Abstract
Background:
Across the health care landscape, patients experience disparities based on insurance, sex, gender, race, and other determinants. Such findings have been reported in orthopaedic sports medicine; nonetheless, the overall quality of the literature, including its limitations and impact, is unknown. Understanding this will allow researchers to address areas of need and ultimately reduce disparities.
Purpose:
To explore trends in orthopaedic sports medicine disparities research, with attention to study design, community engagement, and the development of interventions.
Study Design:
Scoping review; Level of evidence, 3.
Methods:
The Clarivate Web of Science platform was queried for English-language articles in the orthopedics and sports sciences categories between 2013 and 2022 with the following keywords: “disparities,”“disparity,”“inequity,”“inequities,”“diversity,”“socioeconomic,”“sex,”“gender,”“insurance,”“race,” and “neighborhood.” Abstracts were reviewed manually to determine study inclusion. Bibliometric data were collected, as was information on the area of focus, study design, determinants of interest, funding sources, and intervention design. Descriptive statistics were recorded.
Results:
The query yielded 7274 articles, of which 86 addressed disparities or diversity topics in sports medicine. A total of 57 (66.3%) articles were published between 2019 and 2022, and 24 (27.9%) were published in 2022. Predominant journals included the Orthopaedic Journal of Sports Medicine (23.3%) and the American Journal of Sports Medicine (12.8%). Also, 29 articles (33.7%) focused on anterior cruciate ligament (ACL) injuries, and 12 (14%) on rotator cuff tears. Of the 80 observational research articles, the majority (63.8%) were retrospective, and there was a lack of randomized controlled trials or qualitative/mixed methods designs. No studies primarily utilized a community-engaged approach. A total of 31 publications (36%) studied multiple determinants or descriptive data, while 30.2% focused on sex or gender, and 18.6% on insurance. Only 2 (2.3%) studied neighborhood factors. Notably, only 1 study focused on an intervention. Further, only 3 studies (3.5%) were supported directly by the National Institutes of Health funding.
Conclusion:
This study provides insights into the evolving landscape of sports medicine disparities research. Although the volume of this research has increased substantially in recent years, the literature consists mostly of retrospective studies with a lack of qualitative methodology, community engagement, and development of interventions to reduce disparities. These findings highlight areas for future research.
Health equity, as defined by the United States (U.S.) Department of Health and Human Services, refers to “the attainment of the highest level of health for all people,” and a health disparity as “a particular type of health difference that is closely linked with social, economic, and/or environmental disadvantage.” 19 These disadvantages can be associated with a wide spectrum of factors, such as income level, neighborhood resources, race, ethnicity, insurance, sex, gender, education level, and others. The literature has shown that such social determinants correlate with health consequences, including rates of injury, risk of chronic illnesses, and overall mortality.3,6,19 Similar findings have been reported in the sports medicine literature, including disparities in access to medical care for high school athletes and timely surgical care of anterior cruciate ligament (ACL) injuries.23,31 Therefore, authors have called for a better understanding of disparities in sports medicine and their implications. 3
After identifying the presence of a disparity, health inequity research seeks to understand its root causes and ultimately intervene to eliminate it. Observational studies are commonly used in disparities research to examine the impact of social determinants on health outcomes. 13 While these studies are essential for identifying and analyzing the factors that contribute to health disparities, many social determinants, such as race, income, education, and neighborhood environment, are interconnected, making it difficult to isolate their effects. 11 In addition to traditional quantitative and clinical approaches, qualitative methods and community engagement are important in exploring the experiences of those affected by inequities and effectively engaging with these patient populations.25,26 Furthermore, to effectively reduce health disparities and achieve equity, it is essential to study real-world, evidence-based interventions.5,6,21
Addressing these methodological challenges is essential for reducing barriers to health equity. In the field of orthopaedic sports medicine, the content and quality of health equity research are unclear and potentially limited in scope, particularly regarding methodology, community involvement, and interventions to reduce disparities. 2 Without a clear understanding of the current landscape of health equity research in sports medicine, it is difficult to gauge whether progress is being made and what future efforts are still necessary. A systematic evaluation of the current literature can elucidate areas of further need. Therefore, the purpose of this study was to investigate trends and characteristics of disparities research in sports medicine with attention to study design, community engagement, and intervention implementation.
