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Pain & Recovery

Chronic postoperative pain (CPSP) following TKA: prevalence, impact on patient satisfaction, and differentiation from implant failure or infection.

Overview

Chronic pain following knee arthroplasty is a significant determinant of long-term success, associated with worse joint-specific function and health-related quality of life at one year [1]. However, resolution is common; by two years postoperatively, two in five patients experience resolution of chronic pain and achieve functional outcomes clinically equal to those without chronic pain at one year [1]. Patients generally report significant and persistent relief of pain, improved physical function, and satisfaction with the result two to seven years after knee replacement [3]. Even in complex cases such as total knee arthroplasty with valgus deformity, most participants experience only mild to moderate post-surgery pain, while the intervention substantially improves quality of life and enables daily activities resumption [8].

Preoperative patient factors critically influence outcomes in ligamentous procedures. Preoperative opioid users are more likely to continue taking opioids, demonstrate significantly worse patient-reported outcomes at baseline and one year postoperatively, and are less likely to achieve a patient acceptable symptomatic state following anterior cruciate ligament (ACL) reconstruction [27]. Similarly, individuals with preoperative depression may report inferior outcomes in terms of pain and functionality after ACL reconstruction [63]. Despite these baseline disadvantages, individuals with preoperative depression exhibit significant improvements across all outcome measures after ACL reconstruction, including reductions in depression levels [63].

For acute soft-tissue injuries, pain-free criteria are essential for safe return to activity. Meeting clinically pain-free criteria results in fewer reinjuries compared with not meeting the criteria in the return to sport after criteria-based rehabilitation of acute adductor injuries in male athletes [2]. For arthroscopic isolated type II SLAP repair, return to sports should not be allowed earlier than six months after surgery, when patients have reached pain-free function and recovered strength [11].

Anatomy & Pathophysiology

Kinematics and Biomechanics

Knee biomechanical markers correlate with patient-reported function in osteoarthritis to a greater extent than X-ray grading, providing complementary assessment information [32]. Gait biomechanics influence short-term osteoarthritis pain fluctuations [55], while gender-specific gait kinematics necessitate tailored analysis and rehabilitation protocols [54]. Application of a biomechanical device to the feet reduces pain and improves function in osteoarthritis patients [33]. Research should focus on technologies that 'unload' the joint to address aberrant biomechanics, potentially reversing structural damage or delaying invasive reconstruction [65].

In anterior cruciate ligament (ACL) reconstruction, greater knee flexion excursion or moment during hopping associates with better knee function [31]. Patients with lower function demonstrate hop-landing biomechanics previously linked to early patellofemoral osteoarthritis [31]. Lower knee self-efficacy correlates with greater asymmetries in quadriceps neuromuscular function and jump-landing biomechanics post-ACL reconstruction [41]. Immersive virtual reality improves movement patterns after ACL reconstruction, yielding knee joint biomechanics approximating healthy controls [46]. Knee pain does not substantially impact movement biomechanics up to 10 years post-ACL reconstruction, as walking and forward lunge mechanics remain comparable between individuals with and without pain [38]. ACL-injured patients exhibit different kinematics during single-leg squatting compared to healthy controls [44].

Total knee arthroplasty (TKA) outcomes depend on kinematic restoration. Better replication of natural knee kinematics may explain superior patient satisfaction in medial pivot TKA compared to posterior stabilized TKA [43]. Patellar thickness affects patellofemoral kinematics after TKA [36]. Patellofemoral kinematics and retropatellar pressure change differently after TKA depending on whether a medial stabilized or posterior stabilized implant is used [61]. Patients reporting good knee-related quality of life one year post-TKA show improved gait biomechanics, whereas those with poor outcomes remain unchanged in biomechanics despite similar pain reduction [47]. Unicompartmental knee arthroplasty significantly enhances knee joint kinematics, facilitating the transition from basic to advanced functional activities [45].

Ligamentous and Structural Integrity

In posterior cruciate retaining total knee arthroplasty, postoperative lateral laxity greater than 0.9 mm at 90-degree flexion associates with physiological kinematic motion and fewer knee symptoms in patient-reported outcomes [35]. Neuromuscular electrical stimulation is safe for knee joint biomechanics, with no pathological changes in knee function observed [34].

Patellofemoral Joint

Sagittal plane patellofemoral joint kinematics is an area of interest in studying mechanical factors associated with patellofemoral pain [39]. Subtle scarring of the anterior interval changes the biomechanics of the anterior structures of the knee and may lead to refractory anterior knee pain [40].

Meniscal Healing

Meniscal healing requires both biologic and kinematic factors, and restoring proper knee biomechanics is pivotal [53].

Classification

Chronic Pain Trajectories: Chronic pain at 1 year following knee arthroplasty is associated with worse joint-specific function and health-related quality of life [1]. By 2 years, two in five patients with chronic pain at 1 year experience resolution of their chronic pain and have functional outcomes clinically equal to those without chronic pain at 1 year [1].

Pain Phenotypes: Pain phenotypes remained stable in the majority of knees over a 24-month period, but a substantial proportion of knees switched to different pain phenotypes [75]. Detection and definition of typical pain patterns in patients with pain after total knee arthroplasty and assignment of identified pathologies will be applied in the improvement of the diagnostic process [68]. Knowing typical pain patterns enables prediction of the cause of pain as early as possible in the diagnostic process before the state of pain becomes chronic [14].

Psychosocial Classifiers: Anxiety and depression prior to total knee arthroplasty are associated with worse pain and subjective function, although revision rates did not differ between groups and there were no relevant differences in clinical improvement of subjective function and pain [77]. At 24 months, patients with preoperative pain catastrophizing report more pain than those without, although subjective function is similar between groups [6].

