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Online Patient Education Materials for Common Sports Injuries Are Written at Too-High of a Reading Level: A Systematic Review

Open AccessPublished:February 11, 2022DOI:https://doi.org/10.1016/j.asmr.2021.12.017

      Purpose

      To determine the readability of online patient information for common sports injuries.

      Methods

      A systematic search of the literature using PubMed/MEDLINE, Embase, and the CINAHL databases was performed according to Preferred Reporting Items for Systematic Reviews and Meta-Analysis guidelines. Studies were included if they (1) were published between 2000 and September 2020, (2) were English-language publications and complete studies from peer-reviewed journals, (3) evaluated online information directed toward patients with common sports injuries.

      Results

      Eleven studies met inclusion criteria and were included. The mean Flesch-Kincaid Grade Level for online education information was 10.5, whereas the mean Flesch Reading Ease was 51.2, indicating existing health resources are written above the recommended readability grade level (no greater than a sixth-grade reading level). The mean DISCERN score was 41.5, indicating that the quality of information accessible to patients was fair. The accuracy of health content determined by the ACL-Specific Score was reported as moderate level (mean 8.85).

      Conclusions

      This study demonstrates that online patient information regarding common sports injuries the does not match the readability recommendations of the American Medical Association and National Institutes of health.

      Clinical Relevance

      Future health-related information should be written by qualified experts at a level that can be easily understood by patients of all health literacy levels. Surgeons should be more attentive to where patients get their information from and how they interpret it. Accurate, easy to understand educational tools can improve efforts to help patients identify misconceptions about treatment options, and to guide patients to choices that are consistent with their values.
      The value of patient education materials relies on the users’ ability to access and understand the presented information. Within the last several years, the Internet has transformed into the primary source of health information for many people.
      • Doak C.C.
      • Doak L.G.
      • Root J.H.
      Teaching patients with low literacy skills.
      More than 345 million Americans, representing 95.0% of the population, have Internet access, with more than one-half using the Internet to seek health information.
      Internet World Stats. Americas—Internet Usage Statistics, Population and Telecom Reports.
      Moreover, there is an emergent body of literature across multiple specialties supporting the importance of accurate and accessible health information for patients.
      • Jayakumar P.
      • Teunis T.
      • Vranceanu A.M.
      • et al.
      The impact of a patient’s engagement in their health on the magnitude of limitations and experience following upper limb fractures.
      The quality of information provided to patients regarding their care may substantially influence their understanding of their condition/injury.
      • Sambandam S.N.
      • Ramasamy V.
      • Priyanka P.
      • Ilango B.
      Quality analysis of patient information about knee arthroscopy on the World Wide Web.
      Further, patient education may influence treatment choice and outcome expectations.
      • Stacey D.
      • Légaré F.
      • Lewis K.
      • et al.
      Decision aids for people facing health treatment or screening decisions.
      In the orthopaedic setting, effective patient education may contribute to a favorable postoperative course. Johansson et al.
      • Johansson K.
      • Nuutila L.
      • Virtanen H.
      • Katajisto J.
      • Salanterä S.
      Preoperative education for orthopaedic patients: Systematic review.
      reported that preoperative orthopaedic patient education improved pain, length of hospital stay, self-efficacy, and motivation to complete exercises. It is therefore imperative to assess the quality, readability, and accuracy of online patient education materials. Furthermore, patient education tools are now a major focus in management and are counted among the factors considered in health care quality assessment.
      • Cailliez J.
      • Reina N.
      • Molinier F.
      • Chaminade B.
      • Chiron P.
      • Laffosse J.M.
      Patient information ahead of anterior cruciate ligament reconstruction: Experience in a university hospital center.
      Attention to from where patients obtain their information and how they interpret it represents an important step in patient management: the patient, when correctly informed, plays a substantial role in discussing treatment options and subsequent surgical procedures.
      • Cornoiu A.
      • Beischer A.D.
      • Donnan L.
      • Graves S.
      • de Steiger R.
      Multimedia patient education to assist the informed consent process for knee arthroscopy.
      ,
      • Rossi M.J.
      • Guttmann D.
      • MacLennan M.J.
      • Lubowitz J.H.
      Video informed consent improves knee arthroscopy patient comprehension.
      Without quality information, the patient is in less of a position to accurately weigh tests and treatment options that are in line with their goals, values, and preferences.
      • Rossi M.J.
      • Guttmann D.
      • MacLennan M.J.
      • Lubowitz J.H.
      Video informed consent improves knee arthroscopy patient comprehension.
      The purpose of this study was to determine the readability of online patient information for common sports injuries. We hypothesized that the readability of online patient information for common sports injuries would not meet recommended levels.

      Methods

      The systematic review was performed in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) guidelines.
      • Moher D.
      • Shamseer L.
      • Clarke M.
      • et al.
      Preferred reporting items for systematic review and meta-analysis protocols (PRISMA-P) 2015 statement.
      No meta-analysis was undertaken for the included studies, given the heterogeneity of patient education materials assessed.

      Information Sources and Search Strategy

      The literature search was conducted, with the assistance of a research support librarian, using the PICO framework. A comprehensive search was conducted using the PubMed/MEDLINE, Embase, and CINAHL databases. All databases were searched from inception to September 2020. Each database was searched for the following Medical Subject Headings (MeSH) and key words: “athletic injuries,” “education delivery,” “patient engagement,” “shared decision-making,” “preoperative,” and “postoperative.” Search and query of terms used in combination with Boolean operators available as Appendix Tables 1-3, available at www.arthroscopyjournal.org. Each included study’s reference list was also reviewed.

      Eligibility Criteria

      Studies were included if they (1) were published between September 2000 and September 2020 to capture different variations of studies, while excluding obsolete knowledge, and incorporating the present trends in the study topic as compared to the recent past; (2) were English-language publications and complete studies from peer-reviewed journals; and (3) evaluated online information directed toward patients with common sports injuries. Exclusion criteria were publication types other than peer-reviewed studies such as protocols, reviews, or case series.

      Selection Process and Data Collection

      The query yielded 722 studies from PubMed/MEDLINE, 2868 from Embase, and 3652 from CINAHL databases after duplicates were removed. Data were independently extracted by 2 of the coauthors (Y.A. and A.A.) using standard data extraction forms for all studies. These reviewers screened full-text studies using the same procedure with acceptable reproducibility for all decisions. Disagreements were resolved by consensus. The following data items were collected: condition or injury, information source, number of webpages analyzed, authorship, methods of acquiring information, and key study results regarding quality, readability, and accuracy (Table 1).
      • Akinleye S.D.
      • Krochak R.
      • Richardson N.
      • Garofolo G.
      • Culbertson M.D.
      • Erez O.
      Readability of the most commonly accessed arthroscopy-related online patient education materials.
      • Bruce-Brand R.A.
      • Baker J.F.
      • Byrne D.P.
      • Hogan N.A.
      • McCarthy T.
      Assessment of the quality and content of information on anterior cruciate ligament reconstruction on the internet.
      • Cassidy J.T.
      • Fitzgerald E.
      • Cassidy E.S.
      • et al.
      YouTube provides poor information regarding anterior cruciate ligament injury and reconstruction.
      • Dalton D.M.
      • Kelly E.G.
      • Molony D.C.
      Availability of accessible and high-quality information on the Internet for patients regarding the diagnosis and management of rotator cuff tears.
      • Duncan I.C.
      • Kane P.W.
      • Lawson K.A.
      • Cohen S.B.
      • Ciccotti M.G.
      • Dodson C.C.
      Evaluation of information available on the Internet regarding anterior cruciate ligament reconstruction.
      • Garcia G.H.
      • Taylor S.A.
      • Dy C.J.
      • Christ A.
      • Patel R.M.
      • Dines J.S.
      Online resources for shoulder instability: What are patients reading?.
      • Johnson C.C.
      • Garcia G.H.
      • Liu J.N.
      • Stepan J.G.
      • Patel R.M.
      • Dines J.S.
      Internet resources for Tommy John injuries: what are patients reading?.
      • Lawson K.A.
      • Codella S.
      • Ciccotti M.G.
      • Kane P.W.
      • Duncan I.C.
      • Cohen S.B.
      Evaluation of internet information about rotator cuff repair.
      • Wang D.
      • Jayakar R.G.
      • Leong N.L.
      • Leathers M.P.
      • Williams R.J.
      • Jones K.J.
      Evaluation of the quality, accuracy, and readability of online patient resources for the management of articular cartilage defects.
      • Trofa D.P.
      • Parisien R.L.
      • Noticewala M.S.
      • et al.
      Quality and variability of online physical therapy protocols for isolated meniscal repairs.
      • Springer B.
      • Bechler U.
      • Koller U.
      • Windhager R.
      • Waldstein W.
      Online videos provide poor information quality, reliability, and accuracy regarding rehabilitation and return to sport after anterior cruciate ligament reconstruction.

      Outcome Measures

      Measures of Readability

      Three scores were used to calculate readability: Flesch-Kincaid Grade Level (FKGL), Flesch Reading Ease Score (FRES), and Gunning Fog Index (GFI). FKGL measures the grade level that one must complete to comprehend a given text, whereas the FRES measures the readability of a text.
      • Silberg W.M.
      Assessing, controlling, and assuring the quality of medical information on the internet.
      FKGL and FRES range from 0 to 29: very difficult to read or a postgraduate reading level; 30 to 49: difficult to read, college reading level; 50 to 59: fairly difficult to read, high school reading level; 60 to 69: standard difficulty to read, 8th to 9th grade reading level; 70 to 79: fairly easy to read, 7th grade reading level; 80 to 89: easy to read, 5th to 6th grade reading level; 90 to 100: very easy to read, 4th to 5th grade reading level. GFI estimates the years of formal education a person needs to understand the text on first reading.
      • Keogh C.J.
      • McHugh S.M.
      • Clarke Moloney M.
      • et al.
      Assessing the quality of online information for patients with carotid disease.
      • Fitzsimmons P.R.
      • Michael B.D.
      • Hulley J.L.
      • Scott G.O.
      A readability assessment of online Parkinson’s disease information.
      • Roberts H.
      • Zhang D.
      • Dyer G.S.M.
      The readability of AAOS patient education materials: Evaluating the progress since 2008.

