Published On: January 27, 2019Categories: Programming

Written by Joe Vecchione and Chloe Werle

 

There are athletes and coaches who will face hurdles in preparation for the Olympic games. Injuries can be a devastating blow to an athlete should it limit their participation in qualifiers or competing at the games. Sport unfortunately comes with injuries, and when they occur, strength & conditioning (S&C) coaches can play a critical role in the rehabilitation process and ensure an effective and timely return to competition.

The landscape of women’s international football (i.e., soccer in North America) is different from some other Olympic sports. These athletes are not amateurs – they are professionals under contract to teams all around the world. As a result, we (S&C coaches) do not work in a traditional quadrennial model and have limited access to athletes via camps throughout the year. Luckily for us, the European football calendar comes to an end in May and provides an opportunity to have a larger influence on our athlete’s preparation and rehabilitation strategies leading into the Games.

 

Context and Background on the Athlete

Just weeks before the final camp prior to the Games at the end of May, we learned that one of our player’s, Deanne Rose, was unable to play in her final league game due to debilitating Achilles pain in her right leg. This was particularly troubling for Deanne as she reported the pain to be similar to what she experienced in her other leg prior to rupturing her Achilles tendon approximately 18 months before, which was surgically repaired Sept 2022. To make matters more complicated, she was managing a low-grade hamstring strain in her left leg as well.

Deanne is a dynamic winger and has been part of the fabric of the women’s national team (WNT) for nearly a decade. Over the years, she’s suffered from multiple injuries, notably hamstring strains, and in recent times, has been struggling with bilateral Achilles tendinopathy. She presented as a complex case, with multiple factors undoubtedly playing a role in her injury history.

Figure 1. Deanne Rose running intervals during halftime at the

2023 Women’s World Cup under the supervision of her S&C coach.

 

Deanne reported to camp at the end of May and was unable to participate in team training. Prior to her arrival, she had received multiple opinions on her rehabilitation strategy, all of which included extended time away from training. With a little under 2 months away from team selections, time was not on our side which ruled out a complete deload from training activities. Our team quickly got to work planning a reconditioning strategy to give Deanne a chance to make the 2024 Olympic team.

Before we could move forward, it was paramount to have alignment with our head coach, within our medical and sport science team, and of course with Deanne. Not only was this an aggressive timeline, but we needed to coordinate training sessions in multiple sites across North America (Toronto, Vancouver, Los Angeles) given previous commitments from all parties. Apart from logistical challenges, we also needed to review and integrate the information from multiple sources (surgeons, club sport scientist & physio, Achilles rehab consultants) and design a program that Deanne felt confident with. This was not going to work without her buy-in.

After reviewing her case as a medical and sport science team, we agreed there were multiple factors at play. First, there was a significant strength deficit on her left leg (surgically repaired side) which resulted in her taking more load on her right leg when running; this had been going on for 2 years post-surgery and seemed to have contributed to developing a tendinopathy in her right Achilles. The ultrasound imaging of her Achilles tendons revealed we were dealing with two very different tendons, her left side was very stiff and needed to increase compliance, while the right side was compliant and needed to increase stiffness. Finally, Deanne is a heel striker and reaches when running (i.e. overextends). This places additional load on the Achilles and hamstring complex during this repetitive action which we felt was compounding her issues.

I (Joe) remember sitting down with Deanne to present our reconditioning hypothesis. I could sense her frustration with the situation, and it brought me back to a year prior where a similar conversation took place leading into the 2023 Women’s World Cup. This time, after I presented the plan as a visual, I closed my laptop, and I told her honestly that this plan was not ideal or guaranteed to work, that she would have to commit her mind, body, and spirit to making the team. She hung her head for a moment, and I told her, “I believe in you, and we believe in this plan. If you want to make this team, and you believe you can help the team, then we will make that happen together.” There was a shift in her and my energy, and we made a commitment to proceed with our best effort.

