Achilles pain in runners: why the root cause is often your hip

You're listening to the Restoring Human Movement podcast. Thanks for joining the movement, movement. I'm Sebastian Gonzales, show curator and head clinician at Performance Play Sports Care in Southern California. This show's for active people, those who refuse to let pain and injury get in the way of their life and how they want to live it. Trails and trips, fields and courts, whatever moves you. Each episode features rotating host, expert guest, and real clinical conversations that help you move better and trust your body again. Here we go. This will be a quick one that we are covering Achilles issues with runners, hikers, our active individuals, actually people who play pickleball and other various sports actually have this as well.

I'm going to be covering what it is today, some things you can look out for, more common signs and symptoms associated to it, but also some tangents of people who have what we call pseudo-Achilles tendinopathy who are struggling with getting better, but they're actually doing things incorrectly for the situation that they're in. Let me put it that way. So I'm going to give some simple tips, but also some guidance on maybe what you guys should be looking for next. Keep in mind, as always, this is not medical information. It's for educational purposes only. Now, Achilles tendonitis is actually an inflammatory component to an Achilles injury.

If you guys don't know where the Achilles tendon is, it's the big one that attaches to the back of your ankle. It's the most palpable, touchable, identifiable tendon probably in your body other than maybe the biceps tendon, so pretty much everybody should kind of know where it's at. But oddly, a lot of people don't diagnose it super well. If you've been around the injury for a long time, you realize what it is and where it is and so on, but a lot of novice people don't actually know where it is and they actually cannot correctly diagnose themselves either. Usually, it appears as a swollen tendon in the back of the ankle.

It feels like a creaky type of feeling and it's pretty tender and stiff most of the time. It presents single-sided. It increases as you start to use the tendon a little bit more, but it also does warm itself up. Usually, the first step in the morning is pretty stiff. When you've been sitting for a while, it's pretty stiff as well. A lot of people have a lot of fear associated to using it because they feel like their Achilles is going to rupture and pop off the bone, which is a much harder energy to deal with. I'll be honest with you with that, but the Achilles pain itself is not 100% an indicator that that's going to happen.

But if you are concerned at all, you need to take some of the necessary steps to deload parts of the Achilles, but also load it appropriately as well. One thing we know about this injury is that rest doesn't really work well over the course of time. It can help in the short term, but most of the time the consensus is you use your body, be smart about it, and you'll keep a lot of your activity around while you're even recovering from it too. Now, the Achilles tendonitis itself, again, has an inflammatory component. An Achilles tendinopathy is a general overlying category that means tendon issues.

In the past, they try to differentiate between Achilles tendonitis and tendinosis. A tendinosis doesn't have an inflammatory component or it's more of a chronic inflammatory component. It's an older injury. But on a lot of the images, it won't necessarily show that there's new vascularity in the area. Earlier, I mentioned that people don't really diagnose this super well on their own. There was a small, very small paper that I had to put out for one of my credentials about, I want to say about 10 years ago or so. It was a peer-reviewed one and it was, I forget the exact title, it was so long ago, but it was, I had an ultrasound diagnostic ultrasound machine and for any of you who do or have seen a diagnostic ultrasound, it's really great for tendon issues, especially the Achilles tendon.

Like, you can see it clear as day. You can turn on a Doppler to see vascular components to it. But it's very hard to get the diagnosis wrong when you use an Achilles injury and a Doppler-based ultrasound. Now, I'm not saying go out and run and get it, but I'm going to paint a picture here. I went to a running group and I needed people to participate in the study or else I wasn't going to be able to do it. And so I stood up in the beginning and I said, hey, all of you, there's like 100 people there, all of you, if you believe you have Achilles tendonitis, I'm doing a small self-diagnostic study to see if you guys are getting your diagnosis right, just reach out to me after you come back from your run and I will set up a time and do an image for you, no cost.

Let's just see if you get it right. And so someone raised their hand and they said, Achilles tendonitis, what is that? And I said, it's not my, it's part of the study, not my job to tell you whether you think it's on your hand or your foot or your knee, it doesn't matter. The purpose is, can a person self-diagnose it correctly? And so we went from there. At that point, I think I only had about 15 participants, so it wasn't that many. And we found that actually, according to Doppler, only 25% of the people actually had a true Achilles tendonitis. We can't say if they had a tendinosis or an opathy necessarily.