      Measures of Quality and Accuracy

      Six scores were used to calculate quality and accuracy: DISCERN questionnaire, Journal of the American Medical Association (JAMA) benchmark criteria, ACL Specific Score (ASS), the Global Quality score (GQS), Unique quality and accuracy score, and Health On the Net Code (HONcode).
      The DISCERN questionnaire is a standardized quality index of consumer health information that determines publication quality based on 16 questions that pertain to the reliability of the publication, content information, and overall quality rating.
      • Singh A.G.
      • Singh S.
      • Singh P.P.
      YouTube for information on rheumatoid arthritis—A wakeup call?.
      The DISCERN criteria scale ranges from 6-80, with a greater score indicating greater quality.
      The JAMA benchmark criteria assesses 4 core criteria to determine whether the information presented was credible, reasonable, or potentially useable.
      • Bruce-Brand R.A.
      • Baker J.F.
      • Byrne D.P.
      • Hogan N.A.
      • McCarthy T.
      Assessment of the quality and content of information on anterior cruciate ligament reconstruction on the internet.
      The JAMA benchmark criteria scale ranges from 0 to 4, with a greater score indicating greater quality.
      • Bruce-Brand R.A.
      • Baker J.F.
      • Byrne D.P.
      • Hogan N.A.
      • McCarthy T.
      Assessment of the quality and content of information on anterior cruciate ligament reconstruction on the internet.
      The ASS, defined by Bruce-Band et al.,
      • Bruce-Brand R.A.
      • Baker J.F.
      • Byrne D.P.
      • Hogan N.A.
      • McCarthy T.
      Assessment of the quality and content of information on anterior cruciate ligament reconstruction on the internet.
      evaluates informational value of each website pertaining to ACL injuries and reconstruction. One point was assigned for each criterion, with a potential score of 25. The ASS is scored as very good (21-25), good (16-20), moderate (11-15), poor (6-10), or very poor (0-5).
      The GQS was assigned by the reviewer after evaluating the pertinent websites. The GQS uses a 5-point scale to rate overall quality and scores range from 0 to 5, with a greater score indicating greater quality.
      Unique quality and accuracy scores are based on guidelines written by American Academy of Orthopedic Surgeons (greater score = greater quality or accuracy).
      • Bruce-Brand R.A.
      • Baker J.F.
      • Byrne D.P.
      • Hogan N.A.
      • McCarthy T.
      Assessment of the quality and content of information on anterior cruciate ligament reconstruction on the internet.
      • Cassidy J.T.
      • Fitzgerald E.
      • Cassidy E.S.
      • et al.
      YouTube provides poor information regarding anterior cruciate ligament injury and reconstruction.
      • Dalton D.M.
      • Kelly E.G.
      • Molony D.C.
      Availability of accessible and high-quality information on the Internet for patients regarding the diagnosis and management of rotator cuff tears.
      ,
      • Garcia G.H.
      • Taylor S.A.
      • Dy C.J.
      • Christ A.
      • Patel R.M.
      • Dines J.S.
      Online resources for shoulder instability: What are patients reading?.
      ,
      • Johnson C.C.
      • Garcia G.H.
      • Liu J.N.
      • Stepan J.G.
      • Patel R.M.
      • Dines J.S.
      Internet resources for Tommy John injuries: what are patients reading?.
      ,
      • Kaicker J.
      • Debono V.B.
      • Dang W.
      • Buckley N.
      • Thabane L.
      Assessment of the quality and variability of health information on chronic pain websites using the DISCERN instrument.
      ,
      • Patel S.
      • Abdullah M.
      • Wassef C.R.
      • Wassef A.
      • Panchbhavi V.K.
      Quality of patient education on anterior cruciate ligament reconstruction online.
      Finally, the presence of HONcode certification identifies websites that agree to comply with a code of ethics to provide quality objective and transparent medical information.
      • Boyer C.
      • Baujard V.
      • Geissbuhler A.
      Evolution of health web certification through the HONcode experience.

      Assessment of Study Quality

      Study quality was evaluated through the following variables recommended in Crombie’s items for assessing the quality of cross-sectional studies
      • Ma L.L.
      • Wang Y.Y.
      • Yang Z.H.
      • Huang D.
      • Weng H.
      • Zeng X.T.
      Methodological quality (risk of bias) assessment tools for primary and secondary medical studies: What are they and which is better?.
      : (1) appropriateness of design to meet the aims, (2) justification of sample size, (3) adequate description of the data, (4) report number of excluded studies, (5) adequate representativeness of the sample to the total, (6) clearly stated aims and likelihood of reliable and valid measurements, and (7) adequate description of statistical methods. Each parameter received a score of 0, 0.5, or 1 point for not reporting, unclearly reporting, or clearly reporting, respectively. Studies were denoted as high quality if more than 5 of the 7 criteria were described and considered. Studies were denoted as moderate quality if 4-5 of the criteria were described and considered. Quality scores less than 4 were deemed low quality.

      Results

      The query yielded 722 studies from PubMed/MEDLINE, 2868 from Embase, and 3652 from CINAHL databases after duplicates were removed. Applying inclusion and exclusion criteria resulted in 11 studies included for analysis (Fig 1). The article characteristics are included as a tabulated and narrative summary (Table 1).
      • Akinleye S.D.
      • Krochak R.
      • Richardson N.
      • Garofolo G.
      • Culbertson M.D.
      • Erez O.
      Readability of the most commonly accessed arthroscopy-related online patient education materials.
      • Bruce-Brand R.A.
      • Baker J.F.
      • Byrne D.P.
      • Hogan N.A.
      • McCarthy T.
      Assessment of the quality and content of information on anterior cruciate ligament reconstruction on the internet.
      • Cassidy J.T.
      • Fitzgerald E.
      • Cassidy E.S.
      • et al.
      YouTube provides poor information regarding anterior cruciate ligament injury and reconstruction.
      • Dalton D.M.
      • Kelly E.G.
      • Molony D.C.
      Availability of accessible and high-quality information on the Internet for patients regarding the diagnosis and management of rotator cuff tears.
      • Duncan I.C.
      • Kane P.W.
      • Lawson K.A.
      • Cohen S.B.
      • Ciccotti M.G.
      • Dodson C.C.
      Evaluation of information available on the Internet regarding anterior cruciate ligament reconstruction.
      • Garcia G.H.
      • Taylor S.A.
      • Dy C.J.
      • Christ A.
      • Patel R.M.
      • Dines J.S.
      Online resources for shoulder instability: What are patients reading?.
      • Johnson C.C.
      • Garcia G.H.
      • Liu J.N.
      • Stepan J.G.
      • Patel R.M.
      • Dines J.S.
      Internet resources for Tommy John injuries: what are patients reading?.
      • Lawson K.A.
      • Codella S.
      • Ciccotti M.G.
      • Kane P.W.
      • Duncan I.C.
      • Cohen S.B.
      Evaluation of internet information about rotator cuff repair.
      • Wang D.
      • Jayakar R.G.
      • Leong N.L.
      • Leathers M.P.
      • Williams R.J.
      • Jones K.J.
      Evaluation of the quality, accuracy, and readability of online patient resources for the management of articular cartilage defects.
      • Trofa D.P.
      • Parisien R.L.
      • Noticewala M.S.
      • et al.
      Quality and variability of online physical therapy protocols for isolated meniscal repairs.
      • Springer B.
      • Bechler U.
      • Koller U.
      • Windhager R.
      • Waldstein W.
      Online videos provide poor information quality, reliability, and accuracy regarding rehabilitation and return to sport after anterior cruciate ligament reconstruction.
      The most common sports injury studied was ACL tear.
      • Cailliez J.
      • Reina N.
      • Molinier F.
      • Chaminade B.
      • Chiron P.
      • Laffosse J.M.
      Patient information ahead of anterior cruciate ligament reconstruction: Experience in a university hospital center.
      ,
      • Akinleye S.D.
      • Krochak R.
      • Richardson N.
      • Garofolo G.
      • Culbertson M.D.
      • Erez O.
      Readability of the most commonly accessed arthroscopy-related online patient education materials.
      • Bruce-Brand R.A.
      • Baker J.F.
      • Byrne D.P.
      • Hogan N.A.
      • McCarthy T.
      Assessment of the quality and content of information on anterior cruciate ligament reconstruction on the internet.
      • Cassidy J.T.
      • Fitzgerald E.
      • Cassidy E.S.
      • et al.
      YouTube provides poor information regarding anterior cruciate ligament injury and reconstruction.
      ,
      • Duncan I.C.
      • Kane P.W.
      • Lawson K.A.
      • Cohen S.B.
      • Ciccotti M.G.
      • Dodson C.C.
      Evaluation of information available on the Internet regarding anterior cruciate ligament reconstruction.
      ,
      • Springer B.
      • Bechler U.
      • Koller U.
      • Windhager R.
      • Waldstein W.
      Online videos provide poor information quality, reliability, and accuracy regarding rehabilitation and return to sport after anterior cruciate ligament reconstruction.
      Other injuries included meniscus tear,
      • Rossi M.J.
      • Guttmann D.
      • MacLennan M.J.
      • Lubowitz J.H.
      Video informed consent improves knee arthroscopy patient comprehension.
      ,
      • Trofa D.P.
      • Parisien R.L.
      • Noticewala M.S.
      • et al.
      Quality and variability of online physical therapy protocols for isolated meniscal repairs.
      hip labral tear,
      • Akinleye S.D.
      • Krochak R.
      • Richardson N.
      • Garofolo G.
      • Culbertson M.D.
      • Erez O.
      Readability of the most commonly accessed arthroscopy-related online patient education materials.
      shoulder labral tear,
      • Akinleye S.D.
      • Krochak R.
      • Richardson N.
      • Garofolo G.
      • Culbertson M.D.
      • Erez O.
      Readability of the most commonly accessed arthroscopy-related online patient education materials.
      rotator cuff,
      • Dalton D.M.
      • Kelly E.G.
      • Molony D.C.
      Availability of accessible and high-quality information on the Internet for patients regarding the diagnosis and management of rotator cuff tears.
      ,
      • Lawson K.A.
      • Codella S.
      • Ciccotti M.G.
      • Kane P.W.
      • Duncan I.C.
      • Cohen S.B.
      Evaluation of internet information about rotator cuff repair.
      ,
      • Hoppe D.J.
      • Denkers M.
      • Hoppe F.M.
      • Wong I.H.
      The use of video before arthroscopic shoulder surgery to enhance patient recall and satisfaction: A randomized-controlled study.
      ,
      • Syed U.A.M.
      • Aleem A.W.
      • Wowkanech C.
      • et al.
      Neer Award 2018: The effect of preoperative education on opioid consumption in patients undergoing arthroscopic rotator cuff repair: A prospective, randomized clinical trial.
      ulnar collateral ligament tear,
      • Johnson C.C.
      • Garcia G.H.
      • Liu J.N.
      • Stepan J.G.
      • Patel R.M.
      • Dines J.S.
      Internet resources for Tommy John injuries: what are patients reading?.
      articular cartilage defects,
      • Sugand K.
      • Malik H.H.
      • Newman S.
      • Spicer D.
      • Reilly P.
      • Gupte C.M.
      Does using anatomical models improve patient satisfaction in orthopaedic consenting? Single-blinded randomised controlled trial.
      shoulder instability,
      • Garcia G.H.
      • Taylor S.A.
      • Dy C.J.
      • Christ A.
      • Patel R.M.
      • Dines J.S.
      Online resources for shoulder instability: What are patients reading?.
      and ankle fractures.
      • Mayich D.J.
      • Tieszer C.
      • Lawendy A.
      • McCormick W.
      • Sanders D.
      Role of patient information handouts following operative treatment of ankle fractures: A prospective randomized study.
      Eight studies assess education websites, 2 assess YouTube videos, and 1 assess web-based protocols. Physician authorship ranged from 2% to 39%. The number of websites/videos/protocols evaluated in each study ranged from 30 to 200.
      Figure thumbnail gr1
      Fig 1Preferred Reporting items for Systematic Review and Meta-Analysis Statement Diagram depicting the selection process for article inclusion.
      Table 1Characteristics of Studies Included in the Systematic Review
      StudyStudy Design, Level of EvidenceInformation Source(s)Outcome(s)Condition or InjuryConclusion
      Akinleye et al., 2018
      • Akinleye S.D.
      • Krochak R.
      • Richardson N.
      • Garofolo G.
      • Culbertson M.D.
      • Erez O.
      Readability of the most commonly accessed arthroscopy-related online patient education materials.
      Retrospective, IVEducational websitesReadability scoresACL tear, meniscus tear, hip labral tear, rotator cuff tearMost frequently accessed materials for patients with injuries requiring arthroscopic surgery does not match the readability recommendations of the AMA and NIH, and the average reading ability of U.S. adults.
      Bruce-Brand et al., 2013
      • Bruce-Brand R.A.
      • Baker J.F.
      • Byrne D.P.
      • Hogan N.A.
      • McCarthy T.
      Assessment of the quality and content of information on anterior cruciate ligament reconstruction on the internet.
      Retrospective, IVEducational websitesQuality scoresACL reconstructionQuality of information available online regarding ACL reconstruction is of variable quality with many websites omitting basic information regarding treatment options, risks, and prognosis.
      Cassidy et al., 2018
      • Cassidy J.T.
      • Fitzgerald E.
      • Cassidy E.S.
      • et al.
      YouTube provides poor information regarding anterior cruciate ligament injury and reconstruction.
      Retrospective, IVYouTube videosQuality scoresACL injury and reconstructionMajority of videos viewed on YouTube regarding ACL injury and treatment are of low quality
      Dalton et al., 2015
      • Dalton D.M.
      • Kelly E.G.
      • Molony D.C.
      Availability of accessible and high-quality information on the Internet for patients regarding the diagnosis and management of rotator cuff tears.
      Retrospective, IVEducational websitesReadability and quality scoresRotator cuff tearsQuality of available information on rotator cuff tears is poor. Readability of information on rotator cuff disease is inappropriately high.
      Duncan et al., 2013
      • Duncan I.C.
      • Kane P.W.
      • Lawson K.A.
      • Cohen S.B.
      • Ciccotti M.G.
      • Dodson C.C.
      Evaluation of information available on the Internet regarding anterior cruciate ligament reconstruction.
      Retrospective, IVEducational websitesProportion of websites that met prespecified quality criteriaACL reconstructionQuality of internet information available to patients searching for ACL reconstruction appears mixed.
      Garcia et al., 2014
      • Garcia G.H.
      • Taylor S.A.
      • Dy C.J.
      • Christ A.
      • Patel R.M.
      • Dines J.S.
      Online resources for shoulder instability: What are patients reading?.
      Retrospective, IVEducational websitesReadability, quality, and accuracy scoresShoulder instabilityOnline information regarding shoulder instability is often inaccurate and/or at an inappropriately high reading level. The quality of information is highly dependent on the specific search term used.
      Johnson et al., 2016
      • Johnson C.C.
      • Garcia G.H.
      • Liu J.N.
      • Stepan J.G.
      • Patel R.M.
      • Dines J.S.
      Internet resources for Tommy John injuries: what are patients reading?.
      Retrospective, IVEducational websitesReadability, quality, and accuracy scoresUlnar collateral ligamentOnline information on UCL injuries is often inaccurate and written at an inappropriate reading level. Information quality depends on search term used, website authorship, and commercial bias.
      Lawson et al., 2016
      • Lawson K.A.
      • Codella S.
      • Ciccotti M.G.
      • Kane P.W.
      • Duncan I.C.
      • Cohen S.B.
      Evaluation of internet information about rotator cuff repair.
      Retrospective, IVEducational websitesReadability and quality scoresRotator cuff repairWebsites associated with academic institutions produced the highest-quality medical information.
      Wang et al., 2017
      • Wang D.
      • Jayakar R.G.
      • Leong N.L.
      • Leathers M.P.
      • Williams R.J.
      • Jones K.J.
      Evaluation of the quality, accuracy, and readability of online patient resources for the management of articular cartilage defects.
      Retrospective, IVEducational websitesReadability, quality, and accuracy scoresArticular cartilage defectsQuality and readability of online patient resources for articular cartilage defects favor those with a higher level of education. Majority of websites do not distinguish between focal chondral defects and diffuse osteoarthritis, which can fail to provide appropriate patient education and guidance for available treatment.
      Trofa et al., 2019
      • Trofa D.P.
      • Parisien R.L.
      • Noticewala M.S.
      • et al.
      Quality and variability of online physical therapy protocols for isolated meniscal repairs.
      Retrospective, IVWeb-based protocolsProportion of protocols that met prespecified quality criteriaIsolated meniscal repairsWithin the most readily available online protocols there are significant disparities in regard to brace use, ROM, weight-bearing, and strengthening and proprioception exercises.
      Springer et al, 2020
      • Springer B.
      • Bechler U.
      • Koller U.
      • Windhager R.
      • Waldstein W.
      Online videos provide poor information quality, reliability, and accuracy regarding rehabilitation and return to sport after anterior cruciate ligament reconstruction.
      Retrospective, IVYouTube videosQuality scoresACL reconstructionAverage information quality, reliability and accuracy of YouTube videos regarding rehabilitation and RTS after ACL reconstruction are poor. Information quality of related YouTube videos from medically trained professionals is significantly higher compared with commercial videos or personal-testimony videos
      ACL, anterior cruciate ligament; AMA, American Medical Association; NIH, National Institutes of Health; RTS, return to sport; UCL, ulnar collateral ligament.

