Two runners with hip, groin and Achilles pain: a nerve case study

You're listening to the Restoring Human Movement podcast, and now your host. Hi everyone, welcome to the Restoring Human Movement podcast. Thank you for joining the Movement Movement. This is your co-host, Dr. Mandy Riehl. I am all things running, so I treat ultra and trail athletes primarily, and any distance runner of any kind. I also am a distance runner, I also am an ultra runner, so everything in my professional life is centered around running, and I've learned a couple things over the years. Today we're going to be talking about two case studies that have similarities, and both of them had a secondary complaint of Achilles tendonitis.

So the similarities first, both patients are runners. One is a track specialist, usually 1500 and 5k, quite fast. Another one is a marathoner who is not an elite marathoner, but was good enough to qualify for Boston consistently over the years. That track specialist was younger, talking mid-20s. The marathoner was more like early 40s. And both runners actually came in for hip and groin pain. So they didn't really come in for their Achilles, but that was also going on, but their primary complaint was hip and groin pain. In both of these runners, we discovered that the hip and groin pain was a low back nerve-referred pain, and they responded to treatment quite quickly.

But here's where we diverge for one runner versus the other. First, we'll go over patient number one. We'll call her Mia. She's the track runner. So Mia does 1500s and 5ks. She's fast, but not pro. So she had Achilles pain that switched sides for years. So ever since she was, I think since she was running maybe senior year of high school, running track and cross country, and throughout NCAA running for track and cross country, she had this lingering Achilles thing that switched sides. And she found that consistently it was worse with speed work, especially sub-threshold work. So we're talking like 400-meter repeats at quick pace or strides, things like that.

And she also found that it was worse with wearing spikes. Now, her timeline for running actually put her as quite fast track runner before carbon-plated shoes came out, which for those of you who don't know, the whole thing now is fast shoes. So carbon-plated, carbon-fiber-plated shoes like the Nike Alpha Flies or Vapor Flies or Dragon Flies started coming out in the last five years or so. They make distance running faster because your energy return is better. And they do change some things about the biomechanics of the lower limbs, but it's such a performance enhancement that they don't really care, right?

We're going faster. Cool. Our goals are being met. So she had noticed that this getting worse with spikes phenomenon had been happening even before the carbon-plated shoes came out. So we kind of took that variable out for an exciting problem there. Throughout the years of her injuries with the Achilles, it really was impacting her training at peak season. So as the season was really started, she was getting a ton of mileage and then peak intensity training. And as she transitioned into more anaerobic work and that faster speed work, it would get worse and it would inhibit her from really maximizing her training, which especially if you're talking college and post-collegiate running, that is a big problem.

And it was bad enough that she actually elected to have surgery. She had the surgery. She was put in a boot for two, I think two months afterwards and then had no benefit, which every runner's nightmare, right? You go finally get surgery for the thing that's hurting. You're taken out of running for a while. You're put in a boot and then it doesn't help. Thankfully, after a year and a half of rehab, she got back to baseline of her usual Achilles pain and it, you know, was tolerable enough for her to start training again and started to improve her times. But the Achilles thing was still lingering.

When I saw her, again, we were doing hip and groin stuff that was ended up being low back referred, but she mentioned the Achilles thing and we got to the point where her hip and groin were feeling good enough that we checked out her Achilles. And when I examined it, it was actually there was a lump. So a Haglund's deformity where the attachment point of the Achilles on the heel was actually larger than normal. So the bone had grown larger due to the forces that were putting through the Achilles. A lot of people point to this as a problem. It's not always a problem. Sometimes it's just a sign of how you've been using your Achilles over the years.

But I assume that that was what everybody else was kind of treating and why it had no benefit. She didn't have any creakiness with her Achilles tendon. That's usually a sign of swelling in the tendon or the tendon sheath itself. Kind of sounds like an old wooden door and feels like it too. It's pretty weird. I've had it before. And she didn't have any like lump in the Achilles itself. There was no obvious swelling, never had any bruising. And as we started treating the groin and hip pain, once the groin and hip pain got, I'd say like 30% better, she came in and was like, my Achilles pain is better.

Like, interesting. Okay. And then a couple visits later, she was completely out of the hip and groin pain. And she was like accusing me of voodoo. She's like, the Achilles thing is gone. I don't know what you did, but I'm going to keep doing this stuff like that you taught me forever if the Achilles pops up again. Since then, she sent me a couple emails this recent track season that she set new PRs in the 1500. Again, she's been running for like, I don't know, 12 to 15 years at this point. She's mid-20s, right? And that her Achilles hasn't been bugging her even in spikes. So this was a big, big win for her.

But it was interesting, right? She had all of these years of Achilles pain. And again, it switched sides, but kind of settled on one side all these years. And it ended up being a low back referral. When we treated her groin, which was actually a low back referral, her Achilles got better, which is just so trippy to explain. But there's tons of reasons why. There's the old cliche, everything's connected. But in this case, the nerves are directly similar and come from the same place. So if you do have a problem in that nerve, in the spine, yes, it can refer to different areas of the body. Super cool case.

