (10.1177/23259671261432670)
  • [L5] The administration of 25-OH-vitamin D after the production of the experimental fracture improved the mechanical strength of the callus in the healing bone. [18] (10.1002/jor.1100160604)
  • [L2] Active vitamin D3 treatment promoted fracture healing by affecting the levels of these immune factors. [19] (10.1186/s13018-023-03777-7)
  • [L4] These findings suggest a correlation between vitamin D status and radiographic fracture healing outcomes. [20] (10.1016/j.injury.2024.111671)
  • [L5] Combining systemic and localized vitamin D delivery significantly enhanced tendon-to-bone healing, muscle regeneration, and biomechanical strength in a rabbit rotator cuff tear model compared to other treatment groups. [21] (10.1016/j.jse.2025.12.003)
  • [L4] Further research is necessary to elucidate the direct role of vitamin D in the pathogenesis of rotator cuff tears and its impact on clinical outcomes after rotator cuff surgery and total shoulder arthroplasty. [22] (10.5397/cise.2024.00220)
  • [L4] Vitamin D deficiency is highly prevalent in knee OA patients and its severity is associated with bilateral OA and polyarthralgia but not with inflammatory markers. [24] (10.1186/s13018-025-05805-0)
  • [L4] Lower preoperative serum vitamin D levels had a strong correlation with lower tissue vitamin D levels and lower serum vitamin D levels at 1 year after surgery. [25] (10.1177/03635465221145711)
  • [L3] Low-dose vitamin D supplementation was beneficial for vitamin D–sufficient TKA patients to achieve higher levels and maintain sufficiency, while deficient patients benefitted from medium-to-high dose supplementation, though only 33.7% achieved repletion. [26] (10.5435/jaaos-d-24-00005)
  • [L1] This study's findings do not justify routine testing and supplementation of vitamin D in patients undergoing RCR. [28] (10.1016/j.xrrt.2025.02.006)
  • [L4] These parameters might be considered diagnostic non-invasive predictors of bone health for clinical use in epidemiological contexts. [29] (10.1186/s12891-023-06960-3)
  • [Paper] These results suggest that BMP signaling plays a role in the induction of an osteoblastic phenotype in human dermal fibroblasts in response to vitamin D3 stimulation. [30] (10.1002/jor.20728)
  • [L5] With 1 a,25(OH)2D3 treatment, apoptosis was evident at higher concentrations only. [32] (10.1002/jor.21585)
  • [Paper] We conclude that retinoic acid and vitamin D are likely to be antagonists of thyroid hormone signaling in the growth plate. [33] (10.1016/s0736-0266(00)00024-3)
  • [L2] Although vitamin D status alone may not influence immediate recovery, maintaining adequate levels may improve longer term survival after PFF surgery. [34] (10.5435/jaaosglobal-d-25-00108)
  • [L1] Combined calcium and vitamin D supplementation may improve pelvic BMD and correct serum 25OHD deficiencies in postmenopausal women with osteoporosis, but does not reduce clinical fracture risk in postmenopausal women with osteoporosis. [35] (10.1186/s12891-025-09089-7)
  • [L1] Supplementation with 50,000 international units vitamin D3 on the day of surgery failed to demonstrate statistical significant differences in functional KSS, TUGT times, or complications in the early postoperative period compared to placebo. [36] (10.1016/j.arth.2022.08.020)
  • [L4] Regular sling core stabilization training based on calcium and vitamin D supplementation can improve bone mineral density and prevent low back pain in a patient with primary osteoporosis over a 6-year period. [37] (10.1186/s12891-023-06896-8)

See Also

  • Osteoarthritis

References

[1] Effects of Vitamin D Supplementation in Elite Athletes: A Systematic Review. Orthopaedic Journal of Sports Medicine. 2024. DOI: 10.1177/23259671231220371

[2] A Diagnosis of Vitamin D Deficiency Is Associated With Increased Rates of Anterior Cruciate Ligament Tears and Reconstruction Failure. Arthroscopy. 2023. DOI: 10.1016/j.arthro.2023.04.011

[3] Vitamin D and the Risk of Stress Fractures in Athletes and Military Personnel: A Systematic Review and Meta-analysis. The American Journal of Sports Medicine. 2026. DOI: 10.1177/03635465261441254

[4] Forgetting the Frail: National Trends in Vitamin D Prescription After Fragility Fracture—A Large Insurance Claims Database Study. Journal of the American Academy of Orthopaedic Surgeons. 2024. DOI: 10.5435/jaaos-d-23-00932

[5] Prevalence of Vitamin D Deficiency in Patients With Charcot Arthropathy: A Single-Center Analysis. JAAOS: Global Research and Reviews. 2022. DOI: 10.5435/jaaosglobal-d-22-00162

[6] Higher prevalence of vitamin D deficiency among arthroplasty patients presenting in winter. Journal of Orthopaedic Surgery and Research. 2025. DOI: 10.1186/s13018-025-06482-9

[7] The Effect of Serum Vitamin D Level on Wound Healing Process After Open Carpal Tunnel Release Surgery: Clinical Outcomes of 55 Cases. Journal of the American Academy of Orthopaedic Surgeons. 2025. DOI: 10.5435/jaaos-d-25-00410

[8] The Role of Vitamin D in Postoperative Tendon Healing: A Scoping Review. Orthopaedic Journal of Sports Medicine. 2025. DOI: 10.1177/23259671251371300

[9] Vitamin D deficiency and adverse body composition in adolescents. Journal of Orthopaedic Surgery and Research. 2025. DOI: 10.1186/s13018-025-06091-6

[10] Impact of Vitamin D Deficiency on Short- and Long-Term Mortality in Patients Receiving Hip Fracture Surgery Under General Anesthesia: A Matched Cohort Study. The Journal of Arthroplasty. 2025. DOI: 10.1016/j.arth.2025.04.080