Methods
In this bibliometric study, we examined articles falling within the categories of “orthopedics” and “sports sciences” in the Clarivate Web of Science database. The search strategy employed a timeframe from January 1, 2013, to December 31, 2022, applying filters for document type (“article” and “review article”) and language (English). The following keywords were utilized in separate queries: “disparity,”“disparities,”“inequities,”“inequity,”“diversity,”“socioeconomic,”“sex,”“gender,”“insurance,”“race,” and “neighborhood.” Publications were included in the study if they were relevant to disparities, health equity, or diversity topics in sports medicine. Notably, we included articles that reported and subsequently discussed a disparity or inequity, even if it was not the primary outcome of interest. Book chapters, meeting abstracts, proceedings papers, retracted publications, and non-English articles were excluded. Each publication in the initial query was reviewed individually by 2 of 5 reviewers (J.S.V., A.A., A.M.A., P.C.S., and E.H.D.) to determine inclusion eligibility. The title was reviewed first, and any studies that were irrelevant were excluded, with a low threshold to include articles initially to avoid incorrect exclusion. Any discrepancies were resolved by the senior author (N.M.P.). The abstract was then reviewed to further determine eligibility and subsequently begin data collection. Full manuscripts were reviewed for each article, especially if any datapoints were unclear from the abstract.
Data extraction involved bibliometric parameters that were largely generated directly from Web of Science, such as publication information, citations, and journal impact factor. We also reviewed each abstract and full manuscript, when necessary, to collect data on study design, population, or social determinant of interest, funding sources, whether an intervention was designed or implemented, and other variables. The region of origin was based on the location of the corresponding author and categorized according to the U.S. Census guidelines. Studies originating from any country other than the U.S. were categorized as “international.” Standardized forms in Microsoft Excel were employed for systematic data collection by reviewers, who were trained by the senior author. Key findings were summarized using standard descriptive statistics.
Results
A total of 86 articles relevant to disparities in sports medicine were included (see Supplemental Table and references for details). Notably, there was an increase in publications over time, with 24 articles (27.9%) in 2022 alone and 57 (66.3%) between 2019 and 2022 (Figure 1). Also, 46 articles (53.5%) were open access, suggesting that nearly half of the studies remain behind a paywall. Geographically, 25 articles (29.1%) originated from outside the U.S., with another 19 articles (22.1%) from institutions in the Northeast region of the U.S. The Orthopaedic Journal of Sports Medicine was the predominant journal, comprising 23.3% of articles in this analysis. The mean journal impact factor was 3.5 ± 1.5. A completely pediatric focus was observed in 25 articles (29.1%). ACL injury was the most common area of study (29 articles; 33.7%), within which authors investigated a number of outcomes of interest, including time to surgery, concomitant pathology at the time of surgery, surgical versus nonoperative treatment, reoperation, and patient-reported outcome measures. The majority of the observational ACL studies (17/27; 63%) were retrospective, and none focused on interventions to reduce disparities. Additional details regarding characteristics of the included articles can be found in Table 1.
Annual trends in sports medicine disparities research from 2013 to 2022.
Descriptive Characteristics a
ACL, anterior cruciate ligament.
Areas of focus with <5 articles were included in the “other” category. Region of origin refers to the United States, aside from “international.”
Observational research was published in 80 articles (93%), while the remainder were narrative review articles. Of the articles that were observational research, 51 of 80 (63.8%) had a retrospective design (Figure 2). There were no randomized controlled trials. No studies utilized qualitative or mixed methods, and none applied a community-engaged approach.
Study design of 80 observational research articles. RCT, randomized controlled trial; SR, systematic review.
A total of 31 articles (36%) discussed multiple demographic variables or determinants. Of the publications that primarily focused on a single determinant, 26 (30.2%) dealt with sex or gender, 16 (18.6%) with insurance, and 2 (2.3%) with neighborhood factors. These studies investigated the relationships between the aforementioned determinants and various outcomes of interest, including initial presentation, patient-reported outcomes, reoperation, and complications. None of the prospective studies specifically focused on race, ethnicity, or insurance. Only 1 article studied an intervention (a retrospective study on the impact of Medicaid expansion on outpatient access for a fictitious adolescent with shoulder instability), but the authors did not directly design or test the intervention. 16
Six studies reported the National Institutes of Health (NIH) funding, with 2 completed under K23 Career Development Awards, 9,14 and 1 under an R01 award. 24 The remaining 3 articles were related to resources derived from broader institutional NIH grants that did not directly fund the studies or authors.4,8,28 Therefore, only 3 of 86 studies (3.5%) were directly supported by the NIH.