      Readability, Quality, and Accuracy of Information

      Table 2
      • Akinleye S.D.
      • Krochak R.
      • Richardson N.
      • Garofolo G.
      • Culbertson M.D.
      • Erez O.
      Readability of the most commonly accessed arthroscopy-related online patient education materials.
      • Bruce-Brand R.A.
      • Baker J.F.
      • Byrne D.P.
      • Hogan N.A.
      • McCarthy T.
      Assessment of the quality and content of information on anterior cruciate ligament reconstruction on the internet.
      • Cassidy J.T.
      • Fitzgerald E.
      • Cassidy E.S.
      • et al.
      YouTube provides poor information regarding anterior cruciate ligament injury and reconstruction.
      • Dalton D.M.
      • Kelly E.G.
      • Molony D.C.
      Availability of accessible and high-quality information on the Internet for patients regarding the diagnosis and management of rotator cuff tears.
      • Duncan I.C.
      • Kane P.W.
      • Lawson K.A.
      • Cohen S.B.
      • Ciccotti M.G.
      • Dodson C.C.
      Evaluation of information available on the Internet regarding anterior cruciate ligament reconstruction.
      • Garcia G.H.
      • Taylor S.A.
      • Dy C.J.
      • Christ A.
      • Patel R.M.
      • Dines J.S.
      Online resources for shoulder instability: What are patients reading?.
      • Johnson C.C.
      • Garcia G.H.
      • Liu J.N.
      • Stepan J.G.
      • Patel R.M.
      • Dines J.S.
      Internet resources for Tommy John injuries: what are patients reading?.
      • Lawson K.A.
      • Codella S.
      • Ciccotti M.G.
      • Kane P.W.
      • Duncan I.C.
      • Cohen S.B.
      Evaluation of internet information about rotator cuff repair.
      • Wang D.
      • Jayakar R.G.
      • Leong N.L.
      • Leathers M.P.
      • Williams R.J.
      • Jones K.J.
      Evaluation of the quality, accuracy, and readability of online patient resources for the management of articular cartilage defects.
      • Trofa D.P.
      • Parisien R.L.
      • Noticewala M.S.
      • et al.
      Quality and variability of online physical therapy protocols for isolated meniscal repairs.
      • Springer B.
      • Bechler U.
      • Koller U.
      • Windhager R.
      • Waldstein W.
      Online videos provide poor information quality, reliability, and accuracy regarding rehabilitation and return to sport after anterior cruciate ligament reconstruction.
      reports the readability, quality, and accuracy of online patient information for sports medicine related injuries. Six of 11 (54.5%) studies evaluated components of readability (Table 3).
      • Akinleye S.D.
      • Krochak R.
      • Richardson N.
      • Garofolo G.
      • Culbertson M.D.
      • Erez O.
      Readability of the most commonly accessed arthroscopy-related online patient education materials.
      ,
      • Dalton D.M.
      • Kelly E.G.
      • Molony D.C.
      Availability of accessible and high-quality information on the Internet for patients regarding the diagnosis and management of rotator cuff tears.
      ,
      • Garcia G.H.
      • Taylor S.A.
      • Dy C.J.
      • Christ A.
      • Patel R.M.
      • Dines J.S.
      Online resources for shoulder instability: What are patients reading?.
      • Johnson C.C.
      • Garcia G.H.
      • Liu J.N.
      • Stepan J.G.
      • Patel R.M.
      • Dines J.S.
      Internet resources for Tommy John injuries: what are patients reading?.
      • Lawson K.A.
      • Codella S.
      • Ciccotti M.G.
      • Kane P.W.
      • Duncan I.C.
      • Cohen S.B.
      Evaluation of internet information about rotator cuff repair.
      • Wang D.
      • Jayakar R.G.
      • Leong N.L.
      • Leathers M.P.
      • Williams R.J.
      • Jones K.J.
      Evaluation of the quality, accuracy, and readability of online patient resources for the management of articular cartilage defects.
      The mean FKGL was 10.5 (range 8.1-13.4), which is defined as “very difficult to read,” or a postgraduate reading level. The mean FRES was 51.18 (range 50.17-52.14), which is defined as “fairly difficult to read,” or a high school reading level. Only one study reported a mean GFI of 9.02, which is higher than the threshold (index less than 8) for universal understanding.
      • Wang D.
      • Jayakar R.G.
      • Leong N.L.
      • Leathers M.P.
      • Williams R.J.
      • Jones K.J.
      Evaluation of the quality, accuracy, and readability of online patient resources for the management of articular cartilage defects.
      Table 2Characteristics of Online Education Materials
      CitationCondition or InjuryNMethodSearch EnginesSearch Terms% Physician AuthoredOutcome Scores, Mean (SD)
      Readability
      Akinleye et al., 2018
      • Akinleye S.D.
      • Krochak R.
      • Richardson N.
      • Garofolo G.
      • Culbertson M.D.
      • Erez O.
      Readability of the most commonly accessed arthroscopy-related online patient education materials.
      ACL tear, meniscus tear, hip labral tear, shoulder labral tear, and rotator cuff tear5010 most-visited sites for each condition were analyzed.GoogleACL tear, meniscus tear, rotator cuff tear, shoulder labral tear, and hip labral tear16% private practiceFKGL, 9.0

      FRES, 52.14
      Quality
      Bruce-Brand et al., 2013
      • Bruce-Brand R.A.
      • Baker J.F.
      • Byrne D.P.
      • Hogan N.A.
      • McCarthy T.
      Assessment of the quality and content of information on anterior cruciate ligament reconstruction on the internet.
      ACL tear, meniscus tear, hip labral tear, shoulder labral tear, and rotator cuff tear45Reviewed first 30 results from Google, 10 from Yahoo, Bing, and Ask.Google, Yahoo, Bing, AskACL reconstruction11% physicianDISCERN, 41.11 (13.3)

