{
  "id": "hockey-return-to-play-protocol",
  "version": "1.0.0",
  "title": "Hockey return-to-play protocol",
  "summary": "Coach-safe RTP structure for concussion, knee, groin/hip, shoulder, ankle, and overload cases. It connects injury type, RTP phase, medical clearance, objective gates, load response, and coach decision.",
  "safety_principle": "Coaches can remove, modify, observe, document, and enforce restrictions. Medical or qualified performance staff own diagnosis and clearance after concussion, surgery, major trauma, suspected fracture, or persistent symptoms.",
  "objective_gates": [
    {
      "id": "medical-clearance-red-flags",
      "label": "Medical clearance and red flags",
      "measure": "Clearance state, red-flag screen, restriction owner, and same-day removal rules.",
      "default_gate": "Required before concussion progression, contact, post-op escalation, suspected fracture, major trauma, or persistent/worsening symptoms.",
      "evidence_level": "High safety / consensus",
      "coach_use": "Blocks high-risk exposure when clearance is missing or red flags are present.",
      "medical_note": "Diagnosis and clearance stay with medical or qualified performance staff."
    },
    {
      "id": "symptoms-effusion-pain",
      "label": "Symptoms, pain, and swelling",
      "measure": "Pain 0-10, concussion symptoms, swelling/effusion, instability, and 24-hour response.",
      "default_gate": "No symptom return during the current step; no next-day flare; trace-to-zero effusion for ACL-style knee clearance where used.",
      "evidence_level": "Strong safety / common RTS gate",
      "coach_use": "Turns the next session green, yellow, or red based on response to the last dose.",
      "medical_note": "Concussion symptoms or worsening neurological signs override all other positive tests."
    },
    {
      "id": "range-of-motion",
      "label": "Range of motion",
      "measure": "Clinical ROM screen plus sport-specific range under skating, shooting, and contact posture.",
      "default_gate": "Full or medically accepted ROM for the planned task with no pain, instability, or compensation.",
      "evidence_level": "Moderate / consensus",
      "coach_use": "Prevents jumping to speed, contact, or battle drills before movement capacity is back.",
      "medical_note": "Clinician defines acceptable ROM after surgery, fracture, or high-grade injury."
    },
    {
      "id": "strength-symmetry",
      "label": "Strength symmetry",
      "measure": "Isokinetic or handheld dynamometry, 1RM proxy, adductor squeeze, NordBord, or equivalent phase test.",
      "default_gate": "ACL/knee RTS commonly targets >=90% quadriceps and relevant limb symmetry; soft-tissue cases use clinician-set phase thresholds.",
      "evidence_level": "Best supported in ACL; useful but less standardized elsewhere",
      "coach_use": "Confirms tissue capacity before full-speed skating, cutting, contact, or competition.",
      "medical_note": "Use the medical/performance battery, not an improvised coach-only strength test, for clearance."
    },
    {
      "id": "hop-power-agility",
      "label": "Hop, power, and agility",
      "measure": "Single hop, triple hop, crossover hop, 6 m timed hop, CMJ, deceleration, and change-of-direction quality.",
      "default_gate": "ACL/knee RTS commonly targets >=90% LSI across hop tests plus clean landing/deceleration mechanics.",
      "evidence_level": "Common ACL gate; not valid as a standalone clearance test",
      "coach_use": "Checks whether strength transfers into dynamic movement without visible asymmetry.",
      "medical_note": "Pair distance/time scores with landing quality; symmetrical distance can hide poor mechanics."
    },
    {
      "id": "sport-specific-reactive",
      "label": "Sport-specific reactive tasks",
      "measure": "Starts/stops, crossovers, puck pressure, battle posture, small-area games, contact, and dual-task/reactive reads.",
      "default_gate": "Player tolerates repeated hockey exposure under fatigue without symptom flare, quality loss, or confidence collapse.",
      "evidence_level": "Consensus / emerging evidence",
      "coach_use": "Bridges clinic tests to hockey chaos before competition minutes.",
      "medical_note": "Reactive and dual-task work should be added after basic capacity gates are stable."
    },
    {
      "id": "psychological-readiness",
      "label": "Psychological readiness",
      "measure": "Confidence, fear of reinjury, motivation, ACL-RSI/IKDC or clinician-selected PROs.",
      "default_gate": "Readiness is acceptable for the exposure; ACL contexts often use ACL-RSI and other PROs alongside physical gates.",
      "evidence_level": "Strongest support in ACL; useful screen across injuries",
      "coach_use": "Flags players who pass physical tasks but are not ready for full speed, contact, or match pressure.",
      "medical_note": "Low readiness should trigger graded exposure or sport-psych/performance support, not pressure to play."