Discussion
The present study found a steep increase in the volume of disparities research in sports medicine, especially since 2019. The majority of the observational research articles were retrospective, without any randomized controlled trials, qualitative research, or community engagement. No studies were designed or tested an original intervention, and <4% were funded by the NIH. Therefore, while the body of disparities research continues to grow, several key areas require substantial progress.
The medical literature, including in orthopaedic sports medicine, is replete with examples of health and health care disparities. Braveman et al 7 recommend a systematic use of policy and resources to address social determinants of health to address the root cause of health disparities, and thus avoid inequitable health outcomes. This must be preceded by an understanding of the mechanisms of specific disparities as well as partnerships with the people experiencing them. The present bibliometric analysis delves into the current state of sports medicine disparities research, highlighting the limitations of the current body of literature and outlining areas for future growth. There has been a steep increase in research volume over the last decade. Despite this, a majority of the studies continue to employ a retrospective study design. We also noted an absence of community-engaged approaches and qualitative or mixed methods studies. Furthermore, no studies developed or tested an original intervention, and only 3.5% were directly supported by the NIH. 12
The annual number of research articles on health disparities in orthopaedic sports medicine has grown substantially since 2019. While this may reflect increased genuine interest in addressing systemic inequities, it could also be related to the increasing popularity of these subjects and opportunities for academic productivity. The latter is part of a phenomenon that is been labeled “health equity tourism,” in which researchers with little or no previous expertise in health equity pivot to this field because of funding and opportunities for productivity rather than a long-term commitment to developing expertise and generating long-term, transformative change.15,18 This may lead to a proliferation of studies that do not adequately address or even mischaracterize the root causes of health disparities. 18 Consequently, the influx of such research can dilute the impact of rigorous studies, hinder the development of effective interventions, and potentially even harm communities rather than help. Sensitivity to this trend by journals and researchers is important to ensure that future work is impactful. The present study describes the current state of disparities research in orthopaedic sports medicine and highlights areas for development so that future research will indeed be meaningful.
Barriers to effective health equity research include a lack of time, resources, expertise, and funding. At present, only 4% of academic orthopaedic surgeons have earned NIH funding. 17 In our analysis, only 3.5% of studies were directly supported by the NIH, highlighting a need for more financial support of such research. As health equity research has only recently become more common in orthopaedics, this may explain the relatively few studies with NIH funding. Still, the rarity of such funding in broader orthopaedic research is notable. A lack of funding, and possibly of time and expertise, likely contribute to the ubiquity of retrospective research (63.8%) in our analysis. While such studies may adequately identify health disparities, a retrospective study design poses unique challenges. Given ethical constraints of exposure to social risk factors and thus the absence of randomization, overlapping social determinants of health may obscure the correlation between specific variables of interest. 13 Despite analytical techniques to address confounding—including regression analysis, propensity score matching, instrumental variable analysis, and marginal structural models—no method reduces the effect of confounding completely. 13 Prospective methodologies can provide stronger evidence and alleviate many biases inherent to retrospective designs. 29 A well-conducted prospective study whose primary question is related to health equity can help identify disparities or evaluate the impact of an intervention without such biases. The Multicenter Orthopaedic Outcomes Network (MOON) Knee Group, which is supported by NIH R01 funding, has been successful in conducting large-scale prospective clinical research. 20 In a MOON study that was included in our analysis, Ramkumar et al 24 identify independent risk factors for loss to follow-up after ACL reconstruction, defined as patients who did not return completed patient-reported outcome scores by mail. 24 They concluded that while education level does not predict loss to follow-up, men and non-White patients are at increased risk 2 years after surgery. 24 Although this study identifies differences between groups, further work is needed to understand why such findings exist and how to address them to improve the generalizability of future research. For example, a qualitative approach may provide new, context-specific insights based on direct community experience that are crucial for developing effective interventions. 13 While previous quantitative studies have helped identify disparities, future mixed methods research may allow researchers to better understand the actual mechanisms underlying the disparities.
