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Advancing overuse injury monitoring: A new validated tool for non-contact sports
*Corresponding author: Nirjhar Samant, Department of Orthopaedics, SGPGI, Lucknow, Uttar Pradesh, India. nirjharsamant11@gmail.com
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Received: ,
Accepted: ,
How to cite this article: Samant N, Tyagi N, Sharma P. Advancing overuse injury monitoring: A new validated tool for non-contact sports. J Arthrosc Surg Sports Med. doi: 10.25259/JASSM_77_2025
Abstract
Objectives:
Sports are basically classified into three types: contact sports, non-contact sports, and collision sports. Repetitive microtrauma leading to subclinical injuries constitutes a major chunk of injuries in non-contact sports. The objective of this study was to develop and validate an overuse injury questionnaire, termed the SGPGI non-contact sports overuse injury questionnaire (SNOI-Q), which would be easy to understand and athlete-friendly to use for the detection of overuse injuries among non-contact sportspersons.
Materials and Methods:
This was a cross-sectional study to develop and validate the SNOI-Q. We endeavored to obtain a healthy sample size of 122 participants in our study. To ascertain convergent validity, the McNemar’s test was used to determine the differences in prevalence of overuse injury as identified by SNOI-Q and Oslo Sports Trauma Research Centre Overuse Injury Questionnaire (OSTRC-O2) among participants. The correlation between severity scores produced by SGPGI non-contact sports overuse injury questionnaire (SNOI-Q) and OSTRC-O2 was determined using Spearman’s correlation. Internal consistency reliability estimation was used to assess the reliability of SNOI-Q in identifying the prevalence of the overuse problem among participants.
Results:
Additional screening questions were added at the start of the SNOI-Q questionnaire. In SNOI-Q, quantitative and more specific options and a Visual Analog Scale (out of a maximum score of 10) were used for more accuracy, and “gatekeeper” questions were added. The SNOI-Q method detected a prevalence of 32.79%. The categorical agreement analysis using Cohen’s Kappa produced a coefficient of 0.740 with an observed agreement of 84.2%. Both intraclass correlation coefficient values obtained in this analysis fall into the excellent reliability category, well exceeding the 0.90 threshold.
Conclusion:
The study’s main achievement was the successful development and validation of SNOI-Q, specifically designed for non-contact sports athletes. The questionnaire can facilitate better injury prevention strategies and monitoring programs for non-contact sport athletes in future applications.
Keywords
Injury
Non-contact
Overuse
Monitoring
Sports
INTRODUCTION
Sports are classified as contact sports, where players physically engage with opponents, and non-contact sports, where no physical contact occurs.[1]
Traumatic injuries are common in contact sports and result from falls, collisions, or impacts with equipment or players. Overuse injuries develop gradually from repetitive microtrauma and often go unnoticed for a long time; they are also called covert, silent, or hidden injuries.[2-5]
In 2013, the Oslo Sports Trauma Research Centre Overuse Injury Questionnaire (OSTRC-O) was developed and validated for registering overuse injuries in sports epidemiology.[6] It has since been widely used in numerous epidemiological studies concerning overuse injury.[7-10] The updated OSTRC-O2 questionnaire was introduced to improve respondent experience and data quality by revising wording, logic, and response categories.[11] The Youth Overuse Injury Questionnaire (YOvIQ) screening questionnaire was designed to better assess the prevalence and severity of overuse injuries in youth athletes while reducing incomplete data.[7]
The most commonly used questionnaire is OSTRC-O2.[11] The OSTRC-O2 is limited because its body-region specific, requiring multiple questionnaires for players with injuries in different areas. Weekly completion is inconvenient and often missed. In contact sports, where traumatic injuries are common, and their usefulness declines; in non-contact sports, overuse injuries are more relevant. Epidemiologically, using a longer recall period and less frequent questionnaires better captures overuse injuries in non-contact sports participants.
