*This talk was presented at the 2015 American Medical Athletic Association  Annual Boston Marathon Sports Medicine Symposium by:

Mark Cucuzzella MD, Professor West Virginia University School of Medicine

How to Run the Boston Marathon 2015

April 20 will be my twenty-first running of the Boston Marathon and 15th consecutive.  My only misses since 1989 were for military duties and a foot surgery. In all these races, I have 5 finishes under 2:30, 6 between 2:30 and 2:35; 3 between 2:35 and 2:40; 4 between 2:40-2:44; and 2 under 2:50. I have one DNF in my first one in 1989 with all the rookie mistakes. The average time of the 19 finishes is 2:36.  Along the way I have also compiled 21 Marine Corps starts and finishes with an average of 2:38 with a current string of 15.

Looking back at these marathons has given me a  new perspective on running. In today’s culture there is a trend and emphasis on high-intensity training as the path to success.  I agree that for immediate performance this is true, but the jury is out if we are talking about long-term health and balance if one has a busy life. There are also lots of folks who read stuff, write stuff, make claims as to what is true based on short term results, but do not actually run or are former runners.

The late Dr. George Sheehan often wrote “we are all an experiment of one”.  This is true, but I think one must understand the principles of overall health and how to treat your body to keep the experiment going.  Since my foot surgeries in 2000, I have not done any training which would be considered “hard” or “anaerobic” by modern extreme fitness zealots. Most proponents of “pain is gain” cannot produce this type of sustainable performance data in themselves or any of their clients or athletes.  I have not missed a Boston or Marine Corps since 2000 (and have not had running related injury since then either) and despite some years of extreme weather at these races the times are all consistent with the gentle physiologic age related decline.

Here is a photo of my first Marine Corps Marathon in 1988.  I was in my first year of medical school and had taken the summer off of running after four years of college running and the toll it had taken on my body.  I also lived in LA that summer and tried to run one day and the air so bad my lungs actually hurt.

MCM 88I quickly put on 20 pounds as I did not change my diet from the “runners diet” of low fat and high carbs (notice a bit bulkier body).  On return to medical school I again found the joy in running for stress relief and to allow me to concentrate better in studies. Two weeks before the race I joined a friend for a long run and ended up running about 16 miles.  He convinced me to line up with him in D.C, two weeks later where I finished in 2:34 in my minimal Nike Duelists.  I was hooked.

Unfortunately I wore these same shoes in Boston the following spring to fly down the hills in the first half of the race (1:08 split) but my quads were mashed potatoes by Boston College.  So took the T home for one of only two marathon DNFs. Learned that lesson!  (the other DNF  in NYC in 1991 when I lined up with severe plantar fasciitis).  I wore an old Florida Track Club singlet given to me by my Loyola High School Phil Kirby since I did not feel like I had returned to fitness as a  runner worthy of representing my University or the US Air Force.

MCM 90This next finish photo is two years later 1990 when I was chasing my first sub 2:30.  In those years, the Marine Corps Race finished on top of Iwo Jima and my sub 2:30 evaporated with the Hains Point winds (miles 20-23 used to be there) and the steep last half mile climb and finished in 2:31.  I again felt like a runner and wore my college colors (University of Virginia) and even the painters cap with the bill flipped up in homage to Dick Beardsley who ran Alberto Salazar to the line at Boston a few years prior.

For a great read on the 1982 “Duel in the Sun” read this book excerpt from John Brant here  http://www.runnersworld.com/boston-marathon/duel-in-the-sun


So what is the “secret sauce” of long-term healthy running?

  • Run for joy
  • Recover
  • Do not run too hard; finish each run as if you could do it again
  • Keep “fast and agile” with short sprints and drills
  • Keep mobile, esp in the ankles and hips.
  • Keep your foundation strong–this is your foot.  Wear flat shoes shaped like your foot to stand, walk, run, and play.  Go barefoot as often as you can.
  • Learn the skill of running and keep trying to master this.  A tool like TrueForm motorless treadmill helps.
  • Do simple strength training with Kettle Bells and Burpees
  • Be your own body sensor and coach
  • Don’t sit
  • Eat real food
  • Do not put pain into your body
  • And pass it forward…we all continue to learn by teaching and sharing with others.