Recovery Trajectories: Six distinct early recovery trajectories were identified after total shoulder arthroplasty, with 83.7% of patients (the 'Faster group') experiencing very low pain scores after only 2 weeks [15]. Recovery trajectories over six weeks in patients selected for high-intensity physiotherapy after total knee arthroplasty can distinguish outcome after one year [29].

Other Considerations: Assessment Strategy: Assessing the intensity of pain at rest and pain with movement separately is a helpful strategy for follow-up studies regarding pain relief after total knee arthroplasty for osteoarthritis [24]. Patient-reported outcomes and objective activity data reflect different aspects of recovery and should be interpreted as complementary rather than hierarchical measures [20].

Regional Analgesia: IPACK block addition to multimodal analgesia is related to better results in pain scores, morphine usage, and functional recovery without increasing the risk of complications [10].

Geographic Outcomes: Patients from the United Kingdom have significantly worse functional outcomes but similar pain relief compared with those from the United States and Australia after total knee arthroplasty [9].

Return to Sport Criteria: Meeting clinically pain-free criteria results in fewer reinjuries compared with not meeting the criteria in the context of return to sport after criteria-based rehabilitation of acute adductor injuries in male athletes [2].

Rotator Cuff Classification: Twenty-six different criteria described by multiple classification systems have been identified for the magnetic resonance assessment of rotator cuff after repair [62].

Clinical Presentation

Chronic Arthropathy and Arthroplasty Outcomes: Chronic pain at 1 year following knee arthroplasty is associated with worse joint-specific function and health-related quality of life [1]. By 2 years, two in five patients with chronic pain at 1 year experience resolution of their chronic pain and have functional outcomes clinically equal to those without chronic pain at 1 year [1]. Patients report significant and persistent relief of pain, improved physical function, and satisfaction with the result two to seven years postoperatively after knee replacement [3]. At 24 months after total knee arthroplasty, subjective function is similar between patients with and without preoperative pain catastrophizing, although patients with pain catastrophizing report more pain [6]. Most participants experienced mild to moderate post-surgery pain after total knee arthroplasty with valgus deformity, but the intervention substantially improved quality of life and enabled daily activities resumption [8]. Patients from the United Kingdom had significantly worse functional outcomes but similar pain relief compared with those from the United States and Australia after total knee arthroplasty [9].

Diagnostic Assessment and Pain Patterns: Knowing typical pain patterns enables prediction of the cause of pain as early as possible in the diagnostic process for unhappy patients after total knee arthroplasty, before the state of pain becomes chronic [14]. Patient-reported outcomes and objective activity data reflect different aspects of recovery and should be interpreted as complementary rather than hierarchical measures following total knee arthroplasty [20]. Only 23% of patients reporting no pain relief on one measure reported it on both measures, indicating that different individuals may report no pain relief depending on which pain measure was used after total knee replacement [22]. Assessing the intensity of pain at rest and pain with movement separately and considering changes in pain on an individual level are helpful strategies in follow-up studies for total knee arthroplasty for osteoarthritis [24]. A derived cut-off for identifying individuals with chronic pain after knee replacement can be used for patient selection in research settings to design and assess interventions that support patients in their management of chronic post-surgical pain [25].

Acute Injury and Specific Pathologies: Meeting clinically pain-free criteria results in fewer reinjuries compared with not meeting the criteria in the return to sport after criteria-based rehabilitation of acute adductor injuries in male athletes [2]. It is uncommon for individual patients to report clinically significant knee pain at multiple follow-up timepoints (2, 6, and 10 years) after ACL reconstruction [5]. A patient with symptomatic bipartite patella achieved complete symptom resolution and full athletic recovery at one-year follow-up after arthroscopic treatment [7]. Significantly more patients with reported pain show more severe damages in osteoarthritis in morbidly obese children and adolescents [26]. The thickness change ratio and preservation ratio of the infrapatellar fat pad are related to anterior knee pain in patients following medial patellofemoral ligament reconstruction [42].

Adjunctive Therapies and Systemic Factors: Periarticular injections (PMDI) provide additional pain relief limited to the immediate postoperative period but do not improve pain relief after postoperative day 1, patient satisfaction, or functional recovery after simultaneous bilateral total knee arthroplasty [4]. Extracorporeal shock wave therapy (ESWT) can produce rapid pain relief and functional improvement in the treatment of primary bone marrow edema syndrome of the knee [18]. Lowered pressure pain threshold (PPT) due to sensitization may adversely affect functional recovery and pain perception after arthroscopic rotator cuff repair [48]. Efforts to reduce perceived exertion during work may improve recovery from long-term pain in different body regions [58]. Change in physical activity did not explain future clinical outcomes of pain and function in older adults with knee pain [60].

Investigations

Plain radiography: Presentation factors that increase the likelihood of a diagnostic X-ray include pain for longer than 6 months, the presence of medial or diffuse pain, and mechanical symptoms [74]. Radiographic severity of arthritic changes can predict knee-specific functional improvement following total knee arthroplasty, but the extent of global functional improvement cannot be predicted by it [90]. A low radiological severity of osteoarthritis was not associated with pain 12 months postoperatively after total knee replacement [70]. Commonly used structural features from radiographs and MRI scans cannot predict KOA pain and symptoms—even when imaging features are codified by established grading systems like IRF or MOAKS [95].