This study aimed to develop and validate the SGPGI non-contact sports overuse injury questionnaire (SNOI-Q) for non-contact sports. The goal was to create an easy-to-understand, athlete-friendly tool that accurately determines the prevalence and severity of overuse injuries while minimizing incomplete data.
MATERIALS AND METHODS
Study design
This was a cross-sectional study to develop and validate the SNOI-Q.
Participants
Athletes were included if they were over 18, participated in non-contact sports, and had at least 1 year of formal training aimed at competition. Those in contact or collision sports, under 18, or recreational/amateur athletes without professional coaching were excluded.
Developing the overuse injury questionnaire for non-contact sports
The first SNOI-Q draft was based on existing literature and scoring systems for detecting overuse injuries in sports. To make it accessible to non-contact sport athletes, it featured a longer recall period, flexible response frequency, 6-monthly or as-needed completion, a Visual Analog Scale (VAS) scoring system, bolded keywords, screening questions to rule out traumatic injuries, and one questionnaire per player. This approach recognizes that overuse in one area can cause biomechanical changes and secondary symptoms. The recall period in SNOI-Q was revised to “the past 6 months” as its predecessors considered a recall period from 7 days[11] to 3 months.[7] Given that the symptoms of overuse injuries are known to fluctuate,[12] it was considered appropriate to extend the recall period. This adjustment aims to enhance the likelihood of identifying overuse injuries that may have been in remission and, consequently, not detected by existing questionnaires [Table 1].
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The order of questions in SNOI-Q is: Screening Questions; if cleared, the athlete proceeds to participation-related, discomfort-related, game/training modification-related, and then competition and endurance questions [Figure 1].
- Flow diagram for filling the SNOI-Q questionnaire.
The developed questionnaire SNIO-Q was validated against the gold standard OSTRC-O2[11] for the detection of overuse injuries [Figure 2].
- Phases in designing and validation of the questionnaire.
The following steps were taken for validation of the questionnaire:
Establishing content validity through end-user evaluation
Experts – a sports injury specialist, international coach, former player, and medical professor – reviewed the first draft of SNOI-Q. To ensure it suited the target group, they held a feedback session with 15 non-contact sports participants recruited through convenience sampling to gather user insights.
OSTRC-O2, the most common questionnaire for detecting overuse sports injuries, served as the Gold Standard. OSTRC-O2 and SNOI-Q were labeled as Questionnaire A and B. A team member led the feedback session, assured anonymity, and encouraged open responses. Participants were asked about sports-related injuries in the past 6 months and about discomfort during or after training affecting performance. All observations were documented, and every participant was encouraged to contribute.
Psychometric evaluation of overuse injury questionnaire for non-contact sports
Both SNOI-Q (6-month recall) and OSTRC-O2 (7-day recall) were investigated by sportspersons across different non-contact sports (e.g., cricket, badminton, swimming, and athletics) through physical forms. Participants were recruited from a prominent multi-disciplinary sports training center in the city. While there is no standardized requirement for sample size in a validation study, we endeavored to obtain a healthy sample size of 122 participants, as similar works previously utilized a sample size ranging from 63 to 145.[8,13] Ethical approval for this study was sought from the Institutional Ethics Committee at SGPGI (IEC code: 2022-180-EMP-129).
Data observation
The presence of an overuse injury was determined by the response to Question 1 in OSTRC-O2[11] and screening 1 and screening 2 questions in SNOI-Q. Any response other than option “a” for Question 1 in OSTRC-O2, or selecting “No” for screening question 1 and “Yes” for screening question 2 in SNOI-Q, was considered indicative of an overuse injury.
According to the “gatekeeper” logic in OSTRC-O2,[11] athletes who chose option “a” or “d” in Question 1 were not given further questions and were considered to have completed the questionnaire for that anatomical area. In SNIO-Q, three gatekeeper questions determine exclusion. Athletes choosing option “a” in screening question 1 or option “b” in question 2 were excluded from overuse injury assessment and received no further questions. The third gatekeeper asked about participation; if a player could not participate due to discomfort, they received the maximum severity score of 40 and no further questions.