 

Reconditioning Intervention

When we sat down as a sport science team to map out the road to Paris selections, we worked backwards with the end in mind. There were a couple key things Deanne had to manage to be at her best for an intersquad game on June 29th which would be the final evaluation for team selections:

  • Tolerating 5 training sessions over 6 days in a high-intensity environment where she would not be modified (train-train-off-train-train-train).
  • Practicing 3 days in a row (which had historically increased her Achilles symptoms), with the final day being the intersquad game.
  • Aggressive loading plan of 10-15% increase in on-feet volume week over week for 5 weeks, along with incremental increases in intensity and a biweekly increase in frequency of sessions. (see Figure 2 below)

 

Based on our reconditioning hypothesis, there were a few components we knew we had to prioritize in the loading plan leading into selections. The link between strength and tendon health is well established (1), and given Deanne’s previous injury and asymmetry at the time, we knew we needed to prioritize strength development. The challenge was that a large strength dose would lead to tendon stiffness and soreness that would negatively impact our ability to load on-field the subsequent day. To maximize strength and tendon loading and provide a 48-hour recovery period, based on recommendations for managing tendinopathies (2), we performed both a field and gym session, followed by a recovery day. We began with this 1 on, 1 off cadence for the better part of 3 weeks, gradually increasing session density (increasing the duration of football activities while decreasing rest intervals).

We started with 3 sessions per week in the first 2 weeks, then gradually increased to 4 for the second 2 weeks, and finally had 5 sessions of football in the final week. When adding a successive session in the week (i.e., W2 – train-train-off-train-off-train, W4 – train-train-off-train-train-train), we started with a light, running focused session (see pink cells  on W2 or W4; note: football training sessions are titled Train in bold) which progressed to a football training session the next week. Following these heuristics allowed us to gradually increase the intensity and density of training sessions, while minimizing tendinopathy flare ups.

 

Figure 2. Five week return to play loading plan for Deanna Rose

 

On-Field Principles

The on-field loading progression began with a return to running program focused on technique and changing her mechanics. Given her injury history and mechanics, we felt there was a clear link between the recurring nature of her injuries and her running mechanics. With it being the end of her season, and having close to 5 weeks with Deanne, we decided to undergo a technique change intervention using contrasting methods (3), with the hypothesis that if we could limit her reaching and heel-striking, we could decrease the strain on her hamstrings and Achilles respectively. The early signs seemed to indicate we were on the right page with our hypothesis, and continued with an intensive program to transfer the progress to her running form into a football environment.

As we began to integrate Deanne back to football in week 2, there were a few principles we used to reduce Achilles symptoms. Firstly, the football and running were intermittent in nature, starting with <30s bouts and increasing gradually. This helped reduce compensations during movement and limited the calf from working under fatigue which would lead to Achilles symptoms. Along this same line, we limited extended small-sided work which brings about a high frequency of change of directions (CODs); these types of activities can place a high demand on the calf complex due to the multi-directional acceleration and decelerations which had aggravated symptoms in the past. When reviewing the output from the GPS metrics, this type of information does not come through and is a reminder that not all load is created equally; how you achieve it matters, resulting in differing levels of strain on the tissues of the body.

 

Off-Field Principles

Based on the imaging of Deanne’s Achilles tendons and feedback from her team of specialists, we needed to rehab each side a little differently in the gym. Given the stiffness of her tendons were significantly different due to the surgical intervention (left leg) and tendinopathy (right leg), we used different loads to achieve the desired adaptations. Using plantarflexed isometrics on a horizontal leg press for 5x5s holds, the right leg was loaded to 90% max voluntary contraction (MVC) to stiffen the tendon (due to higher force demands), and the left leg to 60% to achieve an increase in compliance. In addition to isometrics, and keeping in line with the tendon strengthening literature, we used high-load, tempo training with a 3:2:1 tempo (3s eccentric, 2s concentric, 1s isometric) for isolated calf and soleus strengthening to continue strengthening the tendon, as well as the surrounding musculature of the calf and soleus.

