{
  "id": "hip-groin-hamstring-rtp-ladder",
  "title": "Hip, groin, and hamstring RTP ladder",
  "summary": "Criteria-based progression for coach-safe modification and return-to-performance across hip, groin/adductor, hip flexor, and hamstring pain.",
  "safety_principle": "Coaches observe, modify, document, and enforce restrictions. Clinicians own diagnosis, persistent symptoms, major trauma, imaging decisions, and clearance. Suspected concussion follows the concussion pathway only.",
  "decision_bands": [
    {
      "label": "Green",
      "rule": "Pain low and stable, no compensation, 24 h response stable, restrictions allow the planned exposure.",
      "action": "Run the planned phase and log pain, load, and next-day response."
    },
    {
      "label": "Yellow",
      "rule": "Pain, control, or response is uncertain; a gate is incomplete or the next dose is a meaningful jump.",
      "action": "Reduce volume, speed, direction change, or contact; keep the player in modified work."
    },
    {
      "label": "Red",
      "rule": "Red flag, missing clearance, pain 4+/10 during hockey work, next-day flare, or altered mechanics.",
      "action": "Hold high-risk work and route to medical/physio review."
    }
  ],
  "daily_checks": [
    {
      "key": "pain_current_0_10",
      "target": "0-2 green, 3 yellow, 4+ red for hockey exposure"
    },
    {
      "key": "pain_24h_delta",
      "target": "No increase, or no more than +2/10 and back toward baseline"
    },
    {
      "key": "single_leg_control",
      "target": "No hip drop, trunk shift, guarding, or stride compensation"
    },
    {
      "key": "strength_symmetry_pct",
      "target": "Phase demand met; aim near 90% before full speed/contact"
    },
    {
      "key": "skating_quality",
      "target": "No shortened stride, push-off avoidance, or crossover guarding"
    },
    {
      "key": "medical_clearance_state",
      "target": "Required for red flags, major trauma, surgery, fracture suspicion, concussion"
    },
    {
      "key": "pain_48h_return_to_baseline",
      "target": "Symptoms return to baseline within 24-48 h after the last progression dose"
    }
  ],
  "objective_gates": [
    {
      "key": "pain_VAS",
      "label": "Pain VAS/NRS during sport-relevant task",
      "type": "number_0_10",
      "target": "0-2/10 for controlled progression and sport-specific drills; 3/10 means modify; 4+ means hold/review.",
      "stage": "Stage 1 -> Stage 5",
      "applies_to": ["hip", "adductor_groin", "hamstring"],
      "owner": "coach logs; clinician interprets when symptoms persist or escalate"
    },
    {
      "key": "palpation_pain_VAS",
      "label": "Palpation pain at involved structure",
      "type": "number_0_10",
      "target": "<=2-3/10 before increasing sport-specific exposure; higher or unclear pain location stays clinician-owned.",
      "stage": "Stage 1 -> Stage 3",
      "applies_to": ["adductor_groin", "hip"],
      "owner": "clinician/physio; coach documents reported pain only"
    },
    {
      "key": "adductor_squeeze_pain_VAS",
      "label": "Adductor squeeze pain response",
      "type": "number_0_10",
      "target": "<=2-3/10 and stable next-day response before progressing lateral, crossover, or battle exposure.",
      "stage": "Stage 2 -> Stage 4",
      "applies_to": ["adductor_groin"],
      "owner": "physio/performance"
    },
    {
      "key": "isometric_strength_LSI",
      "label": "Isometric strength limb symmetry index",
      "type": "ratio_0_1",
      "target": ">=0.90 before full-speed, high-force, contact, or unrestricted sport return when the test is relevant to the injured region.",
      "stage": "Stage 2 -> Stage 4",
      "applies_to": ["hip", "adductor_groin", "hamstring"],
      "owner": "physio/performance"
    },
    {
      "key": "adductor_squeeze_force_N",
      "label": "Adductor squeeze force",
      "type": "number_newtons_or_n_per_kg",
      "target": "Track absolute N, N/kg, and side-to-side trend against local baseline; do not use a single universal cut-off as coach clearance.",
      "stage": "Stage 2 -> Stage 5",
      "applies_to": ["adductor_groin"],
      "owner": "physio/performance"
    },
    {
      "key": "cod_crossover_tolerance",
      "label": "Change-of-direction and crossover tolerance",
      "type": "green|yellow|red",
      "target": "Closed and open COD/crossover drills completed without pain flare, next-day worsening, or protective mechanics.",
      "stage": "Stage 4 -> Stage 5",
      "applies_to": ["adductor_groin", "hip", "hamstring"],
      "owner": "performance/coach with medical restriction check"
    },
    {
      "key": "sport_specific_minutes_tolerated",
      "label": "Sport-specific minutes tolerated",
      "type": "number_minutes",