      JAMA, 2.1 (1.2)

      HONcode-certified (18%)

      Quality score, 12.29 (5.49); scale 0-25
      Cassidy et al., 2018
      • Cassidy J.T.
      • Fitzgerald E.
      • Cassidy E.S.
      • et al.
      YouTube provides poor information regarding anterior cruciate ligament injury and reconstruction.
      ACL injury and reconstruction39Considered results from only first three pages for each search.YouTubeACL, ACL with/without associated terms of injury, reconstruction, and surgery2% private practiceDISCERN, 2.2 (0.9); modified scale 0-5

      JAMA, 2.4 (0.7)

      ASS, 5.5 (3.2)
      Duncan et al., 2013
      • Duncan I.C.
      • Kane P.W.
      • Lawson K.A.
      • Cohen S.B.
      • Ciccotti M.G.
      • Dodson C.C.
      Evaluation of information available on the Internet regarding anterior cruciate ligament reconstruction.
      ACL reconstruction200Identified top 50 sites from each of the 4 search engines.Google, Yahoo, Bing, AskACL reconstruction36% private physician or physician groups with no academic affiliation(41.5%) had ability to contact author, (60%) had discussion of disorder, (31%) had treatment options, (29%) explained eligibility for ACL reconstruction, (20.5%) mentioned related injuries, (62.5%) reported surgical technique, (55%) mentioned graft selection, (30%) included complications, (48.5%) discussed rehabilitation, (26%) had peer-reviewed references
      Trofa et al., 2019
      • Trofa D.P.
      • Parisien R.L.
      • Noticewala M.S.
      • et al.
      Quality and variability of online physical therapy protocols for isolated meniscal repairs.
      Isolated meniscal repairs30Twenty official meniscal repair rehabilitation protocols identified through the Electronic Residency Application Service and first 10 protocols identified by the Google search were included.Electronic Residency Application Service, GoogleMeniscal repair physical therapy protocol(86.6%) recommended immediate postoperative bracing; (40.0%) permitted immediate weight-bearing as tolerated (WBAT) postoperatively, remaining protocols permitted WBAT at an average of 4.0 (range, 1-7) weeks. Most protocols (73.3%) initiating immediate passive ROM to 90°. Only 5 protocols (16.7%) employed functional testing as a marker for return to athletics.
      Springer et al., 2020
      • Springer B.
      • Bechler U.
      • Koller U.
      • Windhager R.
      • Waldstein W.
      Online videos provide poor information quality, reliability, and accuracy regarding rehabilitation and return to sport after anterior cruciate ligament reconstruction.
      Anterior cruciate ligament reconstruction140Use of Onion Router software for nonbiased search results. Only videos within first 3 pages were included in the analysis. Analyzed information on rehabilitation and return to sport.YouTubeRehabilitation:

      ACL rehab, ACL rehabilitation, ACL rehabilitation protocol, ACL rehabilitation program, rehab ACL surgery; Return to sport: return to sport after ACL reconstruction, ACL surgery return to sport, return to sport after ACL surgery, return to play after ACL surgery, return to play after ACL reconstruction
      Rehabilitation: 13.6% educational physician

      RTS: 23.2% educational physician
      Rehabilitation:

      JAMA, 1.32 (0.64)

      GQS, 1.95 (1.1)

      Quality score, 5.0 (3.4); scale 0-20

      RTS:

      JAMA, 1.6 (0.7)

      GQS, 1.6 (0.8)

      Quality score, 3.1 (3.4); scale 0-20
      Readability and quality
      Dalton et al., 2015
      • Dalton D.M.
      • Kelly E.G.
      • Molony D.C.
      Availability of accessible and high-quality information on the Internet for patients regarding the diagnosis and management of rotator cuff tears.
      Rotator cuff tears59Top 25 results from each search engine were analyzed.Top 5 search enginesRotator cuff tear36% physician/surgeonFKGL, 8.10 (1.74)

      FRES, 51.24 (11.42)

      GFI, 9.02 (2.34)

      DISCERN, 39.47 (11.39)

      JAMA, 1.72

      HONcode-certified (25%)
      Lawson et al., 2016
      • Lawson K.A.
      • Codella S.
      • Ciccotti M.G.
      • Kane P.W.
      • Duncan I.C.
      • Cohen S.B.
      Evaluation of internet information about rotator cuff repair.
      Rotator cuff repair150Top 50 sites from each website were identified. Searched at 2 time points: 2011 and 2014.Google, Yahoo, BingRotator cuff repairTime 1 (2011): 38% private practice

      Time 2 (2014): 38% private practice
      FKGL, 10.98

      FRES, 50.17

      DISCERN, 44

      HONcode-certified (11%)
      Readability, quality, and accuracy
      Garcia et al., 2014
      • Garcia G.H.
      • Taylor S.A.
      • Dy C.J.
      • Christ A.
      • Patel R.M.
      • Dines J.S.
      Online resources for shoulder instability: What are patients reading?.
      Shoulder instability82Evaluated the first 25 results from each search.Google, Yahoo, BingShoulder instability, loose shoulder, and shoulder dislocation16% physician with academic affiliation

      39% physician without academic affiliation
      FKGL, 10.96 (2.5)

      Quality score, 9.48 (5.11); scale 0-25

      Accuracy score, 8.61 (2.6); scale 0-12
      Johnson et al., 2016
      • Johnson C.C.
      • Garcia G.H.
      • Liu J.N.
      • Stepan J.G.
      • Patel R.M.
      • Dines J.S.
      Internet resources for Tommy John injuries: what are patients reading?.
      UCL injuries113Evaluated the first 25 results from each search.Google, Yahoo, BingElbow ulnar collateral ligament injury, tommy john injury, and pitcher's elbow29% physicianFKGL, 10.71 (2.6)

      JAMA, 1.72

      HONcode-certified (3.5%)

      Quality score, 8.8 (6.8); scale 0-32

      Accuracy score, 6.26 (2.9); scale 0-12
      Wang et al., 2017
      • Wang D.
      • Jayakar R.G.
      • Leong N.L.
      • Leathers M.P.
      • Williams R.J.
      • Jones K.J.
      Evaluation of the quality, accuracy, and readability of online patient resources for the management of articular cartilage defects.
      Articular cartilage defects53First 25 results from each engine were collected and reviewed.Google, Yahoo, BingCartilage defect, cartilage damage, cartilage injuryFKGL, 13.4 (8.0)