Prevalence of overuse injury = Players reporting overuse injury/Total number of questionnaire respondents.
For severity score calculations, the scale of 0-8-17-25 was utilized in OSTRC-O2[11] and a scale of 0–10 was applied in Questions 2–5 of SNOI-Q, a score of 1 was given by default to all athletes who filled questions from 2 to 5, the final severity score of the athlete was taken as sum of the scores of questions from 2 to 5 or 1, whichever was higher. For OSTRC-O2, each athlete’s severity score was the total of Questions 1–4 (0 = no injury, 100 = highest severity). For SNOI-Q, the score was the sum of Questions 2–5(1 = least severity, 40 = highest severity).
Athletes choosing option “a” or “d” in OSTRC-O2 received severity scores of 0 and 100, respectively. In SNOI-Q, selecting option “b” (No participation) in Part B of Question 1 scored 40. The severity score objectively measures overuse consequences and supports ongoing monitoring.[6]
Validity
To establish convergent validity, the McNemar’s test compared overuse injury prevalence identified by the SNOI-Q and OSTRC-O2. A non-significant P-value indicated no significant difference between the questionnaires, supporting convergent validity.
In OSTRC-O2,[11] a severity score of more than 75 was considered as severe injury, 50–75 represented moderate injury, and a severity score of <50 was considered as minor injury; whereas, in SNOI-Q, a severity score of more than 30, 20–30, and <20 indicated severe, moderate, and minor injuries, respectively. Severity scores from the SNOI-Q and OSTRC-O2 were compared using Spearman’s correlation coefficient. A strong correlation indicated substantial convergent validity. Kappa values of 0.41–0.60 show moderate agreement, while 0.61–0.80 indicate substantial agreement. Statistical significance was accepted at P < 0.05 for both tests.
Reliability
Internal consistency reliability was used to assess the SNOIQ’s ability to identify overuse problems. A Cronbach’s alpha of 0.70 was considered acceptable.[14] An intraclass correlation coefficient (ICC) was calculated using single-measure, absolute-agreement, 2-way random, and mixed effects models for severity scores. ICC values below 0.50 indicate poor reliability; 0.50–0.75, moderate; 0.75–0.90, good and above 0.90, excellent reliability.[15] These guidelines were correspondingly adopted for their 95% confidence intervals.
RESULTS
Content validity assessment of overuse injury questionnaire (SNOI-Q)
Content experts suggested adding Yes/No options and quantitative visual symbols to SNOI-Q questions for clarity and accuracy. These changes, along with extra screening questions at the start, were implemented. Terms such as “discomfort” replaced “difficulty” for better understanding. SNOI-Q now features specific quantitative options, a VAS scale (out of 10), gatekeeper questions, a new question on endurance/stamina to address overuse injury, and separate sections for training and competition.
In Questions 2–5, quantitative symbolization was added by providing scores: 0–10. This enabled the participants to quantify their otherwise subjective judgment. These changes are reflected in Table 1.
Non-contact sports athletes found Questionnaire B (SNOI-Q) easier due to bolded keywords, binary options, simpler terms, and quantitative symbols that clarified questions. They preferred its order, which aided in recalling past performances over training modifications, supporting the revised structure. Athletes with overuse injuries were referred to physicians for further evaluation and follow-up if needed.