      "target": "Progress 15 -> 25 -> 40 min blocks only when pain stays <=3/10 and returns to baseline within 24-48 h.",
      "stage": "Stage 3 -> Stage 5",
      "applies_to": ["hip", "adductor_groin", "hamstring"],
      "owner": "coach/performance"
    },
    {
      "key": "Askling_time",
      "label": "Askling/H-test or local hamstring high-speed tolerance metric",
      "type": "number_or_status",
      "target": "Pain-free and no apprehension before full-speed hamstring exposure; compare time/status to local baseline or contralateral side when available.",
      "stage": "Stage 4 -> Stage 5",
      "applies_to": ["hamstring"],
      "owner": "physio/performance"
    },
    {
      "key": "max_sprint_m_s",
      "display_key": "max_sprint_m/s",
      "label": "Maximum sprint/skating speed tolerated",
      "type": "number_m_per_s",
      "target": "Near individual baseline or planned competition exposure without pain flare, next-day worsening, or protective mechanics.",
      "stage": "Stage 4 -> Stage 5",
      "applies_to": ["hip", "adductor_groin", "hamstring"],
      "owner": "performance/coach with medical restriction check"
    }
  ],
  "injury_specific_gates": [
    {
      "injury_family": "hip_fai_labrum",
      "classification_note": "Post-arthroscopy or suspected intra-articular hip cases require clinician ownership; time alone is not a clearance gate.",
      "progression": "Load tolerance -> pain-free range/control -> strength symmetry -> unilateral/sport-specific function -> full hockey exposure.",
      "required_fields": ["pain_VAS", "isometric_strength_LSI", "single_leg_control", "skating_quality", "medical_clearance_state"],
      "coach_boundary": "Coach can modify skating exposure and document symptoms; clinician clears surgery/labrum/FAI return."
    },
    {
      "injury_family": "adductor_groin_doha",
      "classification_note": "Use a Doha-style clinical category such as adductor-related, iliopsoas-related, inguinal-related, pubic-related, or other hip/groin cause.",
      "progression": "Isometric adductor tolerance -> progressive adductor loading -> Copenhagen-like capacity -> cutting/crossover tolerance -> sport return.",
      "required_fields": ["pain_VAS", "isometric_strength_LSI", "strength_symmetry_pct", "skating_quality", "pain_24h_delta"],
      "coach_boundary": "Coach should not diagnose the groin category; classification and persistent pain route to clinician."
    },
    {
      "injury_family": "hamstring",
      "classification_note": "Hamstring RTP should include pain-free sport drills, eccentric capacity, high-speed tolerance, and no apprehension.",
      "progression": "Eccentric/Nordic tolerance -> acceleration/deceleration -> Askling/H-test or local high-speed tolerance -> near-baseline sprint/skating speed -> sport return.",
      "required_fields": ["pain_VAS", "isometric_strength_LSI", "Askling_time", "max_sprint_m_s", "skating_quality"],
      "coach_boundary": "Coach can cap speed and reps; clinician/performance decides high-speed gate and full return."
    }
  ],
  "clinical_classification": [
    {
      "key": "adductor_related",
      "label": "Adductor-related groin pain",
      "clinical_signal": "Adductor-region tenderness and pain in the adductor region during resisted adduction.",
      "coach_use": "Do not diagnose; log pain location, squeeze response, skating/crossover tolerance, and clinician category."
    },
    {
      "key": "iliopsoas_related",
      "label": "Iliopsoas-related groin pain",
      "clinical_signal": "Pain with resisted hip flexion and/or hip-flexor stretch pattern, interpreted clinically.",
      "coach_use": "Avoid forcing mohawks, deep hip flexion, and high-speed recovery until the clinician-owned category is clear."
    },
    {
      "key": "inguinal_related",
      "label": "Inguinal-related groin pain",
      "clinical_signal": "Inguinal canal-region pain/tenderness with aggravation on abdominal resistance or pressure increase, without palpable hernia.",
      "coach_use": "Route to medical review; coaches should not clear contact, Valsalva-heavy strength, or hard battles from this category."
    },
    {
      "key": "pubic_related",
      "label": "Pubic-related groin pain",
      "clinical_signal": "Local tenderness of the pubic symphysis or immediately adjacent bone, interpreted clinically.",
      "coach_use": "Keep load progression conservative and clinician-led when repeated skating, adductor load, or impact provokes symptoms."
    },
    {
      "key": "hip_related_or_other",
      "label": "Hip-related or other cause",
      "clinical_signal": "Hip joint, neurological, rheumatological, urological, gastrointestinal, dermatological, oncological, or surgical causes remain differential considerations.",
      "coach_use": "Use this as a referral boundary, not a practice-clearance bucket."