      Quality score, 7.4 (4.4); scale 0-25

      Accuracy score, 11.7 (0.6); scale 0-12
      NOTE. FKGL: Flesch-Kincaid Grade Level measures grade level one must complete to comprehend a given text. FRES: Flesch Reading Ease Score measures readability of a text. Score 0-29: very difficult, postgraduate; 30-49: difficult, college; 50-59: fairly difficult, high school; 60-69: standard, 8th to 9th grade; 70-79: fairly easy, 7th grade; 80-89: easy, 5th to 6th grade; 90-100: very easy, 4th to 5th grade. GFI: Gunning Fog Index estimates years of formal education a person needs to understand the text on first reading. DISCERN questionnaire is a standardized quality index of consumer health information. Scale 6-80 (greater score = greater quality). JAMA (Journal of the American Medical Association) benchmark criteria. Scale 0-4 (greater score = greater quality). ASS (ACL-Specific Score) scores as very good (21-25), good (16-20), moderate (11-15), poor (6-10), and very poor (0-5). GQS (Global Quality Score) scale 0-4 (greater score = greater quality). Unique quality and accuracy scores based on guidelines written by American Academy of Orthopedic Surgeons (higher score = higher quality or accuracy). Scores vary by condition.
      ACL, anterior cruciate ligament; RTS, return to sport; SD, standard deviation; UCL, ulnar collateral ligament.
      Table 3Readability Scores
      StudyMean FKGL (SD)Mean FRES (SD)Mean GFI (SD)
      Akinleye et al., 2018
      • Akinleye S.D.
      • Krochak R.
      • Richardson N.
      • Garofolo G.
      • Culbertson M.D.
      • Erez O.
      Readability of the most commonly accessed arthroscopy-related online patient education materials.
      9.0052.14
      Dalton et al., 2015
      • Dalton D.M.
      • Kelly E.G.
      • Molony D.C.
      Availability of accessible and high-quality information on the Internet for patients regarding the diagnosis and management of rotator cuff tears.
      8.10 (1.74)51.24 (11.42)9.02 (2.34)
      Garcia et al., 2014
      • Singh A.G.
      • Singh S.
      • Singh P.P.
      YouTube for information on rheumatoid arthritis—A wakeup call?.
      10.96 (2.5)
      Johnson et al., 2016
      • Johnson C.C.
      • Garcia G.H.
      • Liu J.N.
      • Stepan J.G.
      • Patel R.M.
      • Dines J.S.
      Internet resources for Tommy John injuries: what are patients reading?.
      10.71 (2.6)
      Lawson et al., 2016
      • Lawson K.A.
      • Codella S.
      • Ciccotti M.G.
      • Kane P.W.
      • Duncan I.C.
      • Cohen S.B.
      Evaluation of internet information about rotator cuff repair.
      10.9850.17
      Wang et al., 2017
      • Wang D.
      • Jayakar R.G.
      • Leong N.L.
      • Leathers M.P.
      • Williams R.J.
      • Jones K.J.
      Evaluation of the quality, accuracy, and readability of online patient resources for the management of articular cartilage defects.
      13.40 (8.0)
      Average10.5251.189.02
      NOTE. FKGL: Flesch-Kincaid Grade Level measures grade level one must complete to comprehend a given text. FRES: Flesch Reading Ease Score measures readability of a text. Score 0-29: very difficult, postgraduate; 30-49: difficult, college; 50-59: fairly difficult, high school; 60-69: standard, 8th to 9th grade; 70-79: fairly easy, 7th grade; 80-89: easy, 5th to 6th grade; 90-100: very easy, 4th to 5th grade. GFI: Gunning Fog Index estimates years of formal education a person needs to understand the text on first reading.
      SD, standard deviation.
      Ten of 11 (90.9%) studies evaluated components of quality (Table 4).
      • Bruce-Brand R.A.
      • Baker J.F.
      • Byrne D.P.
      • Hogan N.A.
      • McCarthy T.
      Assessment of the quality and content of information on anterior cruciate ligament reconstruction on the internet.
      • Cassidy J.T.
      • Fitzgerald E.
      • Cassidy E.S.
      • et al.
      YouTube provides poor information regarding anterior cruciate ligament injury and reconstruction.
      • Dalton D.M.
      • Kelly E.G.
      • Molony D.C.
      Availability of accessible and high-quality information on the Internet for patients regarding the diagnosis and management of rotator cuff tears.
      • Duncan I.C.
      • Kane P.W.
      • Lawson K.A.
      • Cohen S.B.
      • Ciccotti M.G.
      • Dodson C.C.
      Evaluation of information available on the Internet regarding anterior cruciate ligament reconstruction.
      • Garcia G.H.
      • Taylor S.A.
      • Dy C.J.
      • Christ A.
      • Patel R.M.
      • Dines J.S.
      Online resources for shoulder instability: What are patients reading?.
      • Johnson C.C.
      • Garcia G.H.
      • Liu J.N.
      • Stepan J.G.
      • Patel R.M.
      • Dines J.S.
      Internet resources for Tommy John injuries: what are patients reading?.
      • Lawson K.A.
      • Codella S.
      • Ciccotti M.G.
      • Kane P.W.
      • Duncan I.C.
      • Cohen S.B.
      Evaluation of internet information about rotator cuff repair.
      • Wang D.
      • Jayakar R.G.
      • Leong N.L.
      • Leathers M.P.
      • Williams R.J.
      • Jones K.J.
      Evaluation of the quality, accuracy, and readability of online patient resources for the management of articular cartilage defects.
      • Trofa D.P.
      • Parisien R.L.
      • Noticewala M.S.
      • et al.
      Quality and variability of online physical therapy protocols for isolated meniscal repairs.
      • Springer B.
      • Bechler U.
      • Koller U.
      • Windhager R.
      • Waldstein W.
      Online videos provide poor information quality, reliability, and accuracy regarding rehabilitation and return to sport after anterior cruciate ligament reconstruction.
      Overall, the quality of information accessible to patients was classified as fair, with a mean DISCERN score of 41.5 (range 39.47-44). The mean JAMA benchmark score for websites was 1.8 (range 1.32-2.4). Only one study reported a poor ASS of 5.5.
      • Lawson K.A.
      • Codella S.
      • Ciccotti M.G.
      • Kane P.W.
      • Duncan I.C.
      • Cohen S.B.
      Evaluation of internet information about rotator cuff repair.
      Bruce-Band et al.
      • Bruce-Brand R.A.
      • Baker J.F.
      • Byrne D.P.
      • Hogan N.A.
      • McCarthy T.
      Assessment of the quality and content of information on anterior cruciate ligament reconstruction on the internet.
      and Dalton et al.
      • Wang D.
      • Jayakar R.G.
      • Leong N.L.
      • Leathers M.P.
      • Williams R.J.
      • Jones K.J.
      Evaluation of the quality, accuracy, and readability of online patient resources for the management of articular cartilage defects.
      demonstrated that HONcode-certified sites (2 studies in total), were significantly more difficult to read (P = .004).
      Table 4Quality Scores
      StudyMean DISCERN (SD)Mean JAMA (SD)Mean ASS (SD)Mean GQS (SD)HONcode-Certified, no., %Mean Unique Quality Score (SD)
      Bruce-Brand et al., 2013
      • Bruce-Brand R.A.
      • Baker J.F.
      • Byrne D.P.
      • Hogan N.A.
      • McCarthy T.
      Assessment of the quality and content of information on anterior cruciate ligament reconstruction on the internet.
      41.10 (13.3)2.10 (1.2)8, 18%12.29 (5.49) scale 0-25
      Cassidy et al., 2018
      • Cassidy J.T.
      • Fitzgerald E.
      • Cassidy E.S.
      • et al.
      YouTube provides poor information regarding anterior cruciate ligament injury and reconstruction.
      2.20 (0.9)∗ modified DISCERN scale (0-5)2.40 (0.7)5.50 (3.2)
      Dalton et al., 2015
      • Dalton D.M.
      • Kelly E.G.
      • Molony D.C.
      Availability of accessible and high-quality information on the Internet for patients regarding the diagnosis and management of rotator cuff tears.
      39.47 (11.39)1.7215, 25%
      Duncan et al., 2013
      • Duncan I.C.
      • Kane P.W.
      • Lawson K.A.
      • Cohen S.B.
      • Ciccotti M.G.
      • Dodson C.C.
      Evaluation of information available on the Internet regarding anterior cruciate ligament reconstruction.
      Garcia et al., 2014
      • Garcia G.H.
      • Taylor S.A.
      • Dy C.J.
      • Christ A.
      • Patel R.M.
      • Dines J.S.
      Online resources for shoulder instability: What are patients reading?.
      9.48 (5.11) scale 0-25
      Johnson et al., 2016
      • Johnson C.C.
      • Garcia G.H.
      • Liu J.N.
      • Stepan J.G.
      • Patel R.M.
      • Dines J.S.
      Internet resources for Tommy John injuries: what are patients reading?.
      1.434, 3.5%8.80 (6.8) scale 0-32
      Lawson et al., 2016
      • Lawson K.A.
      • Codella S.
      • Ciccotti M.G.
      • Kane P.W.
      • Duncan I.C.
      • Cohen S.B.
      Evaluation of internet information about rotator cuff repair.
      44.0012,11%
      Wang et al., 2017
      • Wang D.
      • Jayakar R.G.
      • Leong N.L.
      • Leathers M.P.
      • Williams R.J.
      • Jones K.J.
      Evaluation of the quality, accuracy, and readability of online patient resources for the management of articular cartilage defects.
      7.40 (4.4) scale 0-25
      Trofa et al., 2019
      • Trofa D.P.
      • Parisien R.L.
      • Noticewala M.S.
      • et al.
      Quality and variability of online physical therapy protocols for isolated meniscal repairs.
      Springer et al., 2020
      • Springer B.
      • Bechler U.
      • Koller U.
      • Windhager R.
      • Waldstein W.
      Online videos provide poor information quality, reliability, and accuracy regarding rehabilitation and return to sport after anterior cruciate ligament reconstruction.
      Rehabilitation after ACLR: 1.32 (SD, 0.64) RTS after ACLR: 1.6 (SD, 0.7)Rehabilitation after ACLR: 1.95 (SD, 1.1) RTS after ACLR: 1.6 (SD, 0.8)Rehabilitation: 5.00 (SD, 3.40); RTS 3.10 (SD, 3.40) scale 0-20
      Average41.521.795.501.959.758.60
      NOTE. The DISCERN questionnaire is a standardized quality index of consumer health information. Scale 6-80 (greater score = greater quality). JAMA (Journal of the American Medical Association) benchmark criteria. Scale 0-4 (greater score = greater quality). ASS (ACL Specific Score) scores as very good (21-25), good (16-20), moderate (11-15), poor (6-10), and very poor (0-5). GQS (Global Quality Score) scale 0-4 (greater score = greater quality). Asterisk indicates that a modified discern scale was used. Please move the text following the asterisk to the bottom of the table “modified DISCERN scale (0-5)”.
      SD, standard deviation.
      Three of eleven (27.3%) studies evaluated accuracy (Table 5).
      • Garcia G.H.
      • Taylor S.A.
      • Dy C.J.
      • Christ A.
      • Patel R.M.
      • Dines J.S.
      Online resources for shoulder instability: What are patients reading?.
      ,
      • Johnson C.C.
      • Garcia G.H.
      • Liu J.N.
      • Stepan J.G.
      • Patel R.M.
      • Dines J.S.
      Internet resources for Tommy John injuries: what are patients reading?.
      ,
      • Wang D.
      • Jayakar R.G.
      • Leong N.L.
      • Leathers M.P.
      • Williams R.J.
      • Jones K.J.
      Evaluation of the quality, accuracy, and readability of online patient resources for the management of articular cartilage defects.
      Overall, the accuracy of information was moderate (mean 8.85, range 6.26-11.7).
      • Garcia G.H.
      • Taylor S.A.
      • Dy C.J.
      • Christ A.
      • Patel R.M.
      • Dines J.S.
      Online resources for shoulder instability: What are patients reading?.
      ,
      • Johnson C.C.
      • Garcia G.H.
      • Liu J.N.
      • Stepan J.G.
      • Patel R.M.
      • Dines J.S.
      Internet resources for Tommy John injuries: what are patients reading?.
      ,
      • Wang D.
      • Jayakar R.G.
      • Leong N.L.
      • Leathers M.P.
      • Williams R.J.
      • Jones K.J.
      Evaluation of the quality, accuracy, and readability of online patient resources for the management of articular cartilage defects.
      Table 5Accuracy Scores
      StudyMean Unique Accuracy Score (SD)Scale
      Garcia et al., 2014
      • Garcia G.H.
      • Taylor S.A.
      • Dy C.J.
      • Christ A.
      • Patel R.M.
      • Dines J.S.
      Online resources for shoulder instability: What are patients reading?.
      8.61 (2.6)0-12
      Johnson et al., 2016
      • Lawson K.A.
      • Codella S.
      • Ciccotti M.G.
      • Kane P.W.
      • Duncan I.C.
      • Cohen S.B.
      Evaluation of internet information about rotator cuff repair.
      6.26 (2.9)0-12
      Wang et al., 2017
      • Wang D.
      • Jayakar R.G.
      • Leong N.L.
      • Leathers M.P.
      • Williams R.J.
      • Jones K.J.
      Evaluation of the quality, accuracy, and readability of online patient resources for the management of articular cartilage defects.
      11.70 (0.6)0-12
      Average8.86
      NOTE. Unique quality and accuracy scores based on guidelines written by American Academy of Orthopaedic Surgeons (greater score = greater quality or accuracy). Scores vary by condition.
      SD, standard deviation.