……………………..    Race-Day Strategies   ………………………….

As you enter the week prior to the race here are a few strategies to help you set your plan. The best analogy I can think of is this: if you have trained your body properly with the right mix of aerobic level training and some up tempo stuff in recent weeks, you have built your efficient hybrid engine ready to race the marathon.  Many of you have driven in a Prius and watched the subtle shifts between gas and electric on the dashboard.  You do not perceive these shifts. Your engines (muscles) run on a mixture of gas (sugars)  and electric (fats).  Utilizing gas or electric power depends on the effort.  This is why slow aerobic training is critical for marathon success, you build a massive electric (fat burning)  engine.

You are starting the race with one gallon in the gas tank- assuming you have eaten a nice meal the night before with a light breakfast top off. If you race in all gas mode, your engines will run about 1.5 hours at a strong pace….then you are out of gas. If your effort is mostly electric you can run for hours, but not as swiftly.

With the correct effort you (1) will use the proper fuel mix and you will be efficient for duration of your event and (2)  you can even do some topping off along the way.  Too hard early you will sabotage the day by not only depleting the gas but also shunting all blood flow to working muscles, thereby not allowing  the aid station top offs to assist.

Running  utilizes about 1kcal/Kg/Km. So for a lean marathoner of 80 kg you need about 3360 kcals (80kg x 42 km) to make it. The gas is the glucose utilizing pathway. Even fully carbo loaded, your stored liver glycogen (300-500kcal), muscle glycogen (1000-1500kcal),  and blood glucose (less than 20 kcal). Glucose is easy to access for ready energy but adds up to less than 2000kcal.  The fat utilizing pathway is the electric.  In marathons you must be in hybrid ode to make it.  Hybrid is where your energy (ATP) is coming from both fuel sources.  Conserving the gas and using electric early in the race is critical.

Many runners are in great “10k shape” (an all gas event), run their marathon in the all gas mode….and crash.  Glycogen sparing strategy need not apply in races of less than an hour as long as you had a good pre-event meal to fill the tank. In marathons and ultras, top end anaerobic fitness matters little and can only be applied very near the finish. Glucose gives 36 ATP per molecule with a limited supply, fat 200-400 ATP per molecule and an unlimited supply.  You must tap into the fat burning tank. Now you know how a bird can migrate 7000 miles without an aid station.  It’s all about the pace.

Another key to teaching your body how to burn fat and to maximize aerobic development is to not eat before or during your long runs. If you are reading  this for the first time before this week’s race then apply to your next marathon.  Your body adapts to exposures and if sugar is constantly accessible it will not learn how to burn fat.  You also want to convert your fast twitch fibers to make them as “red” (oxidative) as possible.  Easy and moderate effort long runs of 2 hours in a fasted state will drain the slow twitch fibers (“red” fibers) of glycogen and force more capillarization of the fast twitch (mix “white”/”red”)  fibers, making them more “red”. You are doing speed work by running slow with this method, making the powerful fast twitch fibers aerobic.  Distance runners in events from 800 meters to marathons  through generations have al trained this way.  This is part of the Lydiard method and validated by the life work of Dr. Stephen Siler. Only recently have we been convinced we need lots of sugar before and during long runs.  Race day is different as you are going for performance, not creating adaptations.  More on this later.

So how do you know you are running in your best hybrid mode?

This is difficult because the body sense at this level (Aerobic Threshold) is not as profound as Lactate Threshold (or Anaerobic Threshold).  A slight increase from your optimal pace will switch you from hybrid to all gas without you realizing it. The effects are felt miles later. Charging  and surging early will tap your gas quickly.  If you want to speed up early….DON’T. Relax and maintain comfortable effort, not always a specific speed.  You should feel easy in the early stages, it is a marathon.