MRI: MRI utilization by orthopaedic surgeons results in more appropriate interventions for patients with symptoms and findings most amenable to surgical intervention [96]. Distinct patterns of co-existing MRI lesions have different implications for the pathogenesis of osteoarthritic knee pain occurring with/without joint loading [86]. There is a correlation between the decrease in edema size observed on MRI scans and the decrease in activity pain, but no correlation between the decrease in edema size and the decrease in rest pain [92]. Postoperative residual pain is associated with a high MRI-based signal intensity of the repaired supraspinatus tendon [79]. MRI interpretations demonstrate improved clinical outcome measures ensuing therapeutic intervention with Pentosan Polysulphate Sodium (PPS) in an osteoarthritic patient with concurrent resolution of subchondral Bone Marrow Edema Lesion and joint effusion [78]. The treatment regime for spontaneous osteonecrosis of the knee (SONK) eliminated pathological findings in the MRI of all cases studied and decreased pain levels and functional limitations within a short-time period [85]. The short-term clinical and MRI outcome of second-generation chondrocyte implantation for the treatment of cartilage lesions in the knee are promising [80]. It was uncommon for individual patients to report clinically significant knee pain at multiple follow-up timepoints (2, 6, and 10 years) after ACL reconstruction [5]. MRI contributes less than expected to the understanding of pain and function in knee OA and possibly offers little opportunity to develop structure-modifying treatments in knee OA that could influence the patient's pain and function [87].

Other Considerations: Chronic pain at 1 year following knee arthroplasty is associated with worse joint-specific function and health-related quality of life [1]. By 2 years, two in five patients with chronic pain at 1 year had resolution of their chronic pain and functional outcomes clinically equal to those without chronic pain at 1 year [1]. Meeting clinically pain-free criteria resulted in fewer reinjuries compared with not meeting the criteria in male athletes with acute adductor injuries [2]. A patient with symptomatic bipartite patella achieved complete symptom resolution and full athletic recovery at one-year follow-up after arthroscopic treatment [7]. Corticosteroid injections provide benefit by relieving pain and improving functional outcome scores [16]. Functional outcomes as measured by ROM and pain scores showed appropriate improvement consistent with normal populations without history of XRT after external beam radiation therapy [30]. The effect of preoperative pain on postoperative outcomes seems to become less important when the patient has radiographic evidence of more severe OA [93]. Open debridement and soft tissue release effectively restores motion and allows satisfactory functional recovery as a salvage procedure for the severely arthrofibrotic knee [94].

Treatment

Non-Operative

Multidisciplinary interventions for chronic pain after total knee arthroplasty demonstrate clinically relevant improvements in function, pain, self-efficacy, and quality of life at one year [19]. However, these interventions may be ineffective for patients presenting with severe pain, poor functional status, or high anxiety levels prior to primary total knee arthroplasty [83]. For lumbar spinal stenosis, surgery reduces pain and disability more effectively than nonoperative treatment, with effectiveness sustained over two years, although objective walking ability improvements show no statistical difference between operative and nonoperative groups [84]. In the management of knee osteoarthritis or post-surgical pain, multimodal nonopioid analgesic regimens are recommended for outpatient arthroscopic surgery [67]. Such protocols provide at least equivalent pain control compared with traditional opioid analgesics in anterior cruciate ligament reconstruction (ACLR) [73] and achieve satisfactory pain control in 82% of patients undergoing arthroscopic partial meniscectomy and/or chondroplasty [72]. Extracorporeal shock wave therapy (ESWT) produces rapid pain relief and functional improvement in primary bone marrow edema syndrome of the knee [18]. Corticosteroid injections relieve pain and improve functional outcome scores but may increase retear and revision rates of rotator cuff repair [16]. For shoulder surgery, better counseling and innovative nonopioid pain management protocols are needed based on patient perceptions regarding pain control [69].

Operative

Indications: Unexplained pain is the principal indication for early revision of a failing patellofemoral arthroplasty (PFA) [49]. Return to sports after arthroscopic isolated type II SLAP repair should not be allowed earlier than 6 months after surgery, contingent upon patients reaching pain-free function and recovering strength [11]. Treatment selection for avulsion fracture of the hamstring origin is based on the extent of displacement, with both operative and non-operative groups showing satisfactory overall outcomes with high return to preinjury activity and sports rates [76]. Both operative and nonoperative management of grade III medial collateral ligament (MCL) tears demonstrate clinical improvements between study enrollment and 2-year follow-up when treated concurrently with ACL reconstruction [81].

Surgical Approach / Technique: Continuous barbed suturing improves surgical efficiency, reduces early postoperative pain, accelerates wound healing, and enhances functional recovery without increasing complication rates after primary TKA [21]. An accelerated rehabilitation protocol after matrix-induced autologous chondrocyte implantation is safe and effective, providing comparable, if not superior, clinical outcomes throughout the postoperative timeline compared with traditional approaches [52]. Recovery of daily life activities following knee arthroplasty with a personalized eHealth program is generally slower than provided recommendations, with 8 out of 10 activities not resumed within the recommended time [66].

Pain Management: Periarticular multimodal drug injections (PMDI) provide additional pain relief limited to the immediate postoperative period after simultaneous bilateral total knee arthroplasty (TKA), but do not improve pain relief after postoperative day 1, patient satisfaction, or functional recovery [4]. Moderate-level evidence confirms that the IPACK block is related to better results in pain scores, morphine usage, and functional recovery without increasing the risk of complications when added to multimodal analgesia for primary TKA [10]. Periarticular steroid injections reduce post-operative pain and inflammation, improve short-term functional recovery and clinical parameters, and result in better outcomes without major complications following unicondylar knee arthroplasty [12]. Continuous-flow cryo and cyclic compression therapy after hip fracture surgery aims to lower pain levels, morphine consumption, and blood loss while enhancing functional recovery [13]. Preoperative opioid use is associated with persistent postoperative opioid use, readmission, and postoperative complications after arthroscopic knee surgery [82]. Chronic opioid use, chronic pain, or use of non-narcotic medications carries the highest risk of postoperative opioid use after arthroscopic knee surgery [82]. Predictors of inferior long-term outcome after rotator cuff repair include preoperative use of NSAIDs, longstanding symptoms before surgery, and non-acute onset of shoulder symptoms [71].