      Assessment of Study Quality

      Study quality of articles included in the review ranged from 4.5 to 7, indicating moderate to high quality. Fifteen of 17 studies (88.2%) were high quality based on their quality assessment scores, whereas 2 of 17 (11.8%) were moderate quality. No studies were deemed low quality (Table 6).
      • Akinleye S.D.
      • Krochak R.
      • Richardson N.
      • Garofolo G.
      • Culbertson M.D.
      • Erez O.
      Readability of the most commonly accessed arthroscopy-related online patient education materials.
      • Bruce-Brand R.A.
      • Baker J.F.
      • Byrne D.P.
      • Hogan N.A.
      • McCarthy T.
      Assessment of the quality and content of information on anterior cruciate ligament reconstruction on the internet.
      • Cassidy J.T.
      • Fitzgerald E.
      • Cassidy E.S.
      • et al.
      YouTube provides poor information regarding anterior cruciate ligament injury and reconstruction.
      • Dalton D.M.
      • Kelly E.G.
      • Molony D.C.
      Availability of accessible and high-quality information on the Internet for patients regarding the diagnosis and management of rotator cuff tears.
      • Duncan I.C.
      • Kane P.W.
      • Lawson K.A.
      • Cohen S.B.
      • Ciccotti M.G.
      • Dodson C.C.
      Evaluation of information available on the Internet regarding anterior cruciate ligament reconstruction.
      • Garcia G.H.
      • Taylor S.A.
      • Dy C.J.
      • Christ A.
      • Patel R.M.
      • Dines J.S.
      Online resources for shoulder instability: What are patients reading?.
      • Johnson C.C.
      • Garcia G.H.
      • Liu J.N.
      • Stepan J.G.
      • Patel R.M.
      • Dines J.S.
      Internet resources for Tommy John injuries: what are patients reading?.
      • Lawson K.A.
      • Codella S.
      • Ciccotti M.G.
      • Kane P.W.
      • Duncan I.C.
      • Cohen S.B.
      Evaluation of internet information about rotator cuff repair.
      • Wang D.
      • Jayakar R.G.
      • Leong N.L.
      • Leathers M.P.
      • Williams R.J.
      • Jones K.J.
      Evaluation of the quality, accuracy, and readability of online patient resources for the management of articular cartilage defects.
      • Trofa D.P.
      • Parisien R.L.
      • Noticewala M.S.
      • et al.
      Quality and variability of online physical therapy protocols for isolated meniscal repairs.
      • Springer B.
      • Bechler U.
      • Koller U.
      • Windhager R.
      • Waldstein W.
      Online videos provide poor information quality, reliability, and accuracy regarding rehabilitation and return to sport after anterior cruciate ligament reconstruction.
      Table 6Assessment of Study Quality
      StudyAppropriateness of Design to Meet the AimsJustification of Sample SizeAdequate Description of the DataReport Number of Excluded ResultsAdequate Representativeness of the Sample to the TotalClearly Stated Aims and Likelihood of Reliable and Valid MeasurementsAdequate Description of Statistical MethodsTotal
      Cailliez et al., 2012
      • Cailliez J.
      • Reina N.
      • Molinier F.
      • Chaminade B.
      • Chiron P.
      • Laffosse J.M.
      Patient information ahead of anterior cruciate ligament reconstruction: Experience in a university hospital center.
      YesYesYesYesUnclearYesYesHigh
      Akinleye et al., 2018
      • Akinleye S.D.
      • Krochak R.
      • Richardson N.
      • Garofolo G.
      • Culbertson M.D.
      • Erez O.
      Readability of the most commonly accessed arthroscopy-related online patient education materials.
      YesNoYesYesUnclearYesYesHigh
      Bruce-Brand et al., 2013
      • Bruce-Brand R.A.
      • Baker J.F.
      • Byrne D.P.
      • Hogan N.A.
      • McCarthy T.
      Assessment of the quality and content of information on anterior cruciate ligament reconstruction on the internet.
      YesNoYesYesYesYesYesHigh
      Cassidy et al., 2018
      • Cassidy J.T.
      • Fitzgerald E.
      • Cassidy E.S.
      • et al.
      YouTube provides poor information regarding anterior cruciate ligament injury and reconstruction.
      YesYesYesYesYesYesYesHigh
      Dalton et al., 2015
      • Dalton D.M.
      • Kelly E.G.
      • Molony D.C.
      Availability of accessible and high-quality information on the Internet for patients regarding the diagnosis and management of rotator cuff tears.
      YesUnclearYesYesUnclearYesYesHigh
      Duncan et al., 2013
      • Duncan I.C.
      • Kane P.W.
      • Lawson K.A.
      • Cohen S.B.
      • Ciccotti M.G.
      • Dodson C.C.
      Evaluation of information available on the Internet regarding anterior cruciate ligament reconstruction.
      YesNoYesYesUnclearUnclearUnclearModerate
      Garcia et al., 2014
      • Garcia G.H.
      • Taylor S.A.
      • Dy C.J.
      • Christ A.
      • Patel R.M.
      • Dines J.S.
      Online resources for shoulder instability: What are patients reading?.
      YesNoYesYesUnclearYesYesHigh
      Johnson et al., 2016
      • Johnson C.C.
      • Garcia G.H.
      • Liu J.N.
      • Stepan J.G.
      • Patel R.M.
      • Dines J.S.
      Internet resources for Tommy John injuries: what are patients reading?.
      YesNoYesYesUnclearYesYesHigh
      Lawson et al., 2016
      • Lawson K.A.
      • Codella S.
      • Ciccotti M.G.
      • Kane P.W.
      • Duncan I.C.
      • Cohen S.B.
      Evaluation of internet information about rotator cuff repair.
      YesNoYesYesUnclearYesYesHigh
      Wang et al., 2017
      • Wang D.
      • Jayakar R.G.
      • Leong N.L.
      • Leathers M.P.
      • Williams R.J.
      • Jones K.J.
      Evaluation of the quality, accuracy, and readability of online patient resources for the management of articular cartilage defects.
      YesNoYesYesUnclearYesYesHigh
      Trofa et al., 2019
      • Trofa D.P.
      • Parisien R.L.
      • Noticewala M.S.
      • et al.
      Quality and variability of online physical therapy protocols for isolated meniscal repairs.
      YesUnclearYesYesUnclearUnclearUnclearModerate
      Springer et al., 2020
      • Springer B.
      • Bechler U.
      • Koller U.
      • Windhager R.
      • Waldstein W.
      Online videos provide poor information quality, reliability, and accuracy regarding rehabilitation and return to sport after anterior cruciate ligament reconstruction.
      YesYesYesYesYesYesYesHigh

      Discussion

      Our analysis shows that online patient education material for the most common sports injuries is at a high reading level. Readability of the included studies was calculated as difficult to read, with no studies reporting a FKGL score under the recommended (no greater than a sixth-grade reading level) threshold for readable patient education material.
      • Cotugna N.
      • Vickery C.E.
      • Carpenter-Haefele K.M.
      Evaluation of literacy level of patient education pages in health-related journals.
      This corroborates previous studies that analyzed online patient education material demonstrating poor readability.
      • Wang D.
      • Jayakar R.G.
      • Leong N.L.
      • Leathers M.P.
      • Williams R.J.
      • Jones K.J.
      Evaluation of the quality, accuracy, and readability of online patient resources for the management of articular cartilage defects.
      ,
      • Kaicker J.
      • Debono V.B.
      • Dang W.
      • Buckley N.
      • Thabane L.
      Assessment of the quality and variability of health information on chronic pain websites using the DISCERN instrument.
      Taken together, analysis of the data suggests that many patients may not fully comprehend the continuous stream of online information about a wide range of sports injuries. This may lead to increased hospitalization rate, poor compliance, increased costs, and poor health status.
      • Doak C.C.
      • Doak L.G.
      • Root J.H.
      Teaching patients with low literacy skills.
      ,
      • Albright J.
      • De Guzman C.
      • Acebo P.
      • Paiva D.
      • Faulkner M.
      • Swanson J.
      Readability of patient education materials: Implications for clinical practice.
      ,
      • Cooley M.E.
      • Moriarty H.
      • Berger M.S.
      • Selm-Orr D.
      • Coyle B.
      • Short T.
      Patient literacy and the readability of written cancer educational materials.
      While decision aids are increasingly being used in orthopaedic practice, aids written beyond the recommended reading level diminishes shared decision-making and the ability of a patient to grasp all attributes of care. Future health-related information should be written by qualified experts, at a level that can be easily understood by patients of all health literacy levels. Surgeons should be more attentive to where patients get their information from and how they interpret it. Accurate, easy-to-understand educational tools can improve efforts to help patients identify misconceptions about treatment options, and to guide patients to choices that are consistent with their values.
      The quality and accuracy reported for patient informational resources varied substantially between studies. In general, higher quality sources were more difficult to read (e.g., greater FKGL), which may hinder patients with a poor educational background or English as a second language. Previous studies have found that websites using medical terminology and those that have an advanced reading level are also more accurate.
      • Sugand K.
      • Malik H.H.
      • Newman S.
      • Spicer D.
      • Reilly P.
      • Gupte C.M.
      Does using anatomical models improve patient satisfaction in orthopaedic consenting? Single-blinded randomised controlled trial.
      ,
      • Dy C.J.
      • Taylor S.A.
      • Patel R.M.
      • Kitay A.
      • Roberts T.R.
      • Daluiski A.
      The effect of search term on the quality and accuracy of online information regarding distal radius fractures.
      This confirms a bias that favors patients with greater levels of education and greater health literacy.
      • Akinleye S.D.
      • Krochak R.
      • Richardson N.
      • Garofolo G.
      • Culbertson M.D.
      • Erez O.
      Readability of the most commonly accessed arthroscopy-related online patient education materials.
      ,
      • Bruce-Brand R.A.
      • Baker J.F.
      • Byrne D.P.
      • Hogan N.A.
      • McCarthy T.
      Assessment of the quality and content of information on anterior cruciate ligament reconstruction on the internet.
      ,
      • Dy C.J.
      • Taylor S.A.
      • Patel R.M.
      • Kitay A.
      • Roberts T.R.
      • Daluiski A.
      The effect of search term on the quality and accuracy of online information regarding distal radius fractures.
      While many patients are accessing this information online, it may come up short in its purpose to explain and instruct patients concerning their sports injury and treatment choices. To adequately use the Internet as a resource for health information, clinicians should guide patients to websites that include descriptions of injuries and treatment options that meet their reading level. For example, fifth grade is the average Medicare beneficiary level, and eighth grade is the average U.S. resident reading levels.
      • Stossel L.M.
      • Segar N.
      • Gliatto P.
      • Fallar R.
      • Karani R.
      Readability of patient education materials available at the point of care.
      Information shared on the internet can impact patients' choices, convictions, and mentalities toward their care. In medicine, qualified experts provide clinical advice; however, most online information is written by people who may not have such qualifications. We found that less than 40% were physician authored. Most patients do not have the right tools to evaluate health literature for biases, unreliability, and inaccurate information; such data can leave patients vulnerable to poor healthcare decisions and misinformation.
      • Car J.
      • Lang B.
      • Colledge A.
      • Ung C.
      • Majeed A.
      Interventions for enhancing consumers’ online health literacy.
      Future research may provide updates and more comprehensive insights regarding the characteristics of available patient information. Further, additional work on online patient education of sports injuries should focus on more in-depth assessment of cost utility, impact on total office visit time, and influence on postoperative outcomes, and patient expectations.

      Limitations

      There are several limitations to this study. Heterogeneity of the outcome measures and variation in diagnosis and patient characteristics made it difficult to evaluate and compare studies. Furthermore, studies published several years ago or more may be out of date with respect to currently available online patient resources, particularly since the internet is such a massive and constantly changing source of information

      Conclusions

      This study demonstrates that online patient information regarding common sports injuries does not match the readability recommendations of the American Medical Association and National Institutes of Health.