    },
    {
      "id": "workload-tolerance",
      "label": "Workload tolerance",
      "measure": "Session RPE, external load, high-speed skating, acceleration/deceleration count, shift/minute exposure, and next-day response.",
      "default_gate": "Progressive dose without load spike, symptom return, or 24-hour regression.",
      "evidence_level": "Consensus / risk-management principle",
      "coach_use": "Controls the jump from modified practice to full practice and game exposure.",
      "medical_note": "Workload data are review triggers; they do not clear or diagnose the player."
    }
  ],
  "injury_evidence_profiles": [
    {
      "injury": "ACL / knee ligament RTS",
      "evidence_level": "Most standardized of the musculoskeletal lanes",
      "strongest_gates": [
        "Full or accepted ROM, no pain/instability, and trace-to-zero effusion where used.",
        ">=90% quadriceps strength symmetry and relevant strength indices.",
        ">=90% LSI across hop/agility tests plus landing and deceleration quality.",
        "Psychological readiness and PROs such as ACL-RSI/IKDC where clinically selected.",
        "Stepwise sport reintroduction after full or near-full practice tolerance."
      ],
      "caution": "Time since surgery still matters, but time alone is not a clearance criterion. Clinician or surgeon restrictions override field tests."
    },
    {
      "injury": "Concussion",
      "evidence_level": "Strong safety pathway / medical-owner gate",
      "strongest_gates": [
        "Immediate removal when suspected and no same-day return.",
        "Healthcare-provider approval before return-to-sports progression.",
        "Six-step graduated progression with at least 24 hours per step.",
        "No new or returning symptoms at the current step before progressing."
      ],
      "caution": "Any symptom return stops progression and requires medical contact; coaches never clear concussion."
    },
    {
      "injury": "Lateral ankle sprain",
      "evidence_level": "Consensus framework stronger than precise cutoffs",
      "strongest_gates": [
        "PAASS domains: pain over 24 h and during sport.",
        "Ankle impairments: ROM, strength, endurance, and power.",
        "Athlete perception: confidence, reassurance, stability, and readiness.",
        "Sensorimotor control: balance, proprioception, dynamic postural control.",
        "Sport performance: hopping, jumping, agility, sport-specific drills, full training tolerance."
      ],
      "caution": "Published precise cutoffs are less settled than ACL; use PAASS as a structured assessment map with medical/performance judgement."
    },
    {
      "injury": "Groin, hip, hamstring, shoulder, and overload",
      "evidence_level": "Mixed evidence / criteria-based practice",
      "strongest_gates": [
        "Pain and symptom response during and within 24 hours after exposure.",
        "Strength and control near phase demand or side-to-side expectation.",
        "Sport-specific speed, direction change, shooting/contact posture, and fatigue exposure.",
        "No altered mechanics, guarding, or progressive load intolerance."
      ],
      "caution": "Cutoffs vary by tissue and diagnosis. Use objective tests as gates for progression, not as isolated clearance."
    }
  ],
  "criteria_templates": [
    {
      "id": "injury-management",
      "phase": "Injury management",
      "aim": "Protect the player, rule out red flags, and define the medical owner, restrictions, and first safe training lane.",
      "minimum_evidence": [
        "Incident and symptom log completed.",
        "Red flags screened and escalated.",
        "Clear restriction state: hold, off-ice only, modified, non-contact, or cleared with limits."
      ],
      "coach_decision": "No high-risk exposure until restrictions and follow-up owner are visible in the player plan."
    },
    {
      "id": "rehabilitation-capacity",
      "phase": "Rehabilitation capacity",
      "aim": "Restore pain-controlled movement, strength, balance, confidence, and repeatable mechanics before sport load.",
      "minimum_evidence": [
        "Pain and swelling stable across 24 hours.",
        "Range, strength, control, and balance match the phase demand.",
        "Subjective readiness and confidence are tracked, not left to the final day."
      ],
      "coach_decision": "Progress one variable at a time: volume, speed, direction change, contact, or decision pressure."
    },
    {
      "id": "return-to-participation",
      "phase": "Return to participation",
      "aim": "Reintroduce structured team activity with controlled dose and no expectation of full performance.",
      "minimum_evidence": [
        "Allowed training lane documented.",
        "Daily session dose and next-day response logged.",
        "No altered mechanics, symptom flare, or swelling increase after the previous dose."
      ],
      "coach_decision": "Use modified practice, short shifts, protected stations, or non-contact roles while capacity builds."
