Does Dr. Mark Cucuzzella, 43, ever have time to sleep, take it easy, relax? He’s a highly accomplished marathoner (2:24 PR), race director, family physician, Associate Professor at West Virginia University School of Medicine, Lieutenant Colonel in the Air Force Reserves, and owner of Two Rivers Treads, a Center for Natural Running and Walking, in Sheperdstown, West Virginia. The store opened last May and is the nation’s first retail outlet (it also sells online) aimed specifically for the minimalist and barefoot-running shoe crowd, featuring Newton, Terra Plana, Inov-8, Kigo, Sockwa, as well as low-profile models from Saucony, New Balance, and Brooks. The store also carries healthy, functional children’s shoes from Terra Plana Vivo kids. Cucuzzella is passionate about many things—but getting injured runners back on their feet is right at the top of his list. To this end, he is one of the main guiding forces of a new state-of- the-art running conference, to be held on January 28-30, and which will offer talks and workshops on running injury prevention, gait mechanics, and rehabilitation. For more info on “New Trends in the Prevention of Running Injuries," go here. While Mark clocked 2:34 in the 2010 Boston Marathon at age 43, he used to be an injured runner. How he got to where he is now—pain-free and a true pioneer in the natural running movement—is the subject of the following personal essay that Mark wrote for Zero Drop.
So why would a Family Doctor be researching running injuries, experimenting with all types of running techniques and shoe designs, and even open a store selling only flat shoes in his free time? The answer is a quest to run completely pain free and with effortless efficient function with big toes that do not bend and in the more challenging mission to share the hard lessons learned to others wanting to keep moving for life.
I have been a runner since age 13 and ran competitively at University of Virginia in the mid-1980s. As an often-injured runner, my interest in medicine was sparked after experiencing our team physician Dr. Daniel Kulund of Charlottesville tried some bizarre at the time and innovative approaches to running injuries. He was the first to have people run in the pool for training and rehab and had a deep hot tub size pool in his office with a tether. He gave elite and recreational runners rebirth by his methods. Runners train in water now not just as injury rehab, but for prevention and supplemental training. Twenty years into my medical career, I am reviving the passion I felt at that time by working with innovators in running technique, functional strength, safer aerobic conditioning, and footwear design.
Dr. George Sheehan was another individual whose ideas were also way ahead of his time. I read “Running and Being” in high school and did not really understand what he was talking …but now I do. Holism, prevention, understanding movement and the root causes of injury-- these are the basis of running pain free for life. Here’s one of my favorite passages in something that he wrote in 1975: “If athletes were given less care and more thought, the doctors might come up with some original ideas on why illness persists, why injury doesn’t clear up. If more non-physicians could be induced to lend their ideas and talents, we might see a completely new approach to sports medicine.”
One modern innovator applying these innovative and integrated principles is Jay Dicharry at The University of Virginia Speed Clinic. His inquisitiveness and pursuit of new methods gave me the opportunity to present ChiRunning research at the 2008 and 2009 UVA Running Medicine Conference and our community running event Freedom’s Run as a model for community engagement at that conference. Jay connects form, function, performance, and injury prevention and empowers those he sees with insight, cues, and detailed instruction to self correction. He is producing the needed research and evidence to prove the principles embodied by “natural running.”
We live in a sports medicine world now where running injuries are still treated with rest, ice, new and bulkier shoes, stretching, MRI’s, other fancy tests, and various devices. Despite all this care, of which there is little to no evidence base, runners are still getting injured at the same high rates. Runners are becoming former runners not by choice, but out of suggestion from the health care field as the answer to their body’s discomforts.
I’ve been through the pain cycles in my younger years. Frequently hurt, I managed sub- 2:25 marathons with the usual busy school and job commitments of a physician. I then discovered in 2000 after years of progressive pain in my feet that severe arthritis had engulfed both my large toe joints. The technical term is hallux rigidus and causes are many including: pushing off too hard on a dorsiflexed first toe repetitively, running and walking in shoes with a heel placing unnatural forces on the toe joints, and other genetic and/or biomechanical deficits. Women suffer damaging arthritis in this joint four to five times the rate of men. One reason might be elevating the heel and placing unnatural forces to this joint as they walk and stand all day in ill-fitting shoes or high heels.
I decided to have bone resections for the arthritis changes in both great toe MTP joints (joint where toe attaches to foot). I could not dorsiflex (bend up) either great toe MTP joints due to the degenerative changes. The surgery relieved some of the pain but the joint was still essentially fused straight. I thought my days of running pain-free were done; this was the orthopedic message. Perhaps take up another activity? None were as convenient and relaxing as running.
After taking a few post-operative months off in early 2000, I was set on trying to retool how I ran with only one goal- getting out and enjoying myself. I lived off a wooded park in Denver where everyone ran, Washington Park. It had a forgiving crush-rock surface and 2.5 mile loop which one never tires of.
I also studied what was written on running methods and became particularly interested in common-sense concepts for impact reduction and optimizing forces and momentum. Common themes were shorter stride and quicker cadence, not overstriding and braking, a slight forward lean, and landing more midfoot under one’s center of mass. I also tried to figure out how the Kenyans ran; they had no shoes so had to have low impact styles. I trained “easy” by the method made popular by Phil Maffetone and used by running great Priscilla Welch and six-time Hawaii Ironman winner Mark Allen. I also incorporated a full understanding of the Lydiard method.
