Biomechanical and movement-quality predictors of lower-limb load-related injury in collegiate athletes: a prospective cohort study using functional movement screening, wearable inertial sensing, and explainable machine learning

Lower-limb load-related injuries account for a disproportionate share of time loss in collegiate sport, yet the biomechanical and movement-quality factors distinguishing injured from uninjured athletes remain incompletely characterized. This prospective cohort study followed 161 collegiate athletes for one competitive season, integrating Functional Movement Screen task-level scores with wearable inertial measurement unit-derived features - including peak tibial acceleration asymmetry, surrogate vertical loading rate, and pelvis-trunk stability indices - within an explainable machine learning framework. Four classifiers were compared across FMS-only, wearable-only, and fused configurations under nested five-fold cross-validation with embedded LASSO feature selection. Thirty-seven load-related time-loss injuries were recorded (23.0% incidence). The fused XGBoost model achieved an out-of-fold AUC of 0.70 (95% CI: 0.61-0.79), outperforming FMS-only (AUC 0.62) and wearable-only (AUC 0.64) configurations by statistically significant margins. Peak tibial acceleration asymmetry and surrogate loading rate on the non-dominant limb were the strongest biomechanical predictors; in-line lunge and active straight-leg raise task scores contributed most among FMS inputs. Biomechanical features added an independent AUC increment of 0.07 beyond previous-injury history. SHAP analysis identified an interaction between tibial impact asymmetry and in-line lunge score that met the pre-specified directional stability criterion. These findings establish a physiologically interpretable template for biomechanical phenotyping of injury risk, supporting the combined use of wearable sensing and task-level movement screening in collegiate athletic populations.