    },
    {
      "id": "return-to-sport",
      "phase": "Return to sport",
      "aim": "Expose the player to hockey-specific speed, fatigue, puck decisions, contact, and chaos when gates are met.",
      "minimum_evidence": [
        "Relevant objective tests are passed or medically accepted.",
        "Full practice or near-full practice is tolerated before competition.",
        "Contact and battle exposure are completed when relevant and permitted."
      ],
      "coach_decision": "Move to competition only when the medical owner, coach, player, and data trend agree."
    },
    {
      "id": "return-to-performance",
      "phase": "Return to performance",
      "aim": "Confirm the player can repeat pre-injury or role-required outputs without hidden compensation or delayed flare.",
      "minimum_evidence": [
        "Performance and workload are compared with the player's baseline or role demand.",
        "Readiness, confidence, and symptom trend remain stable under fatigue.",
        "Reintegration minutes and exposure are reviewed for 1-4 weeks after return."
      ],
      "coach_decision": "Keep monitoring after game return; RTP is not complete just because the player appeared in a match."
    }
  ],
  "test_families": [
    {
      "id": "symptoms-readiness",
      "label": "Symptoms and readiness",
      "examples": ["pain 0-10", "swelling/effusion", "sleep", "fatigue", "confidence", "fear of reinjury"],
      "use": "Daily trend gate for progress, hold, or regress. A single good day is not clearance."
    },
    {
      "id": "range-strength",
      "label": "Range and strength",
      "examples": ["ROM screen", "handheld dynamometer", "isokinetic test", "NordBord", "adductor squeeze"],
      "use": "Shows whether the player has enough tissue capacity and side-to-side symmetry for the next phase."
    },
    {
      "id": "power-hop",
      "label": "Power and hop/agility",
      "examples": ["CMJ", "single-leg hop", "Y-balance", "T-test", "deceleration and change-of-direction quality"],
      "use": "Connects clinic capacity to hockey movement before full speed, contact, or competition."
    },
    {
      "id": "hockey-transfer",
      "label": "Hockey transfer",
      "examples": ["starts/stops", "crossovers", "battle posture", "small-area non-contact", "controlled contact"],
      "use": "Confirms the player can tolerate skating, puck work, decisions, fatigue, and contact constraints."
    }
  ],
  "wearable_triggers": [
    {
      "signal": "External load spike",
      "review_trigger": "Skating volume, high-speed work, accelerations, decelerations, or player load jumps above the player's current RTP band.",
      "action": "Hold progression and review 24-hour response before adding another variable."
    },
    {
      "signal": "Internal load mismatch",
      "review_trigger": "Session RPE, heart-rate response, soreness, or fatigue is high for a low external dose.",
      "action": "Treat as yellow: lower complexity or volume and check sleep, stress, and symptoms."
    },
    {
      "signal": "Asymmetry or movement-quality drop",
      "review_trigger": "Wearable, force-plate, video, or coach observation shows side-to-side drift under fatigue.",
      "action": "Return to the previous successful task and notify the medical/performance owner."
    },
    {
      "signal": "Symptom return after exposure",
      "review_trigger": "Pain, swelling, neurological symptoms, or confidence drop appears during or within 24 hours.",
      "action": "Stop the added exposure; red if concussion symptoms or medical red flags are present."
    }
  ],
  "phases": [
    {
      "id": "protect-control",
      "title": "1. Protect and control symptoms",
      "coach_can_do": [
        "Stop or modify practice immediately when mechanics change.",
        "Log pain, symptoms, incident time, and current restrictions.",
        "Keep the player in approved low-risk work only."
      ],
      "progress_gate": "Symptoms are stable or improving, pain is predictable, and medical/physio restrictions allow the next phase.",
      "stop_gate": "Loss of consciousness, worsening neurological signs, inability to bear weight, deformity, sharp pain, swelling escalation, or symptoms returning during concussion progression."
    },
    {
      "id": "restore-capacity",
      "title": "2. Restore mobility, strength, and control",
      "coach_can_do": [
        "Use off-ice or low-intensity on-ice tasks that respect restrictions.",
        "Monitor pain during activity and 24-hour response.",
        "Remove volume, speed, contact, or cutting before stopping all activity."
      ],
      "progress_gate": "Pain stays low, range/control are acceptable, swelling is not increasing, and the next-day response is stable.",
      "stop_gate": "Pain rises above the agreed limit, swelling increases, movement quality worsens, or the player compensates."
