The internet is an increasingly accessed database of information; it has been estimated that 56% of the total world population uses the internet today, compared to only 5% in 2000 [1]. YouTube is considered one of the most popular sources among internet sites with more than 1.9 billion users each month and one billion hours of video watched each day [2]. YouTube videos allow for visual learning of specific content, many of which concern orthopedic information applicable to patient education [3]. Furthermore, it has been demonstrated that decisions made by 75% of patients concerning treatment for their diseases were influenced by the knowledge acquired through online health information searches [4]; therefore, it is essential that these videos provide accurate and reliable information.

Information regarding some of the most prevalent orthopedic conditions encountered in practice, such as anterior cruciate ligament injuries, is often accessed by patients on YouTube to gain a better understanding of their condition despite these videos’ low quality [5]. Other studies have also reported the low-quality educational content and reliability of videos concerning various orthopedic conditions [3,5-8]. As YouTube lacks a formal video regulation process for promoting accurate information, it is possible that YouTube videos concerning many other unexplored orthopedic topics are also of low quality [9]. There is growing concern that the educational information on mainstream websites such as YouTube contains a high proportion of uninformed or deliberately deceptive opinions [10].

Among musculoskeletal complaints that present to primary care offices, shoulder pain is the second most common and is observed in 51% of patients [11]. Therefore, the prevalence of rotator cuff tears has been reported to be as high as 62% in some populations [12]. As orthopedic injuries are one of the leading healthcare areas that are searched for on the internet [13], YouTube has a repository of over 177,000 videos regarding rotator cuff disease [2]; however, the quality and reliability of the information contained in rotator cuff videos on YouTube is unknown. The purpose of the current study was to evaluate the reliability and educational content of YouTube videos concerning the rotator cuff. The authors hypothesized that these videos would have relatively low-quality educational content and poor reliability when these metrics were assessed by outcome tools specific to evaluating online videos.

All of the first 50 videos populated by the initial query were included in the final analysis. The video duration ranged between 1 and 23.5 minutes with a mean±standard deviation video duration of 6.9±4.8 minutes. The mean number of views was 317,500.7±538,585.3, and collectively, the 50 videos were viewed 15,875,035 times. The mean VPI was 296.98±435.3. Other video characteristics are listed in Table 4. Most video uploaders were physicians (46%), while academic institutions accounted for the lowest relative frequency of video uploads at 4%. The video content was primarily classified as being disease-specific (48%), while exercise training content accounted for the lowest proportion of video content at 2%.

The main findings of the current study were that (1) the first 50 YouTube videos alone populated by the key word “rotator cuff” accrued a total of 15,875,035 views by users; (2) the mean JAMA score and RCSS of all videos were 2.7 and 5.6, respectively, suggesting low video reliability and rotator-cuff specific educational content quality; (3) the video reliability and educational value as measured by the JAMA score, GQS, and RCSS differed based on the video upload source and the type of video content; and (4) disease-specific video content was a significant independent predictor of a higher RCSS.

The current study suggests that the rotator cuff is of interest to a large online audience, as an analysis of the first 50 videos queried by the simple search term “rotator cuff” were viewed a total of 15,875,035 times. On average, this means that these 50 videos are viewed 297.50 times per day. This finding is unsurprising because YouTube has become a highly utilized source for gathering health information [20]. Interestingly, the mean number of likes of all videos was 3908.27, while the mean number of dislikes for all videos was only 98.42. Furthermore, the mean VPI (a measure of video popularity) was 296.98, reaffirming that videos concerning the rotator cuff are both highly liked and frequently viewed. This value was high in comparison to other common orthopedic conditions, as previously reported YouTube VPIs include values of 92.6 for disc herniation [6], 174.4 for kyphosis [3], and 301.9 for meniscectomy [15]. Despite the popularity of rotator cuff videos, the mean JAMA score was 2.66±0.96, the mean GQS was 3.68±1.04, and the mean RCSS was 5.64±3.56, suggesting poor video reliability, accuracy, and rotator cuff-specific educational content. Taken together, these findings imply that many viewers are satisfied with videos that provide them with unreliable and low-quality information, which may misinform both their motivation to seek treatment and their expectations for outcomes.

Although most videos were uploaded by physicians and the majority of their content was classified as concerning disease information, the reliability, accuracy, and rotator cuff-specific educational content was low. This information is in accordance with previous studies, which have sought to evaluate the quality and content of orthopedic topics on YouTube. Indeed, other orthopedic-specific YouTube studies concerning kyphosis [3], disc herniation [6], the anterior cruciate ligament [5], lumbar discectomy [21], and femoroacetabular impingement [22] syndrome have all concluded that the quality and reliability of YouTube videos discussing these topics are strikingly low. Given that YouTube lacks an editorial process for videos uploaded to their website and that any user can upload any video of their choice, it is plausible that this lack of restrictions allows for video content to be posted that is inaccurate. These findings highlight the need for higher quality orthopedic-based educational content for viewers and patients on YouTube or for the development of a new online platform that only allows peer-reviewed content.

Interestingly, the ANOVA in the current study demonstrated that the mean JAMA score (a measure of video reliability and quality) was higher for videos that discussed patient experiences as well as videos that were uploaded by a physician. This finding may suggest that patient testimonies of their experiences regarding the treatment of rotator cuff pathology are tangible to other viewers, and that physicians who treat these pathologies provide more reliable information. Furthermore, the mean GQS (an objective measure of educational quality) was higher in videos where the content was based on exercise training and disease information; the mean RCSS was higher in videos concerning disease information and those uploaded by academic institutions, and disease-specific video content was a significant independent predictor of a higher RCSS. As both of these measures are concerned with the objective and specific educational content quality, respectively, it is therefore plausible that information about rotator cuff disease provides the best educational quality for viewers and patients. Furthermore, academic institutions that treat or study the rotator cuff would also be expected to produce higher educational value in their videos. Although these associations exist statistically, it is still important to recognize that overall, the quality and reliability of the videos evaluated in the current study were low and that future efforts should be made to increase the quality of such videos. In particular, treating healthcare providers may play a larger role in identifying and counseling patients on which resources are high-quality. Given that there is clearly a demand for online video content as an educational resource, healthcare providers should make efforts to produce high-quality videos for patient education. As more orthopedic surgeons embrace social media for physician-patient engagement and marketing [23], consideration should be given to utilizing these platforms to offer accurate alternatives to unregulated resources, such as YouTube.

The current study had several limitations. The assessment of a small subset of YouTube videos among the many populated with the query “rotator cuff” may not provide a complete representation of all the available videos on this topic. However, selection bias was minimized by systematically analyzing the first 50 videos, and it has been reported that the majority of internet users confine their searches to the first two pages populated by a search [24], which is consistent with the methods employed here. The current study also used reliability and quality assessment tools, which have not been validated despite their widespread use in studies that seek to evaluate these measures for online resources. As these tools have repeatedly demonstrated excellent inter-observer reliability for all three tools in the literature and in the current study, it is likely that the low-quality findings among the included videos are an accurate assessment.

The overall quality and educational content of YouTube videos concerned with the rotator cuff were low. Physicians should caution patients about using such videos as resources for decision-making and should counsel them appropriately.