[11] Preoperative vitamin D supplementation is a cost-effective intervention in arthroscopic rotator cuff repair. Journal of Shoulder and Elbow Surgery. 2023. DOI: 10.1016/j.jse.2023.05.007

[12] Effect of Vitamin D Deficiency on Periprosthetic Joint Infection and Complications After Primary Total Joint Arthroplasty. The Journal of Arthroplasty. 2024. DOI: 10.1016/j.arth.2024.05.012

[13] Peptide Supplements and Their Therapeutic Applications in Sports Medicine. The American Journal of Sports Medicine. 2026. DOI: 10.1177/03635465261464420

[14] Vitamin D deficiency is associated with adverse medical outcomes following total shoulder arthroplasty. JSES International. 2025. DOI: 10.1016/j.jseint.2025.01.010

[15] Randomized controlled trial of vitamin d supplementation on toll-like receptor-2 (tlr-2) and toll-like receptor-4 (tlr-4) in tuberculosis spondylitis patients. Journal of Orthopaedic Surgery and Research. 2023. DOI: 10.1186/s13018-023-04445-6

[16] Concurrent effects of high-intensity interval training and vitamin D supplementation on bone metabolism among women diagnosed with osteoporosis: a randomized controlled trial. BMC Musculoskeletal Disorders. 2025. DOI: 10.1186/s12891-025-08275-x

[17] Effect of Vitamin D Supplementation on Total Knee Arthroplasty Outcomes: A Systematic Review. Orthopaedic Journal of Sports Medicine. 2026. DOI: 10.1177/23259671261432670

[18] Effect of 25‐OH‐vitamin D on fracture healing in elderly rats. Journal of Orthopaedic Research. 1998. DOI: 10.1002/jor.1100160604

[19] Determination of immune factor levels in serum and local hematoma samples of osteoporotic fracture patients and clinical study of the effect of active vitamin D3 treatment on immune factor levels. Journal of Orthopaedic Surgery and Research. 2023. DOI: 10.1186/s13018-023-03777-7

[20] Vitamin D status in healing of distal humeral fractures: Clinical observations. Injury. 2024. DOI: 10.1016/j.injury.2024.111671

[21] Localized vitamin D delivery via 3D-printed nanofiber sheets combined with systemic supplementation enhances tendon-to-bone healing in a rabbit rotator cuff tear model: a preclinical study. Journal of Shoulder and Elbow Surgery. 2026. DOI: 10.1016/j.jse.2025.12.003

[22] The role of vitamin D in shoulder health: a comprehensive review of its impact on rotator cuff tears and surgical results. Clinics in Shoulder and Elbow. 2024. DOI: 10.5397/cise.2024.00220

[24] Association between vitamin D deficiency, inflammatory markers, and knee osteoarthritis: a retrospective study. Journal of Orthopaedic Surgery and Research. 2025. DOI: 10.1186/s13018-025-05805-0

[25] Serum Vitamin D Level Correlations With Tissue Vitamin D Level and Muscle Performance Before and After Rotator Cuff Repair. The American Journal of Sports Medicine. 2023. DOI: 10.1177/03635465221145711

[26] Vitamin D Supplementation May Prevent or Treat Deficiency After Total Knee Arthroplasty: A Retrospective Cohort Analysis. Journal of the American Academy of Orthopaedic Surgeons. 2024. DOI: 10.5435/jaaos-d-24-00005

[28] Preoperative serum vitamin D deficiency is associated with increased rotator cuff fatty degeneration but is unlikely to influence post repair outcomes: a systematic review and meta-analysis of correlation coefficients. JSES Reviews, Reports, and Techniques. 2025. DOI: 10.1016/j.xrrt.2025.02.006

[29] Hand grip strength, vitamin D status, and diets as predictors of bone health in 6–12 years old school children. BMC Musculoskeletal Disorders. 2023. DOI: 10.1186/s12891-023-06960-3

[30] Endogenous bone morphogenetic proteins mediate 1α, 25‐dihydroxyvitamin D3‐induced expression of osteoblast differentiation markers in human dermal fibroblasts. Journal of Orthopaedic Research. 2008. DOI: 10.1002/jor.20728

[32] Effect of 25‐hydroxyvitamin D3 and 1 α,25 dihydroxyvitamin D3 on differentiation and apoptosis of human osteosarcoma cell lines. Journal of Orthopaedic Research. 2011. DOI: 10.1002/jor.21585

[33] Both retinoic acid and 1,25(OH)2 vitamin D3 inhibit thyroid hormone‐induced terminal differentiaton of growth plate chondrocytes. Journal of Orthopaedic Research. 2001. DOI: 10.1016/s0736-0266(00)00024-3

[34] 25-Hydroxyvitamin D Levels, Free Serum Calcium, Glomerular Filtration Rate, Albumin, and Femoral Fracture Elderly Patient Mortality. JAAOS: Global Research and Reviews. 2026. DOI: 10.5435/jaaosglobal-d-25-00108

[35] The effects of combined calcium and vitamin D supplementation on bone mineral density and fracture risk in postmenopausal women with osteoporosis: a systematic review and meta-analysis of randomized controlled trials. BMC Musculoskeletal Disorders. 2025. DOI: 10.1186/s12891-025-09089-7

[36] Vitamin D3 Supplementation Prior to Total Knee Arthroplasty: A Randomized Controlled Trial. The Journal of Arthroplasty. 2023. DOI: 10.1016/j.arth.2022.08.020

[37] Regular sling core stabilization training improves bone density based on calcium and vitamin D supplementation. BMC Musculoskeletal Disorders. 2023. DOI: 10.1186/s12891-023-06896-8

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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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