I guess they had an opathy because they had a problem down there, but almost nobody got it right, which is mind-blowing because the tendon itself is so large, it's so palpable. When it's inflamed, you can actually see that it's visibly larger. And a lot of these people came in with no visible enlargement whatsoever. So what do you do now? Well, I know that when I have a certain problem going on, an ache or pain in the body, I know that the work is coming from elsewhere. I know that although my Achilles hurts and it's tender, that although I can do management directly to the Achilles and work on it to decrease inflammation and rub the calf in the foot, etc., that doesn't stop the workload from going to it.

You still will have load into the Achilles, which may make it either swollen, tender, stiff, positive of ultrasound findings or not. But either way, it increases the issues there. And that's why I like to say issues. My friend sent me a video the other day. It was on somebody doing an educational video about how the nemicular bone is really important for Achilles issues. And his question was, is this true or is this a myth? And kudos to him to realize that a lot of things out on the internet are kind of BS and very narrow with their context. But for him, actually, it was holding some merit. It was talking about how the muscle around the side of the shin, the peroneus longus, goes around and it wraps underneath this bone called the cuboid and it locks it in place.

It helps with the arch. It helps out with foot mechanics. It deloads the Achilles and the plantar fascia and helps out with Achilles issues as well as heel ones. And he says, it's true or false. And I said, well, it's true, but it's only part of the context. Now for a quick pause before we keep going. Hey, everybody. It's Sebastian. If what we've been describing in the show so far sounds very familiar and you've been dealing with some ache, pain, or stiffness that keeps coming back no matter what you do and no matter what you try, we're offering a free discovery call today where we brainstorm with you what has been working for you, what hasn't been working, and we also try to unravel what is a critical part of the puzzle that you've actually been missing that's keeping you from full recovery and getting back to full activity.

The link's in the description. It only takes a few minutes to fill out the form. Okay, back to the show. A lot of people have up leg mechanic issues that they need to address as well. And I said, look, that's only one cause of possibly having this ongoing Achilles issue, this swelling, etc. where you can't run and jump and it feels stiff and so on. And if not addressed, the condition keeps coming back more frequently. Like you rest it, you do an injection, you take some medications, you boot it, and then all of a sudden you go back to activity and it comes back again. Like that's, like you didn't address the root cause.

Now, this was your root cause that your navicular, or sorry, the cuboid wasn't really locking in place due to weakness of the peroneus longus, etc. Sure. But how do we know that's actually your problem? And he's like, well, we don't. I said, right. Because you haven't been assessed yet. Nobody's really taken taking your history on it. So, a lot of times taking a history on it, and this is the value of having a skilled provider who has a trained eye to watch human movement, but also understanding the context. For a lot of people, they actually have more of a hip issue, which is creating downstream mechanic changes.

Now, for a lot of you runners out there, I don't think hikers really look at it, but they, for a lot of them, like to look at this assessment of like running gait assessment or walking gait assessment where they look at hip drop or knee valgus collapse, et cetera. And they're blaming this glute med muscle and, you know, all that kind of stuff. And some people actually are pretty keen to it. They realize, oh, I've had this hip issue for a long time. I guess this is a part of it. Probably, did you ever get the hip issue addressed? Well, it doesn't hurt. Right. But it clearly, it has a part in your running mechanics.

So, it's going to put load on other areas of the leg, which generates force from the ground. So, it not having pain doesn't really have all that much to do with it. It's, does it function well? Is it strong? Does it have good range of motion in all of its ranges that's comparable to the other side? If it doesn't, it may create these downstream mechanics which create hip drop, which create knee valgus and hip adduction, which, if you've done enough reading, you'll see that this does affect heel and Achilles issues. But so does the cuboid. So, it just depends. Now, I told my friend here that, I said, I think the overall theme here is we need to look at human movement.