You must rehearse in training.  I focus on relaxation and belly breathing.  If I’m breathing one cycle to 5 steps, then I’m hybrid.  If  breathing  faster, I’m using mostly glucose as fuel.  Belly breathe- allow lower belly to blow up like a beach ball on inhalation as your powerful diaphragm contracts.  You will fill the lower lung areas where oxygen exchange occurs. Notice the breathing efforts of those around you. Many are rapid breathing. They will suffer somewhere past half way.  Practice nasal breathing, it forces belly breathing and prevents you from running in too high a gear.  Nasal breathing also allows CO2 to rise naturally to assist in offloading the oxygen to the tissues.  Blowing off CO2 binds the oxygen to the hemoglobin, inhibiting offload to the tissues. Rehearse complete relaxation from the top down- eyes, jaw, shoulders.  Allow your legs to relax and extend behind you. Your core is solid and your legs are the springs. Find you own cue for this.  If you use a Heart Rate Monitor in training strongly consider one during the event.

In a marathon, the last 3-4 miles you will be mostly gas to maintain the same speed as fatigue sets in and heart rate rises.  The breathing is usually on a 3 to 4 steps per breath cycle- that is OK.  Still stay relaxed and use the cues that you have rehearsed to keep your form.

Land softly, especially on the early downhills.  Focus on good form. I run with a midfoot landing harnessing elastic recoil. Gently landing on and rolling  from the heel can work too. Do not overstride with fully extended leg. Focus on posture and hip extension. Your trunk will lean forward slightly…..think “face forward” and look ahead. Run over the ground not into the ground.  I’m never sore after marathons now

. With good form it is “No pain…thank you”. Find a nice rhythm. Races are filled with excitement and distractions.  For you there are no distractions, just peace in the moment.  You get it now- the art of a marathon is to relax and be in the moment.

Your shoes matter too.  Make strong consideration to not running in minimalist racers unless you have trained substantially in them and adapted your structure to less foot support and a natural style gait. I advocate gradually adapting all of your training into more minimal and level shoes.   If you relax your lower legs and load the springy tendons in your feet and lower legs, these shoes with no heel elevation put you in perfect position to allow natural elastic recoil of plantar fascia, Achilles and lower leg tendons, and hip flexors.  New research and runner’s experience is now making the case for running with a focus on form and questions modern running footwear. The evolving world of modern sports medicine is going back to the future too and rediscovering what evolution has taught us.  For more on footwear visit Dr. Mark’s Running School on upper right of home page of Two Rivers Treads ( http://www.tworiverstreads.com ).The recent ACSM guidelines are also a great read on footwear.

Have a course specific plan for your race. My best learning experiences were when the men and women started together and I had the privilege of running alongside and witnessing the patient approach and incredibly efficient running of the top ladies.

In the 1998  Fatuma Roba, the Marathon Gold Medalist in Atlanta and 3 time Boston winner, scooted over the ground with an incredibly efficient motion.  She hydroplaned along, hips extending, arms relaxed, and face always relaxed.  She stayed out of trouble by tucking behind the lead pack of more aggressive ladies.  I followed behind the train and we hit half way in about 1:13.  Fatuma then opened her stride up in the second half moving away from all of us to run a 2:23.  An amazing second half effort.  I was pleased with a 2:27 that day and credit Fatuma as any thoughts to go faster sooner were mitigated by her patience.

A few years later in 2001 I witnessed multiple world champion and Boston winner Catherine “the Great” Ndereba employ the same strategy.  Her light springy stride and complete relaxation of effort were a contrast to other ladies in the pack who’s body language and breathing displayed they were putting out more energy than Katherine.  As a group we hit the half in 1:14.  Katherine kept relaxed down the long downhill at mile 16 then tightened the screws with a huge acceleration over the Newton hills, running a 50 minute last 10 miles for a 2:24.  Catherine helped my day.  By cueing off her pacing and relaxation I ran an even race and finished in 2:29.

The other runner who taught me to have fun out there was the legendary 3 time Boston winner Uta Pippig of Germany.  In 1997 I ran with her until she dropped me at Cleveland Circle (mile 22).  The crowds loved Uta and the noise escalated as she approached.  She smiled the whole way.  Maybe this was her cue to relax, feed off the crowd’s energy, and have fun in the moment. In marathoning you must be present in the moment; not thinking about how far you have to go,  what you may feel like later, wondering if you are going to slow down, fearing  the wall is coming.  Uta ran a strong fourth place that day in 2:28 and I finished a few strides back in 2:29. She is an example of how our brains govern our effort….when we are positive it flows.