    },
    {
      "id": "sport-specific",
      "title": "3. Hockey-specific non-contact",
      "coach_can_do": [
        "Reintroduce speed, direction change, and skill complexity one variable at a time.",
        "Use short shifts and longer rests to protect quality.",
        "Compare movement quality, confidence, and symptom response side to side."
      ],
      "progress_gate": "Player completes skating, acceleration, deceleration, agility, and hockey-skill tasks without symptom flare or quality loss.",
      "stop_gate": "Symptoms return, next-day pain increases more than 2/10, landing/cutting quality drops, or confidence is clearly not ready."
    },
    {
      "id": "contact-competition",
      "title": "4. Controlled contact and competition",
      "coach_can_do": [
        "Start with controlled contact and known constraints.",
        "Keep intensity, contact exposure, and minutes visible.",
        "Collect post-practice symptoms, sRPE, pain, and confidence before game selection."
      ],
      "progress_gate": "Medical clearance is complete when required, objective gates are met, and full practice is tolerated before competition.",
      "stop_gate": "No medical clearance for concussion/surgery/major trauma, symptoms return, or contact produces altered mechanics."
    }
  ],
  "injury_lanes": [
    {
      "id": "concussion",
      "title": "Concussion / suspected head injury",
      "coach_screen": [
        "Remove from play immediately when concussion is suspected.",
        "Do not allow same-day return.",
        "Watch for symptoms during every RTP step."
      ],
      "objective_gates": [
        "Healthcare-provider approval before sports progression.",
        "Back to regular non-sport activities first.",
        "Six graduated steps: light aerobic, moderate, heavy non-contact, full-contact practice, competition.",
        "Each step typically takes at least 24 hours and must not trigger new symptoms."
      ],
      "medical_owner": "Healthcare provider / certified athletic trainer where available",
      "no_go": "Any new or returning symptoms during progression means stop, contact medical provider, and restart from the previous symptom-free step after rest."
    },
    {
      "id": "knee-ligament",
      "title": "Knee ligament and meniscus",
      "coach_screen": [
        "Check swelling trend, range, gait/skating compensation, and confidence.",
        "No cutting, pivoting, contact, or battle drills until cleared for that phase.",
        "Use brace/tape only when prescribed, not as clearance."
      ],
      "objective_gates": [
        "Pain-free or low-pain sport tasks with no swelling increase.",
        "Full or acceptable range of motion for the current phase.",
        "Strength and hop/agility symmetry commonly targeted at 90% or higher for ACL-style RTS.",
        "Landing, deceleration, and cutting quality assessed before full hockey exposure."
      ],
      "medical_owner": "Physio/sports medicine lead, surgeon where surgical",
      "no_go": "Locking, giving way, increasing effusion, altered skating, or unresolved post-op restrictions block progression."
    },
    {
      "id": "groin-hip-hamstring",
      "title": "Groin, hip, and hamstring strains",
      "coach_screen": [
        "Track pain during skating push-off, crossovers, starts/stops, and next-day response.",
        "Watch for stride shortening, guarding, or trunk shift.",
        "Avoid jumping from straight-line work to high-speed cutting."
      ],
      "objective_gates": [
        "Pain stays within the agreed range and returns to baseline within 24 hours.",
        "Strength/control tests are near symmetrical for the demands of the phase.",
        "Player tolerates acceleration, deceleration, change of direction, and repeated skating exposure.",
        "Sport-specific drills precede battle/contact and competition."
      ],
      "medical_owner": "Physio/performance lead",
      "no_go": "Sharp pain, worsening next-day response, altered stride, or recurrent symptoms across 2-3 sessions means regress and review."
    },
    {
      "id": "shoulder-ac",
      "title": "Shoulder / AC joint",
      "coach_screen": [
        "Check pain with stick handling, passing, shooting, falls, board contact, and battle posture.",
        "Keep shooting and contact volume visible.",
        "Use non-contact skill before battle/contact exposure."
      ],
      "objective_gates": [
        "Pain-free or acceptable shoulder range for shooting and contact posture.",
        "Strength/control adequate for stick, puck protection, falls, and contact.",
        "Contact progression completed before games."
      ],
      "medical_owner": "Physio/sports medicine lead, physician where high-grade separation",
      "no_go": "Visible deformity, numbness/tingling, instability, high-grade separation, or pain with basic function requires medical review."
    },
    {
      "id": "ankle-foot",
      "title": "Ankle, foot, and skate-related injuries",
      "coach_screen": [
        "Check weight bearing, swelling, skate tolerance, balance, and edge control.",
        "Start with straight-line skating before crossovers, tight turns, and contact.",
        "Respect brace/tape or boot restrictions from medical staff."