      Supplementary Data

      Appendix

      Appendix Table 1PubMed Search, September 23, 2020
      SearchQuery#
      1"Athletic Injuries"[Mesh] OR "anterior cruciate ligament"[Mesh] OR "anterior cruciate ligament injuries"[Mesh] OR "knee injuries"[Mesh] OR "Knee Dislocation"[Mesh] OR "tibial meniscus injuries"[Mesh] OR "Meniscus"[Mesh] OR "menisci, tibial"[Mesh] OR "Shoulder"[Mesh] OR "Shoulder Injuries"[Mesh] OR "shoulder joint"[Mesh] OR "joint instability"[Mesh] OR "shoulder dislocation"[Mesh] OR "Rotator Cuff"[Mesh] OR "rotator cuff injuries"[Mesh] OR "Patella"[Mesh] OR "patellar dislocation"[Mesh] OR "Tendinopathy"[Mesh] OR "athletic injur∗"[tiab] OR "sport injur∗"[tiab] OR "sports injur∗"[tiab] OR "orthopedic injur∗"[tiab] OR "orthopaedic injur∗"[tiab] OR "ACL"[tiab] OR "ACL injur∗"[tiab] OR "ACL tear"[tiab] OR "anterior cruciate ligament"[tiab] OR "anterior cruciate ligament injur∗"[tiab] OR "anterior cruciate ligament tear"[tiab] OR "meniscus"[tiab] OR "meniscus tear"[tiab] OR "meniscus injur∗"[tiab] OR “shoulder”[tiab] OR “shoulder injur∗”[tiab] OR "shoulder instability"[tiab] OR "shoulder dislocation"[tiab] OR "labral tear"[tiab] OR "rotator cuff tear"[tiab] OR "patellar instability"[tiab] OR “patella”[tiab] OR “patellar dislocation”[tiab] OR “tendinitis”[tiab] OR “Tendinopathy”[tiab] OR "biceps tendinitis"[tiab] OR "slap tear"[tiab] OR “slap lesion”[tiab] OR "knee injur∗"[tiab] OR "knee dislocation"[tiab] OR "tibial menisci"[tiab] OR "tibial meniscus injur∗"[tiab] OR "shoulder joint"[tiab] OR "joint instability"[tiab] OR “rotator cuff”[tiab] OR "rotator cuff injur∗"[tiab]192,053
      2"Patient Education as Topic"[Mesh] OR "models, educational"[Mesh] OR "Information Dissemination"[Mesh] OR "Consumer Health Information"[Mesh] OR "health education"[Mesh] OR "Pamphlets"[Mesh] OR "Mobile Applications"[Mesh] OR "Communications Media"[Mesh] OR “Computers, Handheld”[Mesh] OR "Educational Technology"[Mesh] OR "patient education"[tiab] OR "educational model∗"[tiab] OR "education model∗"[tiab] OR "Information Dissemination"[tiab] OR “dissemination of information”[tiab] OR “communication strateg∗”[tiab] OR "Consumer Health Information"[Tiab] OR “information communication”[tiab] OR "Pamphlet∗"[tiab] OR "booklet∗"[tiab] OR “brochure∗”[tiab] OR "Mobile Application∗"[tiab] OR "app∗"[tiab] OR "mobile app∗"[tiab] OR “smartphone app∗”[tiab] OR “smartphone application∗”[tiab] OR "Communications Media"[tiab] OR "communication"[tiab] OR "Educational Technology"[tiab] OR “education technology”[tiab] OR “handheld computer∗”[tiab] OR “mobile phone”[tiab] OR “smartphone”[tiab] OR “tablet”[tiab] OR "patient communication"[tiab] OR "health communication"[Tiab] OR "health education"[tiab]878,911
      3"patient participation"[Mesh] OR "decision making, shared"[Mesh] OR "patient centered care"[Mesh] OR "rehabilitation"[Mesh] OR "return to sport"[Mesh] OR "preoperative care"[Mesh] OR "preoperative period"[Mesh] OR "perioperative care"[Mesh] OR "postoperative care"[Mesh] OR "patient participation"[Tiab] OR "shared decision making"[Tiab] OR "patient-centered"[Tiab] OR “patient centered”[tiab] OR “patient centered care”[tiab] OR "decision involvement"[Tiab] OR "patient involvement"[Tiab] OR "patient engagement"[Tiab] OR "rehabilitation"[Tiab] OR "patient expectation"[Tiab] OR "patient expectations"[Tiab] OR "return to sport"[Tiab] OR "return to activity"[Tiab] OR (("pre surg∗"[Tiab] OR "pre op∗"[Tiab] OR "presurg∗"[Tiab] OR "before surg∗"[Tiab] OR "preop∗"[Tiab] OR "pre op∗"[Tiab] OR "postop∗"[Tiab] OR "post op∗"[Tiab] OR "post op∗"[Tiab] OR "post surg∗"[Tiab] OR "post surg∗"[Tiab] OR "after surg∗"[Tiab] OR "post procedur∗"[Tiab] OR "peri operative"[Tiab] OR "perioperative"[Tiab]) AND ("education"[Tiab] OR "communication"[Tiab] OR "rehabilitation"[Tiab] OR "engagement"[Tiab]))648,318
      1

