The results from our study are in line with previous research indicating that online orthopaedic health materials are of low quality and pitched at a higher readability level than is appropriate for the average patient (8–10, 20). The mean FRE corresponds to a 10th -12th reading grade level, which is far above the recommended level of difficulty, with only 5 webpages at or below a 6th grade reading level. In 2008, the American Medical Association (AMA) recommended that patient education materials be written at a 6th grade reading level, although the average American reads at a 7th grade level (21, 22). The mean FKG is a grade 8 reading level with 21 webpages at or below a 6th grade reading level. The mean GF corresponds with a grade 9 reading level, with 17 webpages at or below a 6th grade reading level. The FKG and GF are both indicators of the average number of words per sentence and syllables per word, indicating that the information of some webpages is on target in terms of complexity (23). However, all readability scores demonstrate a consistent trend of online material regarding MSFs being pitched above the recommended level of difficulty.
The HONcode tool and JAMA framework were both used to assess the quality of webpages. 13% of webpages held current HONcode certificates, indicating that most of the information pertaining to MSFs is not upheld to a standardized publishing conduct. Only one webpage met all 4 JAMA criteria, and while 41 (54.5%) webpages met at least one of the four JAMA criteria, only 28 were able to indicate authorship and 14 currency. These are arguably the two most important factors in determining the quality of a webpage, as authorship indicates credibility and currency relevance (4). Therefore, the overall quality of webpages was low.
Adequate health literacy is a patient asset and protective against poor patient outcomes and all-cause mortality (24). There is a clear, proportional link between reading skills and health literacy (24). The Programme for International Assessment of Adult Competencies (PIAAC) found that Irish adults of a low socioeconomic class or of foreign birth to have decreased literacy levels compared to the Irish mean (25). This provides a clear target for the increased dissemination of quality health information, using simple, non-medical wording to achieve the best results (24). Additionally, this relationship emphasizes the importance of accessible health information written at an appropriate level of difficulty.
MSFs can be managed non-operatively for a significant period and are considered low risk orthopaedic ailments (1). Due to their prevalence in non-athletes and athletes alike, online health information is particularly important to guide conservative at-home clinical management. This is of particular concern as patient reliance on online health-related information has increased during the Coronavirus-19 (COVID19) pandemic (4). Additionally, due to the nature of the injury, patients should have access to readable, quality information that delineates the symptomatic difference between an MSF requiring non-operative management and one requiring operative management. There is an increased reliance on virtual sources by foot and ankle surgeons due to the COVID19 pandemic (20). As this is the first study examining the readability of online MSFs information, there is great room for improvement that should be prioritized in both the readability and the quality of the existing materials.
Online health materials regarding sports medicine injuries are inappropriately difficult to read for the average Irish citizen (26–29). The American Academy of Orthopaedic Surgeons consistently provides online information regarding sports injuries written at 2.5 grade levels higher than the recommended grade 7 (27). Furthermore, a study examining the readability level of online health pages relating to Achilles tendon rupture found that the average webpage is written at a grade 11 level (29). This study is consistent with the findings of sports injury related materials being pitched to 2 + grade levels above the recommended readability level (27, 29).
As MSFs are found in high density among runners, it is important to identify if online health information regarding MSFs is being pitched primarily to this demographic, thus inappropriately skewing the difficulty of available information (1). There is no evidence in the literature that runners, or any other type of athlete, have a higher health literacy than the average population.
There are some potential limitations to this study. First, the websites were accumulated on one day, limiting the sources to that specific day. Some of these links were no longer functional when the analysis began, and as such were deemed “inaccessible”. Secondly, the exclusion of webpages containing only videos and the inability of readability algorithms to compute figures and tables excludes the value they may bring to a patient’s capacity to comprehend medical information. Finally, the readability formulas used are not recognized as health care literature assessment tools. However, in the absence of other specialized tools, they provide reliable insight into the approachability of online health care information.
This study provides insight into the readability status of online health materials regarding MSFs through reliable, quantitative methods. The findings of this study are consistent with results of other orthopaedic readability studies and reinforces the need for revision of the writing of online health materials to an Irish year 7/ US grade 6 level.