The Top 100 Cited Articles in Clinical Orthopedic Sports Medicine

In several cases, an author contributed more than 1 classic article. In fact, 31 of the top 100 articles were by an individual who had coauthored 2 or more of the publications on this list. The researchers with the largest number of first-authored articles were Noyes^88-92 (5 articles), Neer^81-84 (4 articles), and Rowe,^102-104 Daniel,^35-37 Peterson,^97-99 and Hewett^52-54 (3 articles each) (Table 4^{17,19,21-24,29-31,35-37,42,44,45,52-54,58,61-65,69,70,72,74,80-84,87-92,97-99,101-105,107,109,110,113}). Articles from authors with multiple publications had a common topic.

Last, these articles originated from a number of different countries and institutions. Of the 15 source countries (Figure 2), the United States contributed the most (61 articles). Other countries had prominent representation: Sweden and Switzerland (8 each), United Kingdom (5), and Canada, France, and Norway (3 each). These articles originated from 69 universities, hospitals, and clinics; 21 institutions had 2 or more articles (Table 5). The 5 institutions with the highest number of articles were Hospital for Special Surgery, University of Bern, Columbia College of Physicians and Surgeons/Columbia-Presbyterian Medical Center, Cincinnati Sports Medicine and Orthopaedic Center, and Massachusetts General Hospital.

Discussion

Several trends can be ascertained from analyzing the top 100 clinical articles cited in sports medicine. The 5 most frequent topics discussed were ACL injury and reconstruction, knee rating systems for injury and function, rotator cuff reconstruction, chondrocyte transplantation, and femoroacetabular impingement (Table 3). Of those 5 topics, only ACL injury and reconstruction falls within the top 10 most common orthopedic surgical procedures performed in the United States reported by one analysis.¹¹⁴ The most common orthopedic surgical procedure, knee arthroscopy, ranks 10th of all topics covered by the top 100 articles, whereas the second most common procedure, shoulder arthroscopy, was not discussed by any of those 100 articles. Also notable is the high frequency of knee rating system studies, which correlates well with the fact that 4 of the most common orthopedic surgical procedures are knee procedures. The prevalence of rating system articles reflects the importance of and need for accurate methods in the diagnosis of injuries in sports medicine.

The most cited sports medicine article was written by Insall and colleagues⁶² in 1989, more than 2 decades ago. In this article, “Rationale of the Knee Society Clinical Rating System,” they reported on a rigorous system that rates knee function and ability to walk and climb stairs. The second most cited article, “A Clinical Method of Functional Assessment of the Shoulder,” was written in 1987 by Constant and Murley.³² This article discusses another rating system but offers a functional assessment of the shoulder that is highly reproducible and time-efficient. “Rating Systems in the Evaluation of Knee Ligament Injuries,” the third most cited article, was written in 1985 by Tegner and Lysholm.¹¹³ This article details the complexities and variable uses of different knee ligament injury rating systems. These top 3 articles were all published in Clinical Orthopaedics and Related Research. In addition, all 3 discussed rating systems, reinforcing the need for accurate scoring systems to standardize the diagnosis of injury across the field of orthopedics and qualify outcomes after injury.

A number of studies have introduced physical examination findings, clinical tests, and rating systems used in the clinical setting of sports medicine (and named after the contributing authors). For example, the Neer sign⁸² and the Hawkins-Kennedy test⁵¹ are used to determine shoulder impingement. In knee ligament injuries, the Tegner knee activity score¹¹³ complements other functional scores (eg, Lysholm knee score⁷⁴). For grading joint cartilage breakdown, the Outerbridge classification system⁹⁶ is commonly used. The Fairbank test³⁹ is used to gauge knee instability. In evaluating fatty degeneration of rotator cuff muscles through computed tomography scans, the Goutallier classification⁴⁷ is used. Other metrics, such as the Knee Injury and Osteoarthritis Outcome Score, introduced by Roos and colleagues,¹⁰¹ measure knee injury and osteoarthritis. In other scenarios, studies have improved on surgical techniques—for example, the Neer open modification⁸⁴ of the Bankart procedure. Many of these rating systems and named clinical findings are so ingrained in the practice and vernacular of orthopedics that it is possible they are in fact undercited in the literature.

As in other bibliometric analyses, one concession made here was to credit the first author listed for making the primary contribution to an article. As a result of journal variability and inconsistency, we were precluded from analyzing senior authors. When analyzed for authorship at any position, 3 of the top authors (Table 4) showed contributions to additional articles in the top 100 list. Noyes was listed as last author on 2 other articles,^52,54 raising his total to 7. Daniel was listed as second author on 1 additional article,¹⁰⁵ and Beck was listed as third author on 1 other article,⁴² raising their totals to 4 and 3, respectively.