Other Considerations: Chronic pain at 1 year following knee arthroplasty is associated with worse joint-specific function and health-related quality of life [1]. By 2 years after knee arthroplasty, two in five patients with chronic pain at 1 year experience resolution of their chronic pain and achieve functional outcomes clinically equal to those without chronic pain at 1 year [1]. Patients report significant and persistent relief of pain, improved physical function, and satisfaction with the result two to seven years after knee replacement [3]. Meeting clinically pain-free criteria during criteria-based rehabilitation for acute adductor injuries in male athletes results in fewer reinjuries compared with not meeting the criteria [2]. Most women with valgus deformity experience mild to moderate post-surgery pain after total knee arthroplasty, but the intervention substantially improves quality of life and enables resumption of daily activities [8].

Complications

Chronic Pain: Chronic pain at 1 year following knee arthroplasty is associated with worse joint-specific function and health-related quality of life [1]. By 2 years after knee arthroplasty, two in five patients with chronic pain at 1 year experience resolution of their chronic pain and have functional outcomes clinically equal to those without chronic pain at 1 year [1]. Preoperative pain catastrophizing prior to total knee arthroplasty is associated with more clinical improvement but results in more reported pain at 24 months, although subjective function is similar between groups [6]. Up to half of patients continue to report painful neuropathic symptoms at 15 months after total knee arthroplasty, although neuropathic symptoms generally improve over time [23]. Only 23% of patients reporting no pain relief on one measure reported it on both measures, indicating that different individuals may report no pain relief depending on which pain measure is used after total knee replacement [22]. Patients with reported pain show significantly more severe damages in the context of osteoarthritis in morbidly obese children and adolescents [26].

Pain Management Strategies: Periarticular steroid injections reduce post-operative pain and inflammation, improve short-term functional recovery and clinical parameters, and result in better outcomes without major complications following unicondylar knee arthroplasty [12]. Continuous barbed suturing reduces early postoperative pain, accelerates wound healing, and enhances functional recovery without increasing complication rates after primary total knee arthroplasty [21]. Multimodal analgesia alleviates postoperative anxiety and depression in the short term, reduces perioperative pain, improves postoperative recovery, and shortens the length of hospital stay following total knee arthroplasty [59]. Intraoperative periarticular injections (PMDI) provide additional pain relief limited to the immediate postoperative period but do not improve pain relief after postoperative day 1, patient satisfaction, or functional recovery after simultaneous bilateral total knee arthroplasty [4]. Platelet-rich plasma leads to significantly improved short-term pain relief and function compared with corticosteroid injection at 3 months for partial-thickness rotator cuff tears or tendinopathy, but there is no sustained benefit over corticosteroid at 12 months [17].

Other Considerations: Preoperative opioid use predicts prolonged postoperative opioid use and inferior patient outcomes, including significantly worse patient-reported outcomes at baseline and 1 year postoperatively and a lower likelihood of achieving a patient acceptable symptomatic state following anterior cruciate ligament reconstruction [27].

Recovery

Light activity (weeks): Early mobilization strategies vary by procedure. Following open reduction and internal fixation of distal radial fractures, immobilization periods of 1 and 3 weeks produce superior short-term outcomes for function, range of motion, and pain compared with 6 weeks of immobilization [57]. For total knee arthroplasty, recovery trajectories over six weeks in patients selected for high-intensity physiotherapy can distinguish outcome after one year [29].

Full activity (months): Functional recovery timelines differ by intervention. Patients treated with arthroscopic treatment for symptomatic bipartite patella achieved complete symptom resolution and full athletic recovery at one-year follow-up [7]. Functional recovery after unicompartmental knee replacement continues beyond 6 months and up to 2 years [51]. In total shoulder arthroplasty, six distinct early recovery trajectories of pain are identified, with 83.7% of patients (the 'Faster group') experiencing very low pain scores after only 2 weeks [15].

Complete recovery / outcome plateau (months): Long-term stabilization of function and pain occurs at varying intervals. Patients report significant and persistent relief of pain, improved physical function, and satisfaction with the result two to seven years after knee replacement [3]. Reasonable long-term functional outcome scores can be achieved after infected mini-open rotator cuff repair at 10-year review [37]. There are no significant differences in functional or patient-perceived outcomes between computer-assisted and conventional total knee arthroplasty at five-year follow-up [56]. Geniculate artery embolization (GAE) results in short-term improvements in pain and function for mild to moderate knee osteoarthritis, with decreasing minimal clinically important difference (MCID) achievement observed after 3 to 6 months [64].

Rehabilitation protocol: Multidisciplinary approaches influence recovery metrics. One year after nonsurgical multidisciplinary treatment for chronic pain after total knee arthroplasty, clinically relevant improvement is shown in function, pain, self-efficacy, and quality of life [19].

Functional milestones: Chronic pain status significantly impacts long-term functional benchmarks. Chronic pain at 1 year following knee arthroplasty is associated with worse joint-specific function and health-related quality of life [1]. By 2 years after knee arthroplasty, two in five patients with chronic pain at 1 year experience resolution of that pain and achieve functional outcomes clinically equal to those without chronic pain at 1 year [1]. At 24 months after total knee arthroplasty, subjective function is similar between patients with and without preoperative pain catastrophizing, although patients with pain catastrophizing report more pain [6]. Although neuropathic symptoms improve over time after total knee arthroplasty, up to half of patients continue to report painful neuropathic symptoms at 15 months [23]. It is uncommon for individual patients to report clinically significant knee pain at multiple follow-up timepoints (2, 6, and 10 years) after ACL reconstruction [5].