Profile of study participants
A total of 122 participants responded to the questionnaire to assess the psychometric properties of SNOI-Q. A detailed description of the participants’ characteristics (n = 122, 51.4% females, 48.6% males) is presented in Table 2. On average, participants were 21.2 ± 2.5 years old, had 4.9 ± 2.5 years of experience in the sport, and spent 12.3 ± 3.6 h training in their sport per week.
| Characteristics | Total sample (%) |
|---|---|
| Sex | |
| Female | 63 (51.4) |
| Male | 59 (48.6) |
| Age | |
| <21 years | 72 (59) |
| More than 21 years | 50 (41) |
| Sport | |
| Badminton | 31 (25.4) |
| Swimming | 21 (17.2) |
| Cricket | 28 (22.9) |
| Athletics | 42 (34.4) |
| Years in Sport | |
| 1-3 year | 62 (50.8) |
| More than 3 years | 60 (49.2) |
| Training hours per week outside playing area | |
| <6 h | 48 (39.3) |
| 6-15 h | 54 (44.3) |
| More than 15 h | 20 (16.4) |
| Training hours per week in playing area | |
| <6 h | 63 (51.6) |
| 6-15 h | 40 (32.8) |
| More than 15 h | 19 (15.6) |
Validity
The OSTRC-O2 method identified overuse injuries in 36.89% of 122 players (45 cases), while the SNOI-Q method found 32.79% (40 cases), with a 4.10% difference. The confusion matrix showed 38 true positives, 75 true negatives, 2 false positives, and 7 false negatives, with a 92.6% agreement and disagreement in only 9 cases (7.4%).
The SNOI-Q method demonstrated strong diagnostic validity with 86.79% sensitivity, 97.10% specificity, 95.83% positive predictive value, 90.54% negative predictive value, and 92.62% overall accuracy. In addition, McNemar’s test yielded a Chi-square value of 2.778 with a P > 0.05, indicating no significant systematic difference between the methods.
Severity analysis between SNOI-Q and OSTRC-O2 showed a strong correlation. The Pearson coefficient of 0.967 indicates a very strong linear relationship, with SNOI-Q scores changing proportionally to OSTRC-O2 scores. In addition, the Spearman rank correlation of 0.981 shows an excellent monotonic relationship, meaning both scales rank participants similarly regardless of the exact numeric relationship, also with highly significant results (P < 0.001).
Cohen’s Kappa analysis showed a coefficient of 0.740 and 84.2% observed agreement, indicating substantial agreement between SNOI-Q and OSTRC-O2 severity classifications beyond chance.
Reliability
Cronbach’s alpha values of 0.70 or higher for SNOI-Q responses indicate acceptable internal consistency. ICC analysis between OSTRC-O2 and SNOI-Q showed an excellent agreement, with the ICC (2, 1) model at 0.930 and the ICC (3, 1) model at 0.964 – both exceeding the excellent reliability threshold of 0.90.
DISCUSSION
Overuse injuries, caused by cumulative tissue overload without a clear onset, are a major concern for young elite athletes. Rapid training increases, ongoing growth, and musculoskeletal immaturity heighten this risk.[16-18] An overuse injury results from cumulative microtrauma to bone, muscle, and/or tendon as a function of repetitive stress with insufficient recovery.[19,20]
Theoretical Rationale for SNOI-Q Development
The OSTRC-O was developed to record overuse injury symptoms and their impact on sports participation, training, and performance.[6] As user groups used the OSTRC questionnaires, they found issues with wording and data analysis. In 2017, the original developers reviewed these concerns with an international panel of researchers and clinicians, resulting in the updated OSTRC-O2 with several changes.[11]
Critical modifications and advances
We developed the SNOI-Q questionnaire to detect overuse injuries in non-contact sports, where these injuries are common. SNOI-Q uses a 6-month recall period instead of OSTRC-O2’s 7 days, improving detection of fluctuating symptoms and reducing missed cases during symptom-free periods. This longer timeframe also means less frequent administration in longitudinal studies, minimizing missing data.
A key feature of the questionnaire is its flexibility: athletes complete it every 6 months or sooner if they have significant difficulty participating in sports without a traumatic injury. The player should report to the team physician or doctor if 3 consecutive weekly tests are in the category of overuse injury or a single reading is in the category of severe overuse injury with a score >30. This flexibility was not provided in OSTRC,[6] where players are expected to fill out the questionnaire on a weekly basis.