Separate from the tendon physiological properties, there was a significant strength deficit in her calf and soleus on her post-surgical side (left), with a visible difference in calf circumference. The compensation to accept more load on her right leg was visible when running, leaving us to conclude this was likely a main culprit to developing an overuse injury on her right side approximately 1.5 years later. To address these deficits, we added 2-to-1 eccentric SL calf raises on her left side only (while performing regular SL calf raises on her right side), and performed additional sets of single leg strengthening exercises such as SL BW calf raises and SL Bent Knee Calf Raises (see Figure 3 for full loading prescription during week 3).

Figure 3. Deanne Rose’s week #3 S&C in-gym program.

 

A Note on Isometric Calf Strength Testing:

Before Deanne joined our camp in May, she underwent maximal isometric force plate testing in a straight leg and seated plantar-flexed position to objectively measure her calf strength. The results shared by her club showed no significant asymmetry in her straight leg testing and a slight strength discrepancy in her left side seated testing. When we compared the results of these objective measures to what we observed with her calf girth as well as her inability to perform full range of motion single leg calf raises on her left side, we decided that isometric strength testing would not be the main indicator of success or progress in this process, although being recommended in the scientific literature (4). Instead, we tracked and continued to progress intensity, volume and quality of strength reps in addition to monitoring how she was expressing force on the pitch and handling progressive on-feet reloading.

  • Block D (high load, low reps, tempo training) = 3 bilateral sets + 2 SL sets on left leg
  • Block E (moderate load, high reps) = 3 bilateral sets + 2 SL sets on left leg @ BW
  • Block F (high load, low reps, tempo training) = 3 bilateral sets + 2 SL sets on left leg

Note: For much of this rehab intervention, plyometrics were kept to a minimum. They were slowly introduced in week 3 and maintained, then progressed after selection during Olympic pre-camp.

 

Olympic Selections

Just 6 weeks removed from being unable to play her final league match, Deanne was fully-integrated into our training hub in Toronto – her final opportunity to earn a spot on the team. The path was not easy. Most days consisted of 4-5 hour training days between gym and on-field sessions, numerous treatment sessions, all while coordinating with multiple practitioners and facilities across 4 cities. Deanne’s commitment never wavered, and she never missed a session. More importantly, she hit her target of being able to train 5 training sessions in 6 days without modifications, capped off with a 60-minute intersquad match. Her perseverance and dedication to the plan propelled her to be a standout during the Toronto hub, earning her a place as an alternate on the Olympic team. During warm-up matches, Deanne continued to impress. After one of the warm-up matches, multiple members of the technical staff came to us individually to share that this was some of the best football they’ve seen Deanne play.

As a two time Olympic medallist (gold in Tokyo, bronze in Rio), Deanne was eager to get back to that familiar stage. Returning as an alternate was bittersweet, though being ready to play if called upon was a different type of accomplishment. She contributed to the team equally on the pitch during training, and off the pitch supporting her teammates during what would be a unique Olympic tournament for our team.

 

Collaboration among the Integrated Support Team (IST)

In addition to the unwavering determination Deanne showed throughout her reconditioning, this process could not have been possible without the alignment of our Integrated Support Team (IST). In the span of a few short days, our IST was able to: create an evidence-based plan that was realistic for the timeline, educate the head coach on our direction and garner her support, and present the plan to Deanne and secure her buy-in. This was done while simultaneously preparing a squad of 23 athletes for two international friendly matches.

At the time, our IST had been fortunate to have worked together for three years prior to the Paris Olympics, gaining experience as a group at major events like the 2023 World Cup and 2022 World Cup qualification created trust and synergy among us. Two staff were full time with the program, while the other five staff primarily supported in-camp exclusively. Based on the skill sets of the practitioners, we entrusted two staff (one S&C coach and one Physiotherapist) to co-lead the planning and initial delivery stages of Deanne’s progress. With Deanne’s case being more long-term and continuing outside of camp, it was crucial for our team to have a very organized and aligned set of philosophies and processes when planning, ensuring a smooth hand-off between practitioners. Many follow up phone debriefs, and video/data sharing sessions were necessary to achieve this. An immense amount of trust and constant communication was needed for us to help Deanne achieve her goals between May camp and the Toronto selection hub. Fortunately, we had full confidence in one another’s abilities to deliver the plan accordingly and as a result, we were able to meet these goals.