Other Considerations: Preoperative variables and specific pathologies dictate recovery expectations. Patients with a preoperative symptom duration of medial knee overload/arthritis of two years or greater do not experience inferior patient-reported outcomes (PRO) or clinical outcomes than patients with a symptom duration of less than 2 years at mid-term follow-up (minimum 2 years) after high tibial osteotomy [91]. No prediction can be made regarding whether expectations will be fulfilled after treatment for trapeziometacarpal osteoarthritis based on pre-treatment variables, as residual pain at one year contributes considerably to the variance in fulfilled expectations [88]. The natural course of chronic exertional compartment syndrome (CECS) of the lower leg seems to be persistent symptoms over time [89]. Regarding adjunctive therapies, patients receiving platelet-rich plasma (PRP) for partial-thickness rotator cuff tears or tendinopathy obtain superior improvement in pain and function at short-term follow-up (3 months) compared with corticosteroid injection [17]. There is no sustained benefit of PRP over corticosteroid injection for pain and function at longer-term follow-up (12 months) in patients with partial-thickness rotator cuff tears or tendinopathy [17]

Key Evidence

  • [L3] However, by 2 years, two in five patients had resolution of their chronic pain and had functional outcomes clinically equal to those without chronic pain at 1 year. (10.1002/ksa.12455)
  • [L2] Meeting the clinically pain-free criteria resulted in fewer reinjuries compared with not meeting the criteria. (10.1177/2325967119897247)
  • [L4] Patients reported significant and persistent relief of pain, improved physical function, and satisfaction with the result two to seven years postoperatively. (10.2106/00004623-199802000-00003)
  • [L1] PMDI provides additional pain relief limited to the immediate postoperative period but does not improve pain relief after POD 1, patient satisfaction, or functional recovery. (10.1007/s00167-010-1051-2)
  • [L2] Despite this finding, it was uncommon for individual patients to report clinically significant knee pain at multiple follow-up timepoints. (10.1177/03635465251414661)
  • [L3] At 24 months, subjective function was similar between groups, although patients with pain catastrophizing reported more pain. (10.1016/j.arth.2022.09.016)
  • [L4] In this case, the patient achieved complete symptom resolution and full athletic recovery at one-year follow-up. (10.1007/s00167-010-1229-7)
  • [L4] Most participants experienced mild to moderate post-surgery pain, but the intervention substantially improved quality of life, enabling daily activities resumption. (10.1177/2325967124s00468)
  • [L1] Moderate-level evidence confirmed that IPACK was related to better results in pain scores, morphine usage, and functional recovery without increasing the risk of complications. (10.1186/s13018-022-03266-3)
  • [L4] Thus, a return to sports should not be allowed earlier than 6 months after surgery, when patients have reached pain-free function and recovered strength. (10.1186/s12891-017-1620-3)
  • [L1] Periarticular steroid injections reduce post-operative pain and inflammation, and are clinically relevant as they improve short-term functional recovery and clinical parameters, resulting in better outcomes for patients without having major complications. (10.1007/s00167-010-1126-0)
  • [L1] The study aims to evaluate if the therapy lowers pain levels, morphine consumption, and blood loss while enhancing functional recovery. (10.1186/s12891-016-1000-4)
  • [L3] Knowing these patterns enables a prediction of the cause of the pain to be made as early as possible in the diagnostic process before the state of pain becomes chronic. (10.1007/s00167-021-06567-y)
  • [L2] Six distinct early recovery trajectories were identified after total shoulder arthroplasty, with 83.7% of patients (the 'Faster group') experiencing very low pain scores after only 2 weeks. (10.1016/j.jse.2025.06.016)
  • [L4] Corticosteroid injections provide benefit by relieving pain and improving functional outcome scores. (10.1016/j.arthro.2020.04.044)
  • [L1] Patients who received PRP obtained superior improvement in pain and function at short-term follow-up (3 months), but there was no sustained benefit of PRP over corticosteroid at longer-term follow-up (12 months). (10.1016/j.arthro.2020.10.037)
  • [L2] ESWT can produce rapid pain relief and functional improvement. (10.1186/s12891-015-0837-2)
  • [L2] One year after a multidisciplinary treatment a clinically relevant improvement was shown in terms of function, pain, self-efficacy and QoL. (10.1002/ksa.12058)
  • [L3] Patient-reported outcomes and objective activity data reflect different aspects of recovery and should be interpreted as complementary rather than hierarchical measures. (10.1186/s13018-025-06591-5)
  • [L1] Continuous barbed suturing improves surgical efficiency, reduces early postoperative pain, accelerates wound healing, and enhances functional recovery without increasing complication rates. (10.1186/s13018-025-06471-y)
  • [L3] Only 23% of patients reporting no pain relief on one measure reported it on both measures, indicating that different individuals may report no pain relief depending on which pain measure was used. (10.1302/0301-620x.96b9.33363)
  • [L2] Although neuropathic symptoms improved over time, up to half continued to report painful neuropathic symptoms at 15 months after TKA. (10.1302/0301-620x.106b6.bjj-2023-0889.r1)
  • [L3] Assessing the intensity of pain at rest and pain with movement separately and considering changes in pain on an individual level will be helpful strategies in future follow-up studies. (10.1007/s00167-011-1821-5)
  • [L3] This derived cut-off can be used for patient selection in research settings to design and assess interventions that support patients in their management of chronic post-surgical pain. (10.1186/s12891-018-2270-9)
  • [L3] Significantly, more patients with reported pain show more severe damages. (10.1007/s00167-014-3068-4)
  • [L3] Preoperative opioid users were more likely to continue taking opioids, demonstrate significantly worse patient reported outcomes at baseline and 1-year postoperatively, and were less likely to achieve patient acceptable symptomatic state. (10.1016/j.arthro.2020.06.014)