Another MOON study by Jones et al 14 introduced a novel variable, the socioeconomic status (SES) index, by geocoding neighborhood data and correlating it to descriptive U.S. Census data. 14 The SES index can provide an understanding of the impact of neighborhood socioeconomic status on patient-reported outcomes after ACL reconstruction. The study revealed associations between lower neighborhood SES and education level with worse patient-reported outcomes. Similar metrics that are commonly used in research include the Child Opportunity Index and the Area Deprivation Index, which reflect comprehensive, neighborhood-level resources and opportunities. 1 Similarly, Modi et al 22 conducted a prospective cohort study that demonstrated that lower income is associated with less willingness to consider surgery for shoulder and elbow conditions. In both articles, the authors note the need for qualitative data to better understand patient experiences, perceptions, and decision-making. Interviews or focus groups may elucidate barriers, facilitators, perspectives, and experiences directly from those affected by disparities. Thus, combining quantitative and qualitative data in mixed-methods designs offers the potential to develop a deeper understanding of barriers to health equity and provide a basis for creating evidence-based interventions. 3 Methodological challenges in health equity research are not unique to sports medicine. 27 Unlike quantitative methods, which rely on predefined models and hypotheses, qualitative research is inductive and involves the purposeful selection of participants to generate rich, detailed data that reflect the participants’ perspectives and experiences. 13 By generating and refining conceptual models and hypotheses, qualitative research enhances our understanding of complex and intersecting social determinants of health. When integrated with quantitative methods in mixed methods research, qualitative approaches enable the corroboration and expansion of findings, providing a robust framework for addressing health disparities. 13 Multidisciplinary teams experienced in mixed-method study designs can be effective when conducting health equity research. This may include non-orthopaedists as well as individuals with skills in qualitative research, public health, community engagement, and grant writing. In addition, formal training and mentoring in these areas are important for future surgeon-scientists.
Our study suggests that there is much room for growth in sports medicine health equity research, especially regarding interventions to address disparities. Only 1 article technically evaluated an intervention. The authors conducted a retrospective study to evaluate the impact of Medicaid expansion on access to outpatient care for a fictitious adolescent with a shoulder dislocation. 16 However, they did not design an original intervention or test it in a novel way. Bonner et al 5 define 5 levels of intervention: patient, provider, system, community, and policy. They further emphasize the importance and potential of implementation science, community research, and machine learning to further health equity in surgery, with community partnership key at each level. Community-based participatory research (CBPR) is a transformative approach to address health disparities among marginalized communities by partnering equitably with community members to ensure lasting change. 30 CBPR aims to bridge the gap between scientific research and practical implementation by actively engaging communities in the research process as partners. 10 Once interventions are designed, they can be tested in community-based randomized trials or other prospective studies. Our analysis revealed that no papers utilized CBPR to study health equity in orthopaedic sports medicine. This is another area of need; however, it will require time, expertise, funding, and institutional support to establish meaningful relationships with communities and design interventions.
While our study provides a comprehensive bibliometric analysis of health equity research in sports medicine, drawing causal relationships from bibliometric data presents challenges in a research area that rapidly evolves with changing funding priorities and political landscapes. Furthermore, the relatively low total number of articles precluded more advanced statistical testing. In addition, we cannot account for articles that were within the publication pipeline during the study period or published afterwards. Finally, while our study provides a quantitative interpretation of the existing literature, it does not capture the qualitative impact of research.
This study provides insights into the evolving landscape of sports medicine disparities research. Although the volume of this research has increased substantially in recent years, the literature consists mostly of retrospective studies with a lack of qualitative methodology, community engagement, and development of interventions to reduce disparities. These findings highlight areas for future research. Rather than recapitulating previous retrospective, observational research, future work should focus on alternative methodologies, community engagement, and intervention implementation to improve health equity.
Supplemental Material
sj-pdf-1-ojs-10.1177_23259671251350400 – Supplemental material for Disparities Research in Sports Medicine Lacks Qualitative Studies, Community Engagement, and Original Interventions
Supplemental material, sj-pdf-1-ojs-10.1177_23259671251350400 for Disparities Research in Sports Medicine Lacks Qualitative Studies, Community Engagement, and Original Interventions by Jasmin S. Vargas, Abdullah Arif, Amin M. Alayleh, Peter C. Shen, Eric H. Durudogan and Neeraj M. Patel in Orthopaedic Journal of Sports Medicine
Footnotes
Final revision submitted January 28, 2025; accepted March 11, 2025.
One or more of the authors has declared the following potential conflict of interest or source of funding: N.M.P. is receiving a K23 Career Development Award (K23AR084596) from the National Institute of Arthritis and Musculoskeletal and Skin Diseases. AOSSM checks author disclosures against the Open Payments Database (OPD). AOSSM has not conducted an independent investigation on the OPD and disclaims any liability or responsibility relating thereto.
References
Supplementary Material
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