Introduction

Rotator cuff disorders — ranging across the spectrum from rotator cuff tendonitis and subacromial bursitis to degenerative and traumatic rotator cuff tears — are common musculoskeletal problems that affect 30–50% of people over 50 years of age [1]. Given the strong prevalence of rotator cuff dysfunction in the general population, it follows that the rotator cuff has been one of the most researched topics in orthopaedic shoulder surgery to date [2]. Previous studies have reported the most-cited articles pertaining to the rotator cuff [3,4,5]. However, citation scoring and other conventional bibliometric indicators do not account for the engagement, such as article viewership that is accessed through social media posting and online media production, or advertisements on YouTube. Critical analysis of literature is important as it helps authors to recognize the amount of viewership and who is accessing their articles. Ultimately, researchers are assessed by the quality and quantity of their work in academia, to help guide promotion to tenured positions, which was traditionally evaluated in part by journal impact factor [6]. There are new or alternative metrics that are now able to assess these alternative modes of engagement.

The Altmetric Attention Score (AAS) provides a quantitative assessment of the impact of scholarly articles online and in various forms of social media. The field of orthopaedic surgery has moved toward the utilization of social media as a means of distributing knowledge and exchanging ideas pertaining to musculoskeletal research [7,8,9,10,11,12]. Previous studies have reported the most impactful articles in online media pertaining to other sports medicine topics such as the anterior cruciate ligament [13]. However, the authors are not aware of any prior study that has used AAS to evaluate the rotator cuff articles that generate the greatest online attention.

The purpose of our study was to evaluate the 100 most engaged articles in online media pertaining to the rotator cuff and compare their characteristics to the most-cited rotator cuff articles in the scientific literature, using the Altmetric Attention Score. Our goal was to achieve a better understanding of the online dissemination of the rotator cuff research as an added dimension of rotator cuff research impact. Secondarily, we compared the predominant features of these articles to previous reports of the most-cited rotator cuff articles in the literature [4, 5]. Our overarching goal was to achieve a more comprehensive understanding of the impact of rotator cuff research that extends beyond the realm of conventional bibliometric analysis. We hypothesized that the 100 most impactful articles in online media pertaining to AAS would not be influenced by bibliometric data.

Materials and methods

The Altmetric database was queried on July 20, 2020, to identify articles pertaining to the rotator cuff. The search was performed using the PubMed MeSH terms “rotator cuff” or “supraspinatus” or “infraspinatus” or subscapularis or “teres major” or “teres minor” and yielded 6,183 articles published between 1931 and 2020. These articles were stratified by highest to lowest AAS and the 100 articles with the highest scores were included for analysis. The Altmetric Attention Score is a weighted, automated algorithm that takes into account the quantity of a post’s output and the quality of the post’s source, such as newspaper articles, Twitter posts, blogs, policy documents [14]. These scores can be accessed via the Altmetric Database. All articles that focused on other orthopaedic topics were sequentially excluded until 100 articles were gathered that were directly pertinent to the rotator cuff.

Collected data included title, authors, year of publication, journal name, institutional affiliations, article type, article topic, and online mentions (for example, the number of times the article was mentioned in news, blogs, Twitter, Facebook, and Wikipedia). Article type was identified from the article abstract and classified as original research (subclassified as randomized controlled trial, prospective cohort, retrospective cohort, case–control, case series, case report, or laboratory study), descriptive epidemiology, systematic review/meta-analysis, review, editorial/expert opinion, clinical commentary, or other. Article topics were anatomy, basic science, biomechanics, cost, diagnostics, treatment, epidemiology/risk factors, injury prevention, rehabilitation/return to play, patient satisfaction/quality of life, and other. The geographic origin of the paper was determined by the institutional affiliation of the first author, categorized as American (originating in the United States), European (originating in Europe), or other. The number of citations were provided by Google Scholar (Alphabet, Mountain View, CA), which lists the number of citations for each article.

STATA 15.1 (STATACorp) was used for calculations and statistical analysis. Median and quartiles were calculated for AAS. Spearman correlation and logarithmic regression were used to determine the relationship between online mentions and AAS, and analysis of variance (ANOVA) was used to determine whether article type, topic, or geographic origin were associated with AAS.

Results

The 100 articles with the highest AAS were published between 2009 and 2020, with AAS ranging from 47 to 676 (median: 74.5, 25th percentile: 59.5, 75th percentile: 114.5) (Table 1). The selected articles were most frequently published in the American Journal of Sports Medicine (13), the Journal of Shoulder and Elbow Surgery (11), and the Journal of Bone and Joint Surgery (8) (Fig. 1). The most common article type was Systematic Review/Meta-Analysis (29%), followed by Randomized Control Trial (15%). The most common article topics were Treatment (38%), Epidemiology (19%), and Patient Satisfaction/Quality of Life (10%). Nearly half of the selected articles (44/100, 44%), including the top 3 AAS articles, were published by authors located in Europe. One-quarter of the selected articles (25/100, 25%) were published by authors in the United States, while the remaining articles (31/100, 31%) were published by other.

Table 1 Top 25 rotator cuff articles ranked by altmetric attention score
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Fig. 1
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Most frequently published journals for the 100 articles with the top altmetric attention score when searching for “rotator cuff”

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Among all 100 articles, there were a total of 16,581 Twitter mentions (mean: 165.81), 1077 Facebook mentions (mean: 10.77), and 212 mentions in mainstream online news outlets (mean: 2.12). The online media source that correlated most strongly with AAS was Twitter mentions (r = 0.9007, r2 2 = 0.8112), whereas the other online media sources demonstrated weak correlations with AAS.