  • [L3] These recovery trajectories can distinguish outcome after one year. (10.1186/s12891-021-04037-7)
  • [L4] Functional outcomes as measured by ROM and pain scores showed appropriate improvement consistent with normal populations without history of XRT. (10.1016/j.jse.2021.11.003)
  • [L3] Patients with lower levels of knee function following ACLR demonstrated hop-landing biomechanics previously associated with early patellofemoral osteoarthritis. (10.1007/s00167-018-5197-7)
  • [L2] Knee biomechanical markers are associated with patient-reported knee function to a greater extent than X-ray grading, but both provide complementary information in the assessment of OA patients. (10.1186/s12891-022-05845-1)
  • [L2] The biomechanical device and treatment methodology is effective in significantly reducing pain and improving function in knee OA patients. (10.1186/1471-2474-11-179)
  • [L2] The neuromuscular electrical stimulation appeared to be safe for biomechanics of knee joint with no pathological changes in knee function observed. (10.1155/2013/802534)
  • [L3] Postoperative lateral laxity greater than 0.9 mm at 90-degree flexion was associated with physiological kinematic motion, leading to fewer knee symptoms in the PROMs. (10.1016/j.jisako.2024.100357)
  • [L4] Patellar thickness affects patellofemoral kinematics after TKA. (10.1007/s00167-012-2312-z)
  • [L4] Reasonable long-term functional outcome scores can be achieved. (10.1016/j.jse.2017.09.003)
  • [L3] The comparable walking and forward lunge biomechanics suggest that knee pain has no substantial impact on movement biomechanics up to 10 years post‐surgery. (10.1002/ksa.12630)
  • [L2] Sagittal plane patellofemoral joint kinematics is an area of interest in the study of the mechanical factors associated with patellofemoral pain. (10.1007/s00167-013-2782-7)
  • [L4] Subtle scarring of the anterior interval changes the biomechanics of the anterior structures of the knee and may lead to refractory anterior knee pain. (10.1177/0363546508320480)
  • [L3] Knee self‐efficacy was consistently associated with asymmetries in quadriceps neuromuscular function and jump‐landing biomechanics following ACLR. (10.1002/ksa.70192)
  • [L3] Early detection and targeted intervention of the underlying pain sources can pave the way for tailored rehabilitation programs and improved surgical outcomes. (10.1186/s13018-024-04853-2)
  • [L1] This may be related to better replication of natural knee kinematics with MP TKA. (10.1007/s00167-020-06343-4)
  • [L3] The current kinematic study exhibited biomechanical characteristics of female ACL-injured subjects compared with that of control groups. (10.1007/s00167-009-0892-z)
  • [L3] UKA significantly enhances knee joint kinematics, facilitating the transition from basic to advanced functional activities. (10.1186/s13018-025-05662-x)
  • [L3] Patients after ACLR immersed in a virtual reality environment demonstrated knee joint biomechanics that approximate those of healthy controls. (10.1007/s00167-014-3374-x)
  • [L3] Patients reporting a good outcome in knee-related quality of life improved in knee biomechanics during gait, while patients reporting a poor outcome, despite similar reduction in pain, remained unchanged in knee biomechanics one year after total knee arthroplasty. (10.1186/s12891-017-1479-3)
  • [L3] Lowered PPT due to sensitization may adversely affect functional recovery and pain perception. (10.1007/s00167-023-07632-4)
  • [L3] Unexplained pain is the principal indication for early revision of the failing PFA. (10.1007/s00167-011-1842-0)
  • [L3] Functional recovery after unicompartmental knee replacement continues beyond 6 months and even up to 2 years. (10.1007/s00167-007-0351-7)
  • [L1] The outcomes of this randomized trial demonstrate a safe and effective accelerated rehabilitation protocol as well as a regimen that provides comparable, if not superior, clinical outcomes to patients throughout the postoperative timeline. (10.1177/0363546512445167)
  • [Letter] Meniscal healing is a multifactorial process requiring both biologic and kinematic factors; while restoring proper knee biomechanics is pivotal, optimal rehabilitation protocols remain contradictory, and further studies are needed to understand growth factor kinetics and achieve higher healing rates. (10.1016/j.arthro.2022.06.010)
  • [L3] These results suggest that care should be taken to account for gender when investigating the biomechanical aetiology of knee OA and that gender-specific analysis and rehabilitation protocols should be developed. (10.1186/s12891-016-1013-z)
  • [L4] This highlights a potential role of gait biomechanics in short-term osteoarthritis pain fluctuations. (10.1186/s12891-019-2493-4)
  • [L1] There were no significant differences in functional or patient perceived outcome after mid-term follow-up in this study. (10.1007/s00167-013-2608-7)
  • [L1] Immobilization periods of 1 and 3 weeks produced superior short-term outcomes compared with 6 weeks of immobilization for function, range of motion, and pain. (10.2106/jbjs.17.00912)
  • [L2] This suggests that efforts to reduce perceived exertion during work may improve recovery from chronic pain. (10.1186/1471-2474-13-253)
  • [L2] Multimodal analgesia can alleviate postoperative anxiety and depression in the short term, reduce perioperative pain, improve postoperative recovery, and shorten the length of hospital stay. (10.1186/s13018-023-04192-8)
  • [L1] Change in physical activity did not explain future clinical outcomes of pain and function in this study. (10.1186/s12891-018-1968-z)
  • [L5] Patellofemoral kinematics and retropatellar pressure change after TKA in different manners depending on the type of TKA used. (10.1007/s00167-017-4772-7)
  • [L4] Twenty-six different criteria described by multiple classification systems have been identified for the magnetic resonance assessment of rotator cuff after repair. (10.1007/s00167-014-3486-3)
  • [L4] Individuals with preoperative depression may report inferior outcomes in terms of pain and functionality; nevertheless, despite these challenges, they exhibit significant improvements across all outcome measures after surgery, including reductions in depression levels. (10.1016/j.arthro.2024.01.030)
  • [L4] GAE results in short-term improvements in pain and function with decreasing MCID achievement observed after 3 to 6 months. (10.1016/j.arthro.2024.07.033)