      ],
      "objective_gates": [
        "Walk and skate without limp or compensation.",
        "Single-leg balance and hop/cut tasks meet the phase demand.",
        "No swelling increase after skating exposure."
      ],
      "medical_owner": "Physio/medical lead",
      "no_go": "Unable to bear weight, suspected fracture, focal bone tenderness, swelling escalation, or unstable ankle blocks progression."
    },
    {
      "id": "overload-tendinopathy",
      "title": "Overload and tendinopathy",
      "coach_screen": [
        "Look for recent load spikes, high soreness, poor sleep, and repeated pain signals.",
        "Use 24-hour response and weekly load trend before adding volume.",
        "Prioritize modified participation over all-or-nothing decisions when safe."
      ],
      "objective_gates": [
        "Pain remains stable during and after training.",
        "No next-day worsening beyond the agreed threshold.",
        "Strength and capacity build gradually before repeated high-intensity exposure."
      ],
      "medical_owner": "Performance/physio lead when persistent or worsening",
      "no_go": "Progressive worsening, night pain, neurological signs, or failure to improve after a structured phase needs referral."
    }
  ],
  "decision_bands": [
    {
      "label": "Green",
      "detail": "Meets phase gates, symptoms stable, no compensation, restrictions allow the planned work.",
      "action": "Run the planned phase and log response."
    },
    {
      "label": "Yellow",
      "detail": "Some gate is incomplete, symptoms are elevated, or load response is uncertain.",
      "action": "Modify volume, speed, contact, or complexity and set a follow-up owner."
    },
    {
      "label": "Red",
      "detail": "Red flag, missing clearance, symptom return, severe pain, worsening swelling, or altered mechanics.",
      "action": "Hold high-risk work and refer to medical/physio support."
    }
  ],
  "contract_fields": [
    "injury_type",
    "rtp_phase",
    "medical_clearance_state",
    "symptom_score",
    "next_day_response",
    "strength_symmetry_pct",
    "hop_agility_symmetry_pct",
    "coach_decision",
    "test_battery_status",
    "wearable_trigger",
    "return_stage",
    "objective_gate_status",
    "psych_readiness_score",
    "sport_specific_gate_passed"
  ],
  "integration_targets": [
    "/os/coaching#hockey-return-to-play-protocol",
    "/os/planning?area=development#hockey-return-to-play-protocol",
    "/os/academy#hockey-return-to-play-protocol",
    "/academy#hockey-return-to-play-protocol",
    "/os/recovery#hockey-return-to-play-protocol",
    "/os/analytics#hockey-return-to-play-protocol",
    "/os/reports?report=rtp-protocol#hockey-return-to-play-protocol"
  ],
  "sources": [
    {
      "label": "CDC HEADS UP return to sports",
      "href": "https://www.cdc.gov/heads-up/guidelines/returning-to-sports.html"
    },
    {
      "label": "ACL RTS scoping review (PubMed)",
      "href": "https://pubmed.ncbi.nlm.nih.gov/40865179/"
    },
    {
      "label": "ACL criterion-based milestones (PMC)",
      "href": "https://pmc.ncbi.nlm.nih.gov/articles/PMC9460090/"
    },
    {
      "label": "Common hockey injuries overview",
      "href": "https://synergyreleasesports.com/common-hockey-injuries-and-recovery/"
    },
    {
      "label": "Rethinking Return to Play presentation",
      "href": "https://medialibrary.uantwerpen.be/files/1885/87226a7d-e425-42e3-97f0-d70db46d341f.pdf"
    },
    {
      "label": "Criteria-based lateral ankle sprain RTS review",
      "href": "https://pure.amsterdamumc.nl/ws/portalfiles/portal/156957128/Criteria-based-return-to-sport-decision-making-following-lateral-ankle-sprain-injury.pdf"
    },
    {
      "label": "Ten task-based progression in rehabilitation (PMC)",
      "href": "https://pmc.ncbi.nlm.nih.gov/articles/PMC7735691/"
    },
    {
      "label": "First World Congress in Sports Physical Therapy RTS consensus",
      "href": "https://ifspt.org/wp-content/uploads/2025/05/2016-Consensus-statement-on-return.pdf"
    },
    {
      "label": "ACL current criteria for return to play (PMC)",
      "href": "https://pmc.ncbi.nlm.nih.gov/articles/PMC6829009/"
    },
    {
      "label": "CDC HEADS UP six-step return to play",
      "href": "https://www.cdc.gov/heads-up/guidelines/returning-to-sports.html"
    }
  ]
}