Sample characteristics.

We performed a prospective, longitudinal investigation to determine whether magnetic resonance imaging (MRI)-based radiomic features from thigh intramuscular fat (IMF) can predict future hamstring strain injury (HSI). Further, we sought to determine if muscle imbalance or injury profile along with radiomics could increase prediction accuracy. This study analyzed IDEAL MRI scans of 93 professional American football players (9 injured, 84 uninjured). Radiomic features relating to textural patterns of IMF were extracted from bilateral hamstring and quadriceps muscles. Feature selection identified non-correlated features that were more strongly associated with future HSI. The K-nearest neighbor classifier was employed to assess the performance of the following models: radiomics of hamstring IMF and quadriceps IMF muscle imbalance features (Mb) and injury profile features (Mi), as also integrated models for Mr, Mb and , and integrated Mr and Mb (Mr+b) where (area under the curve (AUC)=0.79; 95%CI:0.78-0.79) significantly outperformed (AUC = 0.69; 95% CI: 0.68-0.70), (AUC = 0.74; 95% CI: 0.73–0.75), (AUC = 0.68; 95% CI: 0.67–0.69), Mi (AUC = 0.68; 95% CI: 0.68-0.69) as well as Mb (AUC = 0.64; 95% CI: 0.63-0.65). The results indicate that future HSI can be predicted when incorporating radiomics features from hamstrings IMF with muscle imbalance and injury profile data. These novel findings merit further validation in a larger population, one that includes populations of injured and uninjured participants, a limitation acknowledged in current study. This approach could inform future strategies to identify factors to mitigate the risk of HSI not just in elite male athletes but also in athletes of both sexes and any level of participation.