Which comes first….

There is an ever increasing attention being paid to the role of proximal issues in the development of lower limb injuries. This most recent publication from Medicine & Science in Sports & Exercise adds to this thinking-

Neuromotor Control of Gluteal Muscles in Runners with Achilles Tendinopathy
Smith, Melinda M.; Honeywill, Conor; Wyndow, Narelle; Crossley, Kay M.; Creaby, Mark W.
Medicine & Science in Sports & Exercise: 10 October 2013
Purpose: The purpose of this study was to compare the neuromotor control of the Gluteus Medius (GMED) and Gluteus Maximus (GMAX) muscles in runners with Achilles tendinopathy to that of healthy controls.

Results: The Achilles tendinopathy group demonstrated a delay in the activation of the GMED relative to heel strike (p < 0.001) and a shorter duration of activation (p < 0.001) compared to that of the Control group. GMED offset time relative to heel strike was not different between the groups (p = 0.063). For GMAX the Achilles tendinopathy group demonstrated a delay in its onset (p = 0.008), a shorter duration of activation (p = 0.002), and earlier offset (p < 0.001) compared to the Control group.
Conclusion: This study provides preliminary evidence of altered neuromotor control of the GMED and GMAX muscles in male runners with Achilles tendinopathy. This study highlights the importance of considering neuromotor control of the gluteal muscles in the assessment and management of patients with Achilles tendinopathy.

Essentially what these authors found was that the in the group with the achilles tendinopathy that:

Gluteus Medius had a delay in onset; shorter duration of activity; but offset was the same as the control group.
Gluteus Maximus had a delay in onset; shorter duration of activity; and an earlier offset than the control group.

It is impossible to know which came first, the weakness in the gluts or the Achilles issues.

It may be the presence of the symptoms of the Achilles tendinopathy altered the gait and caused the findings with the gluteal muscles or is it gluteal muscles causes a gait problem that this was the risk factor and helped increase the load in the achilles tendon, creating the overload or the structure.

Ultimately it may be the pattern of running technique and weakness/timing in the gluts causes the overload the Achilles, leading to pain and the issues become self cycling and the pattern is not broken with out a change of running pattern and gluts control/timing.

Proximal control and pattern is where we should be concentrating as well as locally at the Achilles.