  • [L5] The authors propose that research and development efforts should focus on addressing aberrant biomechanics through technologies that 'unload' the joint, as this may reverse structural damage, delay the need for invasive joint reconstruction, or obviate the need entirely. (10.1007/s00167-011-1403-6)
  • [L3] Generally, recovery was slower than the provided recommendations, with 8 out of 10 activities not resumed within the recommended time. (10.1016/j.arth.2025.11.031)
  • [L5] It is currently recommended that multimodal analgesic regimens be utilized in the management of postoperative pain. (10.2106/00004623-200012000-00010)
  • [L4] The detection and definition of typical pain patterns in patients with pain after TKA and the assignment of identified pathologies will be applied in the improvement of the diagnostic process. (10.1177/2325967119s00218)
  • [L4] This highlights the need for better counseling and innovative nonopioid pain management protocols. (10.1016/j.jseint.2020.12.019)
  • [L3] A low radiological severity of osteoarthritis was not associated with pain 12 months postoperatively. (10.1302/0301-620x.96b11.33726)
  • [L4] Predictors of inferior long-term outcome included preoperative use of NSAIDs, longstanding symptoms before surgery, and non-acute onset of shoulder symptoms. (10.1007/s00167-015-3845-8)
  • [L2] Based on the findings of this study, 82% of patients who undergo arthroscopic partial meniscectomy and/or chondroplasty can achieve satisfactory pain control with nonopioid pain management. (10.1016/j.arthro.2019.03.028)
  • [L1] A multimodal nonopioid pain protocol provided at least equivalent pain control compared with traditional opioid analgesics in patients undergoing ACLR. (10.1177/03635465211045394)
  • [L2] Presentation factors that increase the likelihood of a diagnostic X-ray included pain for longer than 6 months, the presence of medial or diffuse pain, and mechanical symptoms. (10.1007/s00167-014-3003-8)
  • [L2] While the pain phenotypes remained stable in the majority of knees over 24 months period, substantial proportion of knees switched to different pain phenotypes. (10.1186/s12891-024-07286-4)
  • [L4] Overall outcome was satisfactory with high return to preinjury activity and sports rates in both operative and non-operative groups. (10.1007/s00167-020-06222-y)
  • [L2] Revision rates did not differ between groups, and there were no relevant differences in clinical improvement of subjective function and pain. (10.1002/ksa.12336)
  • [Case_report] MRI interpretations demonstrate improved clinical outcome measures ensuing therapeutic intervention with PPS, and warranting further investigation into the efficacy of PPS in the treatment of BML associated pain and dysfunction in the osteoarthritic population via randomized controlled trial, or equivalent rigorous methodological technique. (10.1186/s12891-017-1754-3)
  • [L3] Postoperative residual pain is associated with a high MRI signal intensity of the repaired supraspinatus tendon. (10.1007/s00167-019-05651-8)
  • [L4] The short-term clinical and MRI outcome are promising. (10.1007/s00167-011-1759-7)
  • [L3] Both operative and nonoperative management of MCL tears demonstrated clinical improvements between study enrollment and 2-year follow-up. (10.1016/j.arthro.2018.10.138)
  • [L4] Chronic opioid use, chronic pain, or use of non-narcotic medications carries the highest risk of postoperative opioid use. (10.1016/j.arthro.2020.12.187)
  • [L4] However, these interventions may not be effective in patients who present with severe pain, poor functional status, or high anxiety levels before surgery. (10.1186/s13018-025-05599-1)
  • [L1] The effectiveness for pain and disability was sustained over 2 years, but the objective measure of walking ability improved in both groups, with no statistical difference between operative and nonoperative groups. (10.2106/jbjs.8908.ebo2)
  • [L4] The treatment regime eliminated pathological findings in the MRI of all cases studied and decreased pain levels and functional limitations within a short-time period. (10.1007/s00167-012-2017-3)
  • [L3] Distinct patterns of co-existing MRI lesions have different implications for the pathogenesis of osteoarthritic knee pain occurring with/without joint loading. (10.1186/s12891-020-03686-4)
  • [L4] MRI contributes less than expected to the understanding of pain and function in knee OA and possibly offers little opportunity to develop structure-modifying treatments in knee OA that could influence the patient's pain and function. (10.1007/s00167-013-2434-y)
  • [L2] Based on variables before treatment, no prediction can be made regarding whether expectations will be fulfilled after treatment because residual pain at one year contributes considerably to the variance in fulfilled expectations. (10.1016/j.jhsa.2014.10.066)
  • [L4] The natural course of CECS seems to be persistent symptoms over time. (10.1007/s00167-014-2847-2)
  • [L4] Patients can be counselled that although radiographic severity of arthritic changes can predict knee-specific functional improvement, the extent of their global functional improvement cannot. (10.1007/s00167-015-3806-2)
  • [L4] Patients with a preoperative duration of symptomatic medial knee overload/arthritis of two years or greater do not experience inferior PRO or clinical outcomes than patients with a symptom duration of less than 2 years at mid-term follow-up. (10.1016/j.jisako.2022.03.003)
  • [L3] While there is a correlation between the decrease in edema size observed on MRI scans and the decrease in activity pain, there is no correlation between the decrease in edema size and the decrease in rest pain. (10.1007/s00167-009-0842-9)
  • [L2] However, the effect of preoperative pain on the postoperative outcomes seems to become less important when the patient has radiographic evidence of more severe OA. (10.2106/jbjs.18.00642)
  • [L4] The technique effectively restores motion and allows satisfactory functional recovery. (10.1177/03635465990270050201)
  • [L4] Commonly used structural features from radiographs and MRI scans cannot predict KOA pain and symptoms—even when imaging features are codified by established grading systems like IRF or MOAKS. (10.5435/jaaos-d-24-00509)
  • [L3] MRI utilization by orthopaedic surgeons results in more appropriate interventions for patients with symptoms and findings most amenable to surgical intervention. (10.2106/jbjs.n.00947)