And then just a couple months later, I saw that second patient we're going to talk about. We'll call him Mike. Mike was a semi-serious marathoner. Again, like, good enough to qualify for Boston, was putting in 30 to 60 miles a week, depending on where he was in his training. Not good enough to go pro, but like, really enjoyed it. Daily runner, all that things. Mike also had low back-mediated groin pain. Very similar referral pattern to Mia. And with this, though, he hadn't mentioned the Achilles until much later. It was several visits in. And there wasn't a clear link between the groin-slash-back issue and the Achilles.

So when I looked at his Achilles, he actually had a lump on the side that it had settled on. It was similar in the sense that Mia's Achilles pain switched sides. Mike's did as well. It had settled on one side in the last couple years. There was actually a lump on the Achilles itself. So not a Haglund's deformity, where the bone where the Achilles attaches gets larger, but a little bit of a swelling lump on the Achilles itself. It didn't feel very hard. I assumed it was swelling. But that made my mind go, oh, maybe this is actually an Achilles tendon problem. Even with that, though, my gut was kind of thinking like, okay, he's had 10 years of Achilles tendonitis.

This is odd. Tendons don't usually last that long. So let's try some easier stuff first and see if that helps. Now, one of our go-to things for quick pain relief in certain circumstances is skin rolling or dermal traction. And it hurts like hell for most people when Sebastian or Dawne Costantino does it on me. My palms start sweating. It doesn't last very long. But it's similar to cupping in the sense of you're lifting the skin with the practitioner's hands. But you're lifting the skin in a specific area. And the theory is that it's separating all the layers like skin and muscle and fascia and nerve and just letting the nerve especially breathe a little bit and get blood flow into those tiny, tiny capillaries that provide blood flow to the nerve.

And again, it hurts like hell, but I skin rolled Mike's Achilles just above it, actually, like lower calf to the inside and outside and middle. Those are where those cutaneous nerves, the nerves that supply sensation to areas, start coming out towards the surface into where they're going to innervate the Achilles area. And again, it hurt. He was dying a little bit, but did that for a couple minutes and he retested his Achilles and he, again, accused me of voodoo. His pain got 90% better, which is a larger response than most people I see if I'm doing it for the first time. And it was interesting to me, too, because he did have that lump on his Achilles.

I had very rarely seen that before and it not be a true Achilles problem or wherever tendon, right? If you have a lump on a wrist tendon, that's usually a wrist tendon problem. But the fact that skin rolling helped and we didn't actually do anything to the tendon pointed away from it being true Achilles tendonitis. The next time I saw him, which was I think about three weeks later, we were progressing back into running because his groin and hip were doing well and he had mentioned he could run through the Achilles even if it didn't get better several visits prior to that. He was progressing back into running fairly quickly, actually, with no problem.

And when he came back in, he said that he did the skin rolling every day for about 10 days and it never came back. So I'll be interested to see he's a he's a patient I'm still seeing a little bit and I'll be interested to see if that sticks. But super cool case, especially with the lump there. My theory right now is that there was neurogenic swelling. Dr. Shacklock, Michael Shacklock, talks about this a little bit, but I hadn't seen it much in in the flesh. So super cool case and really easy, right? He had 10 years of Achilles pain and we pinched and lifted his skin for a couple minutes and it went away.

That's awesome. So a couple of takeaways here. The main thing is that chronic Achilles tendonitis, which both of these runners had been diagnosed with, might not actually be tendonitis or tendinopathy, whatever you want to call it, may not actually be a tendon problem. Both of these cases were nerve mediated. So Mia had nerve irritation at the spinal nerve root that innervated both the hip groin area and down towards the Achilles and it was referring pain to both. And Mike had a nerve pain, so to speak, that was more towards the Achilles. So when we did his hip groin treatment that was low back mediated, his Achilles didn't immediately get better.

And then when we did some treatment at the cutaneous nerves down by his Achilles, so local nerve stuff, it did get better. So keep in mind, like nerve problems don't always feel like true sciatica where you're getting a straight line of discomfort down the back of your leg. Nerve problems can feel like anything. Nerves innervate every single feeling in your body. So nerve problems can be achy, it can be sharp, it can be burning, it can just feel like you're super sore. So for people who lift often, it's, hey, my quads are sore for the next five days and that's weird. Or for runners, it's like, hey, just my left glute is sore, but my right one isn't.

That's weird. But keep in mind, nerve problems can feel like anything and they can be really simple to treat if you know what you're looking for. So again, if any of you guys are looking for help or you've tried things for these chronic injuries and it doesn't work, you may need to look in different areas. So not a lot of people assess for nerve problems, but if you've been treating your Achilles tendonitis as Achilles tendonitis and it's not going anywhere and nobody's checked out on you, I think it's very, very useful to find somebody who can. Keep in mind, I am not somebody who podcasts professionally.

I am a doctor of chiropractic and a certified medical exercise specialist. If you need help, either in person or virtually, reach out to us. Our email is in the description and there may be some really, really easy tools that keeps you running pain-free. Check out our other podcasts. We have a ton. Until next time.