Introducing Yes/No response options streamlines the process, and using a 0–10 Visual Analog Scale increases clarity and precision. Replacing “difficulty” with “discomfort” improves the athlete’s understanding. Adding screening gatekeeper questions efficiently distinguishes acute from overuse injuries without follow-up interviews, marking a significant methodological advancement. This questionnaire covers all anatomical regions, rather than specific body regions as in OSTRC-O2,[11] providing comprehensive and representative data. An athlete’s body works as a unit; overuse injuries in one area can cause biomechanical changes and secondary problems elsewhere. Separating training and competition factors, and including an endurance question, provides more nuanced data that reflects the complexity of athletic performance and injury impact.
Validation evidence supporting clinical application
The validation study showed 92.6% agreement between SNOI-Q and OSTRC-O2. Diagnostic metrics confirmed strong validity: sensitivity 86.79%, specificity 97.10%, positive predictive value 95.83%, negative predictive value 90.54%, and accuracy 92.62%. Similar prevalence rates, no significant bias (McNemar’s test), and a Cohen’s Kappa of 0.740 indicate SNOI-Q reliably detects overuse injuries in athletes with substantial agreement in severity classifications.
Reliability analysis showed acceptable internal consistency (Cronbach’s alpha ≥0.70). ICC values above 0.90 indicate the two scales are interchangeable with high confidence in clinical and research settings.
Practical significance
A questionnaire’s main purpose is to detect overuse injuries early and monitor progress. SNIO-Q does this by extending the recall period, using one questionnaire per athlete, and offering flexible completion options, reducing administrative burden while maintaining data quality, especially useful for managing large datasets in India. Gatekeeper logic filters participants to reduce fatigue and improve completion rates. The VAS scale simplifies responses and adds objectivity. These features make SNIO-Q an effective, user-friendly injury surveillance system.
Limitations
The study has several limitations. The 6-month recall period may cause recall bias, as athletes might not accurately remember past injuries or symptoms, though flexible questionnaire timing helps mitigate this. The cross-sectional design also limits the assessment of test–retest reliability and tracking injury changes over time.
Ideally, injuries should be medically confirmed, but this study, like previous ones, did not conduct physical examinations. Recruiting participants from a single sports training center may limit generalizability. Players’ potentially inaccurate responses are another limitation of the questionnaire.
The study examined only four popular non-contact sports, cricket, badminton, swimming, and athletics, so its findings may not represent all non-contact sports. It also excluded athletes under 18, missing youth who could benefit from overuse injury screening.
CONCLUSION
The study developed and validated SNOI-Q, a reliable questionnaire for detecting overuse injuries in non-contact sports athletes. SNOI-Q offers a 6-month recall period and improved user-friendliness.
The questionnaire can improve overuse injury detection and support prevention and monitoring programs for non-contact sport athletes.
Acknowledgments:
The authors would like to thank all the participants who supported and participated in this study.
Authors contribution:
NS: Conceptualized and designed the study and assisted in data collection; NT: Revised the manuscript; PS: Contributed to questionnaire development and manuscript revision. All authors approved the final manuscript.
Declarations
Ethical approval:
The research/study approved by the Institutional Ethics Committee at SGPGI, IEC code: 2022-180-EMP-129, dated January 23, 2023.
Declaration of patient consent:
Patient’s consent not required as patients identity is not disclosed or compromised.
Conflict of interest:
There are no conflicts of interest.
Use of artificial intelligence (AI)-assisted technology for manuscript preparation:
The authors confirm that there was no use of artificial intelligence (AI)-assisted technology for assisting in the writing or editing of the manuscript and no images were manipulated using AI.
Availability of data and materials:
The data supporting the findings of this study are not publicly available due to participant confidentiality but are available from the corresponding author upon reasonable request.
Financial support and sponsorship: Nil.
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