      AND 2

      AND 3
      ("Athletic Injuries"[MeSH Terms] OR "anterior cruciate ligament"[MeSH Terms] OR "anterior cruciate ligament injuries"[MeSH Terms] OR "knee injuries"[MeSH Terms] OR "Knee Dislocation"[MeSH Terms] OR "tibial meniscus injuries"[MeSH Terms] OR "Meniscus"[MeSH Terms] OR "menisci, tibial"[MeSH Terms] OR "Shoulder"[MeSH Terms] OR "Shoulder Injuries"[MeSH Terms] OR "shoulder joint"[MeSH Terms] OR "joint instability"[MeSH Terms] OR "shoulder dislocation"[MeSH Terms] OR "Rotator Cuff"[MeSH Terms] OR "rotator cuff injuries"[MeSH Terms] OR "Patella"[MeSH Terms] OR "patellar dislocation"[MeSH Terms] OR "Tendinopathy"[MeSH Terms] OR "athletic injur∗"[Title/Abstract] OR "sport injur∗"[Title/Abstract] OR "sports injur∗"[Title/Abstract] OR "orthopedic injur∗"[Title/Abstract] OR "orthopaedic injur∗"[Title/Abstract] OR "ACL"[Title/Abstract] OR "acl injur∗"[Title/Abstract] OR "ACL tear"[Title/Abstract] OR "anterior cruciate ligament"[Title/Abstract] OR "anterior cruciate ligament injur∗"[Title/Abstract] OR "anterior cruciate ligament tear"[Title/Abstract] OR "Meniscus"[Title/Abstract] OR "meniscus tear"[Title/Abstract] OR "meniscus injur∗"[Title/Abstract] OR "Shoulder"[Title/Abstract] OR "shoulder injur∗"[Title/Abstract] OR "shoulder instability"[Title/Abstract] OR "shoulder dislocation"[Title/Abstract] OR "labral tear"[Title/Abstract] OR "rotator cuff tear"[Title/Abstract] OR "patellar instability"[Title/Abstract] OR "Patella"[Title/Abstract] OR "patellar dislocation"[Title/Abstract] OR "tendinitis"[Title/Abstract] OR "Tendinopathy"[Title/Abstract] OR "biceps tendinitis"[Title/Abstract] OR "slap tear"[Title/Abstract] OR "slap lesion"[Title/Abstract] OR "knee injur∗"[Title/Abstract] OR "Knee Dislocation"[Title/Abstract] OR "tibial menisci"[Title/Abstract] OR "tibial meniscus injur∗"[Title/Abstract] OR "shoulder joint"[Title/Abstract] OR "joint instability"[Title/Abstract] OR "Rotator Cuff"[Title/Abstract] OR "rotator cuff injur∗"[Title/Abstract]) AND ("Patient Education as Topic"[MeSH Terms] OR "models, educational"[MeSH Terms] OR "Information Dissemination"[MeSH Terms] OR "Consumer Health Information"[MeSH Terms] OR "health education"[MeSH Terms] OR "Pamphlets"[MeSH Terms] OR "Mobile Applications"[MeSH Terms] OR "Communications Media"[MeSH Terms] OR "computers, handheld"[MeSH Terms] OR "Educational Technology"[MeSH Terms] OR "patient education"[Title/Abstract] OR "educational model∗"[Title/Abstract] OR "education model∗"[Title/Abstract] OR "Information Dissemination"[Title/Abstract] OR "dissemination of information"[Title/Abstract] OR "communication strateg∗"[Title/Abstract] OR "Consumer Health Information"[Title/Abstract] OR "information communication"[Title/Abstract] OR "pamphlet∗"[Title/Abstract] OR "booklet∗"[Title/Abstract] OR "brochure∗"[Title/Abstract] OR "mobile application∗"[Title/Abstract] OR "app"[Title/Abstract] OR "mobile app"[Title/Abstract] OR "mobile apps"[Title/Abstract] OR "smartphone apps"[Title/Abstract] OR "smartphone app"[Title/Abstract] OR "smartphone application∗"[Title/Abstract] OR "Communications Media"[Title/Abstract] OR "communication"[Title/Abstract] OR "Educational Technology"[Title/Abstract] OR "education technology"[Title/Abstract] OR "handheld computer∗"[Title/Abstract] OR "mobile phone"[Title/Abstract] OR "smartphone"[Title/Abstract] OR "tablet"[Title/Abstract] OR "patient communication"[Title/Abstract] OR "health communication"[Title/Abstract] OR "health education"[Title/Abstract]) AND ("patient participation"[MeSH Terms] OR "decision making, shared"[MeSH Terms] OR "patient centered care"[MeSH Terms] OR "rehabilitation"[MeSH Terms] OR "return to sport"[MeSH Terms] OR "preoperative care"[MeSH Terms] OR "preoperative period"[MeSH Terms] OR "perioperative care"[MeSH Terms] OR "postoperative care"[MeSH Terms] OR "patient participation"[Title/Abstract] OR "shared decision making"[Title/Abstract] OR "patient-centered"[Title/Abstract] OR "patient-centered"[Title/Abstract] OR "patient centered care"[Title/Abstract] OR "decision involvement"[Title/Abstract] OR "patient involvement"[Title/Abstract] OR "patient engagement"[Title/Abstract] OR "rehabilitation"[Title/Abstract] OR "patient expectation"[Title/Abstract] OR "patient expectations"[Title/Abstract] OR "return to sport"[Title/Abstract] OR "return to activity"[Title/Abstract] OR (("pre surg∗"[Title/Abstract] OR "pre op∗"[Title/Abstract] OR "presurg∗"[Title/Abstract] OR "before surg∗"[Title/Abstract] OR "preop∗"[Title/Abstract] OR "pre op∗"[Title/Abstract] OR "postop∗"[Title/Abstract] OR "post op∗"[Title/Abstract] OR "post op∗"[Title/Abstract] OR "post surg∗"[Title/Abstract] OR "post surg∗"[Title/Abstract] OR "after surg∗"[Title/Abstract] OR "post procedur∗"[Title/Abstract] OR "peri operative"[Title/Abstract] OR "perioperative"[Title/Abstract]) AND ("education"[Title/Abstract] OR "communication"[Title/Abstract] OR "rehabilitation"[Title/Abstract] OR "engagement"[Title/Abstract])))722
      Appendix Table 2CINAHL Plus with Full Text (EBSCO) Search, September 23, 2020
      SearchQuery#
      1TI ( athletic injur∗ OR sport injur∗ OR sports injur∗ OR orthopedic injur∗ OR orthopaedic injur∗ OR ACL OR ACL injur∗ OR ACL tear OR anterior cruciate ligament OR anterior cruciate ligament injur∗ OR anterior cruciate ligament tear OR meniscus OR meniscus tear OR meniscus injur∗ OR shoulder OR shoulder injur∗ OR shoulder instability OR shoulder dislocation OR labral tear OR rotator cuff tear OR patellar instability OR patella OR patellar dislocation OR tendinitis OR Tendinopathy OR biceps tendinitis OR slap tear OR slap lesion OR knee injur∗ OR knee dislocation OR tibial menisci OR tibial meniscus injur∗ OR shoulder joint OR joint instability OR rotator cuff OR rotator cuff injur∗ ) OR AB ( athletic injur∗ OR sport injur∗ OR sports injur∗ OR orthopedic injur∗ OR orthopaedic injur∗ OR ACL OR ACL injur∗ OR ACL tear OR anterior cruciate ligament OR anterior cruciate ligament injur∗ OR anterior cruciate ligament tear OR meniscus OR meniscus tear OR meniscus injur∗ OR shoulder OR shoulder injur∗ OR shoulder instability OR shoulder dislocation OR labral tear OR rotator cuff tear OR patellar instability OR patella OR patellar dislocation OR tendinitis OR Tendinopathy OR biceps tendinitis OR slap tear OR slap lesion OR knee injur∗ OR knee dislocation OR tibial menisci OR tibial meniscus injur∗ OR shoulder joint OR joint instability OR rotator cuff OR rotator cuff injur∗ ) OR MH ( "Anterior Cruciate Ligament" OR "Anterior Cruciate Ligament Injuries" OR "Knee Injuries+" OR "Menisci, Tibial" OR "Meniscal Injuries" OR "Shoulder Instability, Posterior" OR "Shoulder Instability, Multidirectional" OR "Shoulder" OR "Shoulder Dislocation" OR "Shoulder Joint+" OR "Shoulder Injuries+" OR "Joint Instability+" OR "Rotator Cuff Injuries" OR "Patella Dislocation" OR "Athletic Injuries+" )70,903
      2MH ( "Patient Education+" OR "Models, Educational" OR "Selective Dissemination of Information" OR "Consumer Health Information+" OR "Health Education+" OR "Pamphlets" OR "Mobile Applications" OR "Communications Media+" OR "Computers, Hand-Held+" OR "Educational Technology" ) OR TI ( patient education OR educational model∗ OR education model∗ OR Information Dissemination OR dissemination of information OR communication strateg∗ OR Consumer Health Information OR information communication OR Pamphlet∗ OR booklet∗ OR brochure∗ OR Mobile Application∗ OR app∗ OR mobile app∗ OR smartphone app∗ OR smartphone application∗ OR Communications Media OR communication OR Educational Technology OR education technology OR handheld computer∗ OR mobile phone OR smartphone OR tablet OR patient communication OR health communication OR health education ) OR AB ( patient education OR educational model∗ OR education model∗ OR Information Dissemination OR dissemination of information OR communication strateg∗ OR Consumer Health Information OR information communication OR Pamphlet∗ OR booklet∗ OR brochure∗ OR Mobile Application∗ OR app OR apps OR mobile app OR mobile apps OR smartphone apps OR smartphone app OR smartphone application∗ OR Communications Media OR communication OR Educational Technology OR education technology OR handheld computer∗ OR mobile phone OR smartphone OR tablet OR patient communication OR health communication OR health education )650,783
      3( TI ( pre operative OR preoperative OR postoperative OR post operative OR peri operative OR perioperative OR surgery OR surgical ) OR AB ( pre operative OR preoperative OR postoperative OR post operative OR peri operative OR perioperative OR surgery OR surgical ) AND TI ( education OR communication OR rehabilitation OR engagement ) OR AB ( education OR communication OR rehabilitation OR engagement ) ) OR ( MH ( "Decision Making, Shared" OR "Patient Centered Care" OR "Rehabilitation+" OR "Sports Re-Entry" OR "Preoperative Education" OR "Preoperative Period+" OR "Preoperative Care+" OR "Perioperative Care+"OR “Postoperative Period” OR "Postoperative Care+" ) OR AB ( patient participation OR shared decision making OR patient-centered OR patient centered OR patient centered care OR decision involvement OR patient involvement OR patient engagement OR rehabilitation OR patient expectation OR patient expectations OR return to sport OR return to activity ) OR TI ( patient participation OR shared decision making OR patient-centered OR patient centered OR patient centered care OR decision involvement OR patient involvement OR patient engagement OR rehabilitation OR patient expectation OR patient expectations OR return to sport OR return to activity ) )686,596
      41 AND 2 AND 33,652
      NOTE. Limiters - abstract available. Search modes - find all my search terms.
      Appendix Table 3Embase (Elsevier) Search, September 23, 2020
      SearchQuery#
      1'sport injury'/exp OR 'anterior cruciate ligament'/de OR 'anterior cruciate ligament injury'/exp OR 'knee injury'/exp OR 'knee dislocation'/exp OR 'knee meniscus rupture'/exp OR 'knee meniscus'/de OR 'shoulder'/de OR 'shoulder injury'/exp OR 'joint instability'/exp OR 'shoulder dislocation'/exp OR 'rotator cuff'/de OR 'rotator cuff injury'/exp OR 'patella'/de OR 'patella dislocation'/exp OR 'tendinitis'/de OR 'athletic injur∗':ab,ti OR 'sport injur∗':ab,ti OR 'sports injur∗':ab,ti OR 'orthopedic injur∗':ab,ti OR 'orthopaedic injur∗':ab,ti OR 'acl':ab,ti OR 'acl injur∗':ab,ti OR 'acl tear':ab,ti OR 'anterior cruciate ligament':ab,ti OR 'anterior cruciate ligament injur∗':ab,ti OR 'anterior cruciate ligament tear':ab,ti OR 'meniscus':ab,ti OR 'meniscus tear':ab,ti OR 'meniscus injur∗':ab,ti OR 'shoulder':ab,ti OR 'shoulder injur∗':ab,ti OR 'shoulder instability':ab,ti OR 'shoulder dislocation':ab,ti OR 'labral tear':ab,ti OR 'rotator cuff tear':ab,ti OR 'patellar instability':ab,ti OR 'patella':ab,ti OR 'patellar dislocation':ab,ti OR 'tendinitis':ab,ti OR 'tendinopathy':ab,ti OR 'biceps tendinitis':ab,ti OR 'slap tear':ab,ti OR 'slap lesion':ab,ti OR 'knee injur∗':ab,ti OR 'knee dislocation':ab,ti OR 'tibial menisci':ab,ti OR 'tibial meniscus injur∗':ab,ti OR 'shoulder joint':ab,ti OR 'joint instability':ab,ti OR 'rotator cuff':ab,ti OR 'rotator cuff injur∗':ab,ti225,233
      2'patient education'/exp OR 'educational model'/exp OR 'information dissemination'/de OR 'consumer health information'/exp OR 'health education'/de OR 'publication'/exp OR 'mobile application'/exp OR 'interpersonal communication'/exp OR 'personal digital assistant'/exp OR 'educational technology'/exp OR 'patient education':ab,ti OR 'educational model∗':ab,ti OR 'education model∗':ab,ti OR 'information dissemination':ab,ti OR 'dissemination of information':ab,ti OR 'communication strateg∗':ab,ti OR 'consumer health information':ab,ti OR 'information communication':ab,ti OR 'pamphlet∗':ab,ti OR 'booklet∗':ab,ti OR 'brochure∗':ab,ti OR 'mobile application∗':ab,ti OR 'app':ab,ti OR 'apps':ab,ti OR 'mobile app':ab,ti OR 'mobile apps':ab,ti OR 'smartphone app':ab,ti OR 'smartphone apps':ab,ti OR 'smartphone application∗':ab,ti OR 'communications media':ab,ti OR 'communication':ab,ti OR 'educational technology':ab,ti OR 'education technology':ab,ti OR 'handheld computer∗':ab,ti OR 'mobile phone':ab,ti OR 'smartphone':ab,ti OR 'tablet':ab,ti OR 'patient communication':ab,ti OR 'health communication':ab,ti OR 'health education':ab,ti1,344,400
      3'patient participation'/exp OR 'shared decision making'/exp OR 'patient care'/exp OR 'rehabilitation'/exp OR 'return to sport'/exp OR 'preoperative period'/exp OR 'postoperative period'/exp OR 'perioperative period'/exp OR 'patient participation':ab,ti OR 'shared decision making':ab,ti OR 'patient-centered':ab,ti OR 'patient centered':ab,ti OR 'patient centered care':ab,ti OR 'decision involvement':ab,ti OR 'patient involvement':ab,ti OR 'patient engagement':ab,ti OR 'rehabilitation':ab,ti OR 'patient expectation':ab,ti OR 'patient expectations':ab,ti OR 'return to sport':ab,ti OR 'return to activity':ab,ti OR (('pre operative':ab,ti OR 'preoperative':ab,ti OR 'postoperative':ab,ti OR 'post operative':ab,ti OR 'peri operative':ab,ti OR 'perioperative':ab,ti OR 'surgery':ab,ti OR 'surgical':ab,ti) AND ('education':ab,ti OR 'communication':ab,ti OR 'rehabilitation':ab,ti OR 'engagement':ab,ti))2,144,026
      4#1 AND #2 AND #32,868
      Table 3Readability Scores
      StudyMean FKGL (SD)Mean FRES (SD)Mean GFI (SD)
      Akinleye et al., 2018
      • Akinleye S.D.
      • Krochak R.
      • Richardson N.
      • Garofolo G.
      • Culbertson M.D.
      • Erez O.
      Readability of the most commonly accessed arthroscopy-related online patient education materials.
      9.0052.14
      Dalton et al., 2015
      • Dalton D.M.
      • Kelly E.G.
      • Molony D.C.
      Availability of accessible and high-quality information on the Internet for patients regarding the diagnosis and management of rotator cuff tears.
      8.10 (1.74)51.24 (11.42)9.02 (2.34)
      Garcia et al., 2014
      • Singh A.G.
      • Singh S.
      • Singh P.P.
      YouTube for information on rheumatoid arthritis—A wakeup call?.
      10.96 (2.5)
      Johnson et al., 2016
      • Johnson C.C.
      • Garcia G.H.
      • Liu J.N.
      • Stepan J.G.
      • Patel R.M.
      • Dines J.S.
      Internet resources for Tommy John injuries: what are patients reading?.
      10.71 (2.6)
      Lawson et al., 2016
      • Lawson K.A.
      • Codella S.
      • Ciccotti M.G.
      • Kane P.W.
      • Duncan I.C.
      • Cohen S.B.
      Evaluation of internet information about rotator cuff repair.
      10.9850.17
      Wang et al., 2017
      • Wang D.
      • Jayakar R.G.
      • Leong N.L.
      • Leathers M.P.
      • Williams R.J.
      • Jones K.J.
      Evaluation of the quality, accuracy, and readability of online patient resources for the management of articular cartilage defects.
      13.40 (8.0)
      Average10.5251.189.02
      NOTE. FKGL: Flesch-Kincaid Grade Level measures grade level one must complete to comprehend a given text. FRES: Flesch Reading Ease Score measures readability of a text. Score 0-29: very difficult, postgraduate; 30-49: difficult, college; 50-59: fairly difficult, high school; 60-69: standard, 8th to 9th grade; 70-79: fairly easy, 7th grade; 80-89: easy, 5th to 6th grade; 90-100: very easy, 4th to 5th grade. GFI: Gunning Fog Index estimates years of formal education a person needs to understand the text on first reading.
      SD, standard deviation.

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