What human movement that is simulated in running or is within running, that cuboid thing and the hip thing need to actually, needs to actually be normal to stop this injury from reoccurring. And I led him to and I said, single leg mechanics. It's single leg stance mechanics. So, you can do an exercise for your cuboid, you can do one for your glute mean and your adductor and all that kind of stuff. But really, if you do one that's for your single leg mechanics, like a single leg RDL, a B stance RDL and things like that, like that's probably a better carryover. And actually, if coached well, it addresses a lot of these components.

So, I know I touched on gait. Gait is important to some degree, but also we all have to remember that if your gait is affected by a root cause which is unaddressed, your gait will continue to be different. For example, if I kicked you in the leg and told you to run, you would limp. It doesn't mean that you don't, your body doesn't know correct gait mechanics. And it's not to say that once your pain of your leg went away, it wouldn't normalize because a lot of times it does. It's that I've affected your actual body in a way that changed your gait mechanics. So, if you're lacking hip external rotation or internal rotation or extension, it's going to affect your walking mechanics.

For some people, you watch them and their hip will do anything in its power to basically not absorb the force of single leg mechanics. And you look at them from the backside and say they have a right leg problem or a past right hip problem or a right Achilles issue. You'll see them walking and if you take it like, if you watch the right ear, the other ear, watch the right ear, it'll actually seem like it's dumping water out of it as they step on their right leg. So, they step on their right leg and their right ear dumps water out of it. And you look at their left side and it's kind of like holding its water, if you will.

It's kind of like normal perpendicular to the ground. And this is where the spine is compensating. So, there's a lot of compensations that people can have and although this person is walking forward and they are doing human locomotion, they're making it all the way forward and they were probably running and hiking, et cetera, they're doing it in a compensated fashion. And that's probably in this individual we may be talking about their hip has never actually been strengthened. Like they had this old hip injury that was never really fully strengthened. It just, their pain went away so they stopped looking at it.

And now everyone that they're talking to and having a look at their Achilles issues is saying, well, you got the swollen Achilles or your Achilles hurts and it's probably because your calf is tight or you're, you know what, you need to do these small foot exercises and start scrunching this towel up and all that kind of stuff and all that didn't work. Well, I think we should maybe start injections or boot you and so on. Like everybody's looking below the knee which I think is a huge critical mistake if you want to stop this thing from returning all the time. So, if you want some simple suggestions for this, normally the first thing is you get assessed.

Have someone look at joints above and below, look at their range of motion. If you've done it on your own, you see that, you know, I know that the big past history is this one hip is always tight and stiff and it must be, it's probably a part of it somehow. If you've had past low back issues and your back is always stiff in the morning too, that could be part of it too. Or you can look at an overall theme of things like an overall missing part that is very easy to identify. You can take a hard look in the mirror and ask yourself, do you actually resistance train? Like, do you do it hard? Like, are you actually doing it twice a week?

If not, then you probably aren't doing enough anyways. Like, you could just start incorporating machine work. I know I talked about single leg mechanics, but you could just do some basics. Some squats, some hip hinges, some hip thrusts, you know, whatever it may be. Like, even doing just simple band work can be helpful in the early stages when people aren't doing anything. That is one part. If you're not stretching, the area that's stiff may be stretching a little bit. But if you're looking for an exact solution or a cheat code to this, a lot of times having the trained professional look at it and suggesting what to do is very valuable.

I tell you, again, from my personal experience, I have managed my own conditions. I know a lot of the parts. I feel like I know 90% of what I need to know to help a lot of people, including myself. But I would be lying to you if I said that I did all the things well when I managed my own case. Because I'm worried about the condition, I make excuses, I find other things to do. Because a lot of times the things that are missing in people when they have these ongoing problems is they're not doing things because they don't want to and they don't like them. So I don't want to stretch, so I won't. And so this process is going to keep going.

If anything in today's episode resonated with you, visit the link in your podcast player. There you'll find any free resource that we mentioned in the show, any guest links, and a link for a free discovery call with us. We're licensed to work with our outdoor active people via telehealth across many states in the U.S. at this point. In fact, we cover almost half of the population in the U.S. and we add more states every year. Thanks for listening. Subscribe to the show and we'll see you in the next one.