    }
  ],
  "adductor_rtp_measures": [
    {
      "key": "doha_category",
      "target": "adductor_related | iliopsoas_related | inguinal_related | pubic_related | hip_related_or_other",
      "owner": "clinician"
    },
    {
      "key": "palpation_pain_VAS",
      "target": "<=2-3/10 before increasing the next sport-specific dose.",
      "owner": "clinician/physio"
    },
    {
      "key": "adductor_squeeze_pain_VAS",
      "target": "<=2-3/10 with stable 24-48 h response.",
      "owner": "physio/performance"
    },
    {
      "key": "adductor_squeeze_force_N",
      "target": "Track N, N/kg, LSI, and trend vs local baseline.",
      "owner": "physio/performance"
    },
    {
      "key": "sport_specific_minutes_tolerated",
      "target": "15 -> 25 -> 40 min progression without 24-48 h symptom carryover.",
      "owner": "coach/performance"
    }
  ],
  "phases": [
    {
      "id": "protect-calm",
      "title": "Protect and calm symptoms",
      "progress_gate": "Pain is stable, no red flags, basic walking/skating posture is clean, and next-day response does not worsen.",
      "hold_or_regress": "Sharp pain, inability to bear weight, night pain, neurological symptoms, visible swelling/deformity, or pain rising across 2-3 exposures."
    },
    {
      "id": "range-control",
      "title": "Restore range and motor control",
      "progress_gate": "Pain during work stays within the agreed limit and returns to baseline within 24 hours; control tests are clean.",
      "hold_or_regress": "Pain above 3/10, next-day flare above +2/10, Trendelenburg pattern, or clear skating compensation."
    },
    {
      "id": "strength-capacity",
      "title": "Build strength and capacity",
      "progress_gate": "Player tolerates heavier slow strength, repeated low-to-moderate skating, and strength/control is approaching the phase target.",
      "hold_or_regress": "Soreness becomes pain, movement slows or guards, or weekly load jumps faster than the player's response allows."
    },
    {
      "id": "power-speed",
      "title": "Add power, speed, and hockey direction change",
      "progress_gate": "Speed, cuts, starts/stops, and repeated skating exposure are tolerated without pain flare or loss of mechanics.",
      "hold_or_regress": "Pain returns during high-speed work, next-day pain rises, stride shortens, or confidence drops under reactive demand."
    },
    {
      "id": "sport-return",
      "title": "Return to full hockey performance",
      "progress_gate": "Full practice is tolerated, symptoms remain stable, sport tests are near side-to-side targets, and required clearance is complete.",
      "hold_or_regress": "Missing clearance, symptoms return under contact, or the player protects the limb during battles, cuts, or fatigue."
    }
  ],
  "contract_fields": [
    "rtp_ladder_phase",
    "pain_VAS",
    "isometric_strength_LSI",
    "Askling_time",
    "max_sprint_m_s",
    "pain_current_0_10",
    "pain_24h_delta",
    "pain_48h_return_to_baseline",
    "doha_category",
    "palpation_pain_VAS",
    "adductor_squeeze_pain_VAS",
    "adductor_squeeze_force_N",
    "cod_crossover_tolerance",
    "sport_specific_minutes_tolerated",
    "single_leg_control",
    "strength_symmetry_pct",
    "skating_quality",
    "coach_decision"
  ],
  "sources": [
    {
      "label": "Mass General Brigham athletic pubalgia rehab protocol",
      "href": "https://www.massgeneral.org/assets/mgh/pdf/orthopaedics/sports-medicine/physical-therapy/rehabilitation-protocol-for-athletic-pubalgia-non-operative-management.pdf"
    },
    {
      "label": "Doha agreement meeting on terminology and definitions in groin pain in athletes",
      "href": "https://bjsm.bmj.com/content/49/12/768"
    },
    {
      "label": "Physiotutors Doha groin pain classification summary",
      "href": "https://www.physiotutors.com/wiki/groin-pain-classification/"
    },
    {
      "label": "Consensus of return-to-play criteria after adductor longus injury",
      "href": "https://www.mdpi.com/2075-4663/13/5/134"
    },
    {
      "label": "Return-to-play criteria following hamstring injury review",
      "href": "https://pubmed.ncbi.nlm.nih.gov/39666593/"
    },
    {
      "label": "Return to play after hip arthroscopy for FAI review",
      "href": "https://www.physio-network.com/research-reviews/hip-groin/criteria-for-return-to-play-after-hip-arthroscopy-in-the-treatment-of-femoroacetabular-impingement-a-systematic-review/"
    },
    {
      "label": "CDC HEADS UP return to sports",
      "href": "https://www.cdc.gov/heads-up/guidelines/returning-to-sports.html"
    },
    {
      "label": "BJSM Amsterdam concussion consensus",
      "href": "https://bjsm.bmj.com/content/57/11/695"
    }
  ]
}