These methods focused on becoming completely efficient at one’s pure aerobic heart rate. This is the level where fat utilization is the primary fuel source. It builds the aerobic system to its maximal potential. The runner becomes efficient in form and metabolism, building millions of capillary beds and the mitochondria to produce aerobic energy at a set low heart rate. With weeks of practice and patience, the pace drops with the same low heart rate. The runner morphs from a pure gas car (glucose as fuel) to an efficient hybrid, using electric (fat) as primary fuel and turning on the gas when you need it.
Surprisingly by adhering to this “easy” running approach and further study of some improved technique I rebounded to run a 2:28 at 2000 Marine Corps Marathon after only four months back to running and no more than 60 miles per week. I also recovered easier than ever before.
I could visualize the “land with bent knees” and “under center of mass” that these methods were describing. I understood what not to do…do not land on the heels, but did not really get what to do. What areas did one focus on to generate movement? How could I explain this simply to a patient or runner?
At the time, I coached Team in Training in Denver and was a regional doctor there. I shared these principles of low-impact and aerobic-only training with a running group that often became hurt unless guided correctly.
I continued to have successful marathons but still had occasional breakdowns in later miles. I then ran a 2:39 at the 2005 Marine Corps which was not really satisfying, but figured I was getting older and busier with life (kids now).
In December 2005 there was an article in the Sunday Washington Post on ChiRunning and its creator Danny Dreyer. The short piece was intriguing and led me to buy his book. After the first read and a little practice, I realized what I was missing in trying to find and teach efficient injury free running- draw the power from the core and “lift the legs” while off loading the feet. This was a method I could visualize completely. But more importantly as a physician I knew this was a teachable method for the masses of recreational runners who were often injured, trying to run more comfortably, or afraid to or told not to run anymore.
I also studied foot anatomy as related to stance and gait. When a heel is elevated the arch of the foot destabilizes and a domino effect of compensations occur. When a heel is elevated the large toe cannot stabilize the arch in the designed way and the fifth metatarsal, another key stability structure, is lifted off the ground.
Through application of these principles, I have continued to run marathons in under 2:35. I finished 2:34 in the 2010 Boston Marathon to make it 22 of last 24 years with a time under this mark (missed during my medical intern year and in 2009 when I ran 2:37). In my fortieth year, I won the Air Force Marathon outright in 2:31, have won two Master’s Division Marine Corps Marathon, and three successful 50 milers at the highly competitive JFK 50 Mile Run (sixteenth place in 2007 and eleventh place and first Master in 2008, and twenty-first place in 2010). I could not imagine lining up for the ultra distances without the secret weapon of ChiRunning in the tool kit. I am running now in a magical feeling by putting my foot down, leaning slightly in controlled fall, and just picking my foot off the ground. No stress, bending, or pain in the large toe joint.
As a physician seeking to find new innovative ways to treat injury, the ChiRunning method cried out for study. The first step was surveying the users for results and comments. In late 2007 Danny Dreyer sent 25,000 email surveys that netted a ten percent response. This is good in the world of survey research. The results showed dramatic decreases injury and effort, and a quick learning curve. The part which really convinced me to continue to validate this method was the over 1,000 comments, many of which were nothing short of life changing testimonials to ChiRunning. We followed this with a small prospective pilot study in 2008 and even in a small group with a brief intervention found that folks can learn form and reduce effort. My wife is a researcher and she told me once that “the plural of anecdote is not fact." So we are continuing to pursue studies for more proof of principle.
Now that I’d discovered better movement and trying to answer if others could do the same, the natural evolution was the intriguing question of whether footwear matters. At the time I was running for Brooks and had great conversations with a designer Trip Allen. Trip also believed that shoes with heels were an impediment to better mechanics and had prototype designs with no heel lift. He advised me to cut off the heel part of my Brooks Burn – his original design had no heel lift. This shoe felt great and I completed marathons and two JFK 50 Mile runs in the shoe with the hack-sawed heel. Jay Dicharry encouraged the use of a rigid turf toe plate under the large toe joint for protection. This helped the toe but I lost some of the natural feel for the road and trail.
Newton Running Company was born in 2007 and their concepts seemed right in line with what I was learning. They had no other agenda than to teach good form and provide footwear that promoted natural running. I contacted the company in 2009 to see if I could help this mission from the education and medical side and to try with the shoes. As I was already running in pretty flat homemade variety shoes the transition was easy and I could immediately see the complementary benefits to natural form. The outsole and midsole design allowed beautiful relaxed elastic recoil if one relaxed their lower legs- the method taught by Newton and Chi. The taper from 21mm in the forefoot also allowed a gentle rocker effect on takeoff where my big toe would be completely unstressed. In a week I threw away the turf toe plates and was rediscovering my barefoot feel over rough unnatural and natural surfaces. Land flat, lean, lift, relax, and breathe. The unique midsole design also taught me imbalances through the wear patterns and I could self correct. Since it is not made with EVA foam, the midsole materials kept the same properties through 1000 miles, so the older shoes became like old friends.
In two years, I have made fun new discoveries as had Newton running in how we teach movement and feel things ourselves. My new retail store in a small West Virginia town sells only shoes that are flat. Not surprisingly after some education and trying shoes for a test jog, runners feel the difference immediately. There are important principles of mechanics and gait that are affected by elevating the heel as most traditional shoes do. This sets up abnormal torque forces up the kinetic chain as well as shifts the body center of mass forward away from the critical site in the foot meant to bear weight. We have a large body of literature on ourstore website.
The beauty of focusing on form is that we all continue to improve, sometimes in small steps and often in leaps. None of us are close to perfect. Form improvements and complementary footwear have given me running longevity, made it easier and painless, and has given me confidence to keep on running and running.
No pain, no gain should be a thing of the past. No pain, thank you-- that is the natural way.