Figure 4. Joe Vecchione, Deanne Rose and MC Holland (physiotherapist) reviewing video of running mechanics.

 

Post-Olympics Return to Performance

Post Olympics, Deanne had a short period of rest and then returned to club football with clearance to begin building game minutes. She was able to feature in the clubs first game of the 2024-2025 season! It was decided between club and country staff that Deanne still needed to continue with some individualization of her weekly loading. The purpose was to continue to develop strength, with heavy loading on-field and in the gym with a heavy calf-focused session post, followed by a rest day, which mimicked the load cadence utilized in Olympic prep. Depending on minutes played in her weekend matches, Deanne and her club continued post-game calf strengthening, maximizing the development opportunity on game day and the recovery window post-game (48 hours instead of 24) to enhance calf strength and tendon adaptations. It should be noted that this is not common practice in the sport of football, highlighting the importance of case-specific individualization. When Deanne came into camps with the Women’s National Team, we were able to accommodate this cadence as best as possible given the condensed game schedule by modifying load in football sessions and continuing with game day strength work. For the most part, Deanne’s tendinopathy symptoms remained minimal as she continued to adhere to this plan.

 

Conclusion

Often, we hear testimonials from former Olympians that the motivation to represent their country at the biggest sporting event in the world allows them to accomplish feats that at first glance seem near impossible. This sentiment is very true in Deanne’s case. The level of perseverance and commitment she exhibited in her journey towards health and performance allowed the improbable to become possible.

When our IST were first reviewing the facts of where we were starting and where we needed to go, we realized very quickly that the typical cookie-cutter return-to-play plan was not going to suffice. To get Deanne to the Olympics, we would need to strip back to the fundamentals and really individualize the process based on her specific needs. This individualization was necessary in the short-term and became a positive fixture in Deanne’s long-term reality. The collaboration and trust amongst the staff, club and external experts was a critical success factor – but most important was the synergy and buy-in between Deanne and our IST which made all the difference in the world. When everyone believes and trusts in the process, it’s amazing what can be achieved.

 

Author Bios

Joe Vecchione is a sport performance professional with a Master’s of Science in Skill Acquisition. He’s worked in multiple high-performance settings with various sports, including Olympic and World Champion athletes. Currently, he is serving as a Performance Specialist for Bay Football Club of the National Women’s Soccer League. He is also a sessional lecturer in in the University of British Columbia’s Master’s of Kinesiology program, teaching a course titled: Injury prevention: A Multi-disciplinary Approach.

 

 

 

Chloe Werle is a Physical Performance Coach with the Canadian Sport Institute Ontario and the Head of Physical Performance for the Canadian Women’s National Soccer Team. She has worked for Canada Soccer since 2017 and has supported the youth and senior women’s national teams at three World Cups and two Olympic Games. Chloe is very passionate about the youth to senior physical development pathway in Canada. In addition to her duties with the Women’s National Team, she oversees the Physical Performance Department for the Women’s Excel Program, ranging from the National Development Centre Ontario to then U20 Youth Women’s National Team.

 

 

References

  1. Rio, E., Kidgell, D., Moseley, G. L., Gaida, J., Docking, S., Purdam, C., & Cook, J. (2016). Tendon neuroplastic training: changing the way we think about tendon rehabilitation: a narrative review.British journal of sports medicine50(4), 209-215.
  2. Pavlova, A. V., Shim, J. S., Moss, R., Maclean, C., Brandie, D., Mitchell, L., … & Swinton, P. A. (2023). Effect of resistance exercise dose components for tendinopathy management: a systematic review with meta-analysis.British journal of sports medicine57(20), 1327-1334.
  3. Vecchione, J., Madill, C., & Hodges, N. J. (2022). Modifying technique in closed self-paced motor tasks. InThe psychology of closed self-paced motor tasks in sports (pp. 122-145). Routledge.
  4. Marrone, W., Andrews, R., Reynolds, A., Vignona, P., Patel, S., O’Malley, M. (2024) Rehabilitation and Return to Sports after Achilles Tendon Repair. International Journal of Sports Physical Therapy, 19(9), 1152.

 

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