Discussion

This study identified the 100 most mentioned articles in online media pertaining to the rotator cuff. The characteristics of these impactful articles in online media were correlated with Twitter and Facebook citations and had a high proportion of European authorship, with publication in frequently cited American journals. AAS provides a unique dimension of article impact that may be used as an adjunct to citation analysis.

The top 100 rotator cuff articles in online media were published in a wide range of journals. Although the American Journal of Sports Medicine, Journal of Shoulder and Elbow Surgery, and Journal of Bone and Joint Surgery were the most common, these three journals only combined for about one-third of all articles in the top 100. AJSM was also the most represented journal among the most impactful articles in online media pertaining to the ACL, but the AJSM-published articles accounted for a much larger proportion of articles in those studies (44% and 34%, respectively) than in the present study examining the rotator cuff (13%) [7]. These findings suggest that a larger number of journals seem to be actively disseminating rotator cuff research in online media, compared to other major research topics in the field of sports medicine. One contributing factor to this trend may be the fact that ACL injuries tend to affect competitive athletes, whereas rotator cuff dysfunction often affects the general non-athlete population [15, 16]. This could conceivably lead to a lower proportion of the most impactful articles on the rotator cuff being published in subspecialty-specific journals that are focused on sports medicine. This trend parallels the findings of prior studies that have reported a high proportion of the most cited rotator cuff articles published in the Journal of Bone and Joint Surgery, [4, 17] a journal that includes all topics related to orthopaedic surgery and is not restrictive to sports medicine or shoulder surgery. Further investigation is needed to improve our collective knowledge of how rotator cuff research can be distributed most effectively, both in the arena of scientific publication as well as in online media.

The most common article types among the top 100 AAS rotator cuff articles were Systematic Review/Meta-Analysis (29%) and Randomized Control Trial (15%), indicating that higher level-of-evidence studies tend to generate the most attention in online media. These findings are consistent with prior studies that have examined the top AAS articles for other sports medicine topics such as the ACL [13]. In contrast, previous studies investigating the most-cited articles on the rotator cuff found that Case Series were the most common article type, [3, 4] likely due to the fact that many of the cited articles are comprised of the early, seminal work on rotator cuff disease, which laid the foundation for the higher level-of-evidence studies that have been conducted more recently and appear to be generating more online attention. This disparity between the most-cited rotator cuff articles and the highest AAS rotator cuff articles with regard to article type and level of evidence underscores the utility of alternative metrics in providing a more current, real-time snapshot of the impact of rotator cuff research, as compared to the long-term assessment of impact that can be gleaned from conventional bibliometrics.

The most common article topics in our study were Treatment (38%), Epidemiology (19%), and Patient Satisfaction/Quality of Life (10%). Studies that focus on treatment and epidemiology are helpful to healthcare providers because they enhance the understanding of which patients are most likely to get injured and how to provide optimal care for them. Patient satisfaction was the third most common topic in regard to rotator cuff, whereas rehabilitation and return to play were more common in ACL reconstruction. These disparate results are likely due to the fact that ACL injuries are more relevant to athletic individuals, whereas rotator cuff injuries commonly occur in non-athletes who would be more concerned with returning to normal life activities rather than returning to sport.

The largest proportion of top 100 AAS rotator cuff articles were published by authors based in Europe (44%), whereas US studies comprised only one-quarter (25%) of the included articles. This finding conflicts with previous studies that have reported a strong predominance of US articles among the most impactful studies in online media pertaining to the ACL (54%) [13]. European authors are widely regarded to be at the forefront of shoulder research, with several of the major developments in the field of shoulder surgery occurring in France (e.g. Goutallier classification, Grammont prosthesis, Latarjet procedure) [18]. Therefore, it is not surprising that much of the online attention surrounding rotator cuff research is derived from European articles. However, it is interesting that our findings regarding geographic origin contrast with previous studies that have reported a majority of US articles (58% and 60%) [4, 19] among the most-cited rotator cuff studies in the literature. The reasons for this disparity are not certain, but it is possible that European authors, journals, and healthcare organizations may be disseminating rotator cuff research more actively in online media compared to their US counterparts. Further investigation is needed to verify this hypothesis, as well as to elucidate any other factors that may be responsible for this finding.

Authors can find their article’s AAS by clicking the Altmetric link on the cite that hosts their publication, which offers a list of platforms that have interacted with their article. The website includes a comparison of engagement with other articles that have been published within the same scientific genre, over a similar timeframe. There is no definitive numerical score that is used as a benchmark to determine if a score is good or bad, since many factors go into calculating these scores. For instance, if a publication is produced this year that publication will be compared to other publications that are produced this year rather than those produced 10 years ago, which would have had greater opportunity to be disseminated through media and a greater opportunity to collect citations [11].

There are several limitations inherent to Altmetric that may have affected the findings of the present study. Altmetric is updated on a daily basis in a semi-continuous fashion; thus, it is possible to identify a different list of top 100 articles depending upon the specific date on which the search was performed. Moreover, Altmetric does not account for context and is solely dependent upon the volume of online mentions. Thus, both negative and positive discussion equally impact AAS, and a high AAS may not necessarily reflect a high quality study [20,21,22,23].

Conclusion

The most impactful rotator cuff articles in online media generated substantial online attention. These studies were often performed in Europe and tended to be high level of evidence, focusing on treatment of rotator cuff pathology. The rotator cuff articles that produced the most online attention differed from a previous report of the most-cited rotator cuff articles, suggesting that alternative metrics may be used in concert with conventional bibliometrics to obtain a more complete representation of scientific impact. Future use of the Altmetric Attention Score may improve authors’ understanding of their readership demographics by considering online dissemination and the timing of article publication, which are unique to AAS.