See Also

References

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[38] Knee muscle strength and movement biomechanics in individuals with and without knee pain after anterior cruciate ligament reconstruction: A cross‐sectional study. Knee Surgery, Sports Traumatology, Arthroscopy. 2025. DOI: 10.1002/ksa.12630

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[41] Lower knee self‐efficacy is associated with greater asymmetries in quadriceps neuromuscular function and jump‐landing biomechanics post‐ACL reconstruction. Knee Surgery, Sports Traumatology, Arthroscopy. 2025. DOI: 10.1002/ksa.70192

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[75] Phenotypes of osteoarthritis-related knee pain and their transition over time: data from the osteoarthritis initiative. BMC Musculoskeletal Disorders. 2024. DOI: 10.1186/s12891-024-07286-4

[76] Satisfactory clinical outcome of operative and non‐operative treatment of avulsion fracture of the hamstring origin with treatment selection based on extent of displacement: a systematic review. Knee Surgery, Sports Traumatology, Arthroscopy. 2020. DOI: 10.1007/s00167-020-06222-y

[77] Anxiety and depression prior to total knee arthroplasty are associated with worse pain and subjective function: A prospective comparative study. Knee Surgery, Sports Traumatology, Arthroscopy. 2024. DOI: 10.1002/ksa.12336

[78] Improved clinical outcome measures of knee pain and function with concurrent resolution of subchondral Bone Marrow Edema Lesion and joint effusion in an osteoarthritic patient following Pentosan Polysulphate Sodium treatment: a case report. BMC Musculoskeletal Disorders. 2017. DOI: 10.1186/s12891-017-1754-3

[79] Postoperative residual pain is associated with a high magnetic resonance imaging (MRI)‐based signal intensity of the repaired supraspinatus tendon. Knee Surgery, Sports Traumatology, Arthroscopy. 2019. DOI: 10.1007/s00167-019-05651-8

[80] Short‐term outcome of the second generation characterized chondrocyte implantation for the treatment of cartilage lesions in the knee. Knee Surgery, Sports Traumatology, Arthroscopy. 2011. DOI: 10.1007/s00167-011-1759-7

[81] Outcomes of Grade III Medial Collateral Ligament Injuries Treated Concurrently With Anterior Cruciate Ligament Reconstruction: A Multicenter Study. Arthroscopy. 2019. DOI: 10.1016/j.arthro.2018.10.138

[82] Preoperative Opioid Use Is Associated With Persistent Use, Readmission and Postoperative Complications After Arthroscopic Knee Surgery. Arthroscopy. 2020. DOI: 10.1016/j.arthro.2020.12.187

[83] Severe preoperative pain, functional decline, and high anxiety levels hinder the efficacy of multidisciplinary interventions in patients who underwent primary total knee arthroplasty. Journal of Orthopaedic Surgery and Research. 2025. DOI: 10.1186/s13018-025-05599-1

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[85] Spontaneous osteonecrosis of the knee (SONK). Knee Surgery, Sports Traumatology, Arthroscopy. 2012. DOI: 10.1007/s00167-012-2017-3

[86] Co-existing patterns of MRI lesions were differentially associated with knee pain at rest and on joint loading: a within-person knee-matched case-controls study. BMC Musculoskeletal Disorders. 2020. DOI: 10.1186/s12891-020-03686-4

[87] Weak associations between structural changes on MRI and symptoms, function and muscle strength in relation to knee osteoarthritis. Knee Surgery, Sports Traumatology, Arthroscopy. 2013. DOI: 10.1007/s00167-013-2434-y

[88] Evaluation of Expectations and Expectation Fulfillment in Patients Treated for Trapeziometacarpal Osteoarthritis. The Journal of Hand Surgery. 2015. DOI: 10.1016/j.jhsa.2014.10.066

[89] The natural course of chronic exertional compartment syndrome of the lower leg. Knee Surgery, Sports Traumatology, Arthroscopy. 2014. DOI: 10.1007/s00167-014-2847-2

[90] Severe arthritis predicts greater improvements in function following total knee arthroplasty. Knee Surgery, Sports Traumatology, Arthroscopy. 2015. DOI: 10.1007/s00167-015-3806-2

[91] Preoperative symptom duration does not affect clinical outcomes after high tibial osteotomy at a minimum of 2-year follow-up. Journal of ISAKOS. 2022. DOI: 10.1016/j.jisako.2022.03.003

[92] The relationship between bone marrow edema size and knee pain. Knee Surgery, Sports Traumatology, Arthroscopy. 2009. DOI: 10.1007/s00167-009-0842-9

[93] Preoperative Radiographic Osteoarthritis Severity Modifies the Effect of Preoperative Pain on Pain/Function After Total Knee Arthroplasty. Journal of Bone and Joint Surgery. 2019. DOI: 10.2106/jbjs.18.00642

[94] Open Debridement and Soft Tissue Release as a Salvage Procedure for the Severely Arthrofibrotic Knee. The American Journal of Sports Medicine. 1999. DOI: 10.1177/03635465990270050201

[95] The Discordance Between Pain and Imaging in Knee Osteoarthritis. Journal of the American Academy of Orthopaedic Surgeons. 2025. DOI: 10.5435/jaaos-d-24-00509

[96] MRI for the Evaluation of Knee Pain. The Journal of Bone and Joint Surgery-American Volume. 2015. DOI: 10.2106/jbjs.n.00947

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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.

Creative Commons may be contacted at creativecommons.org.