Why Does My Foot Hurt Take Two….Can A Runner Relearn How To Run With 2 Fused First Toe Joints?

The 2009 book “Born to Run” fascinated thousands of readers as author Christopher McDougal tried to answer the question of why his foot hurt.  His discovery and recovery started with learning better running mechanics and was completed with his mission to the Copper Canyon to experience the Tarahumara. Along the way he concluded the modern running shoe designed with thick elevated heels was not the savior of the epidemic of running injuries, and in fact may be contributing.  Current scientific research and the personal healing experiences of legions of runners doing Chi Running and running in shoes without heel elevation (and some even barefoot) is adding layers to the hard evidence and conceptual evidence both needed to change our running training and shoe design culture.

Now why would a Family Doctor be researching running injuries and experimenting with all types of running techniques and shoe designs in his free time?  The answer lies is my quest to run completely pain free and with effortness efficient function with big toes that do not bend and in the more challenging quest 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 80’s.  As an often injured runner, my interest in medicine was sparked after experiencing our team physician Dr. Danial Kulund of Charlottesville try some seemingly bazaar at the time and innovative approaches to running injuries.  He was the first to have people run in the pool and built softer lightweight orthotics in his toaster oven. It seemed like there must be better ways to treat these maladies and Dr. Kulund blazed his own path.  Dr. Kulund was one of the first to encourage water running 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. 20 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 foot wear design.

Dr. George Sheehan was another pioneer and his ideas were also way ahead of his time. I read  “Running and Being” in high school and did not really understand a lot of what he was talking about then…but now I do.  Holism, prevention, understanding movement and the root causes of injury- that is the holy grail of running pain free for life.

“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.”
Dr. George Sheehan 1975

A 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 the 2010 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 to prove the principles that “Natural Running” speaks of.

We live in a sportsmedicine world now where running injuries are still treated with rest, ice, new and bulkier shoes, stretching, MRI’s, other fancy tests, and various other devices.  Despite all this care, of which there is little to no evidence base, we 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 too in younger years. Frequently hurt, I managed sub 2:25  marathons with the usual busy school and job commitments of a physician.  I 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 4 to 5 times the rate of men.  One can reason that a large contributor may be elevating the heel and placing unnatural forces to this joint as we walk and stand all day.

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 crush surface 2.5 mile loop which one never tires of.

I studied what was written on running methods and found the some concepts made sense 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 Priscilla Welch and Mark Allen.  I incorporated a full understanding of the Lydiard method also.

This methods focus 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 patience the pace drops and 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 off this “easy” running and study of some technique I rebounded to run a 2:28 at 2000 Marine Corps Marathon after only 4 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 the 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?

I coached Team in Training in Denver and was the regional doc there. I shared these principles of low impact and aerobic only training with a group that often became hurt unless guided correctly.

I continued to have successful marathons but still had occasional breakdowns in later miles.  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.  The short article was intriguing and led me to buy the 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 physican 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.

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 5th 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. 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 40th year I won the Air Force Marathon outright in 2:31, have won 2 Master’s Division Marine Corps Marathon, and  3 successful 50 milers at the highly competitive JFK 50 Mile Run (16th place in 2007 and 11th place and first Master in 2008, and 21st place in 2010).  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 Chi Running method cryed out for study.  The first step was surveying the users for results and comments.  In late 2007 Danny Dreyer sent 25,000 email surveys with a 10% 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 1000 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 “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 2 JFK 50 Mile runs in the shoe with the hack sawed heel.  Jay Dicharry encourage 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 complimentary footwear.  Shoes without heels were not side curiosity projects.  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 EVA foam, the midsole materials kept the same properties through 1000 miles, so the older shoes became like old friends.

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. We dream of one day running on water. Form improvements and complementary footwear have given me running longevity, made it easier and painless, and has given me confidence I can run forever into the retirement home.

A concluding statement from the Exercise Physiology gurus at the Science of Sport (HTTP://WWW.SPORTSSCIENTISTS.COM/2010_03_01_ARCHIVE.HTML)  ties all this together.  On making the observation that “natural” running form may now indeed be landing on the heels, perhaps by the influence of soft cushioned heels, they state:

“…..I believe the natural way to run is the unadjusted one, but the best way to run is the modified natural form. And of course, equipment will influence this.”

“Natural Running” is applied physics and biomechanics that you can apply to your benefit.  No pain…no gain- a thing of the past.  No pain….thank you- the natural way.

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One Response to Why Does My Foot Hurt Take Two….Can A Runner Relearn How To Run With 2 Fused First Toe Joints?

  1. Kent Kurfman says:

    Hi Mark,

    Great to see how you’re coming along with your training and your study of Chi Running. I was at UVa for the running conference in 2008, heard your presentation there (and think that we may have sat at the same table for lunch that first day). Good fortune with the running store!

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