All of these ladies made sure to get their fluid and nutrition at all stops. The few extra seconds used here paid dividends down the road.  They ran over the road not into the road, especially on the downhills. One could hardly hear them land as they did not employ overstriding technique.  Their posture was tall and their arms always relaxed.  But most vital was their overall efficient energy conservation and utilization strategy.

Save energy for the later stages of the race, this is where things can get tough.  Remember, if you feel really good in the early stages and feel like you want to speed up….DON’T.  It is a marathon and you should feel good in the early miles.  Speed up only when you can “smell the barn”, this occurs when you see the Citgo sign (comes into view at Mile 23). You can smell the barn. Remember, if you feel really good in the early stages and feel like you want to speed up….DON’T.  It is a marathon and you should feel good in the early miles.

Now a few extra ways to get from start to finish quicker on the same gallon.

  • Do not sabotage your event by having a large carbohydrate heavy breakfast the morning of the race.  This will increase your insulin levels and lock out the ability to burn fat.  Fill your glycogen stores by not running and eating adequate amounts of healthy carbohydrates the 3 days prior.  Do not overload, you can only store a specific amount.  A light breakfast of mix carb/fat/protein is a good thing as well as your morning coffee if you are a coffee drinker.
  • If you can add a little gas along the way then you can run more in gas mode.  This helps a little at best.  If running too fast or if temperature high you shunt blood to working muscles to work and skin to cool and diverts from the gut, so nothing digests. Plus you are burning quickly through the glucose/gas.  If you are in hybrid in the early going you can continually add some fuel. So the key is not only the correct fuel, but the right pace.  A Powergel every 30 minutes is easy to digest and tops off the tank.  Carry a few with you at the start.  The weight is nothing compared to the benefit you will get.  If you do the gels then you can drink water instead of the energy drinks which are often less predictable on the run. Boston has a gel station at Mile 17.  Carry 3 at the start (one every 4 miles or so) and reload at mile 17.
  • The early downhills out of Hopkinton are fun but if run too hard can drain your gas quickly and damage your quads….go smooth and easy down them. Allow gravity assist you down. Do not overstride and heel hit on the down hills- remember run over the ground not into the ground.
  • Maintain effort on uphills in Newton.  Your pace will slow. You can easily use all your gas here if your effort increases.  Shorten your stride, relax, and use your arms.  Relax and recover on the downs.  The best downhill is at the top of Heartbreak Hill at mile 21.  Save something and this will be like going down the first hill of the rollercoaster!
  • If you are having a “bad patch” – try to refocus on relaxing, fuel a bit (sometimes a blood glucose drop triggers the sense of doom), and have faith in your training and race plan.  Another nice trick is when you hit mile 21 it is not 5 miles to go, it is 4 and change. Mile 22 is 3 and change to go.  Just run to the next mile marker and count them down one by one. Smile and enjoy the crowds.
  •  If it is windy get behind a group.  This can save lots of physical and mental energy.
  • Do not over drink water. This can lead to a dangerous condition called hyponatremia.  See guidelines
  • If it is going to be hot read this article I wrote after the steamy 2012 Boston Marathon which was published in the American Medical Athletic Association Journal
  • A final tip from 4 time Olympic Trials qualifier Josh Cox who spoke with me before the Air Force Marathon a few years ago.  The night before the race make “the invisible man”.  Get everything you are going to wear/use the next day set up to put on in the morning.  Scrambling to find your number, socks, favorite hat, gels or other item adds stress.  Get the outfit laid out on the floor ready to wear, then get some sleep.

The fun of the marathon is that we are always learning and enjoying the adventure of it.  I’ve done over 100 marathons now with a couple under 2:25 in my younger years.  We learn from experience, taking chances, and occasional failures.  I’ve learned a few things in over 25 years on how to train and race efficiently and economically in the marathon, but still there are uncertainties every time you line up.  I learn something new every time. So relax, taper up, and seize the day.

I’d like to especially thank all the Armed Forces Members around the world who sacrifice daily in the service of their country and for all the volunteers who make the Boston Marathon a Patriot’s Day celebration.  Run a fearless race and may the wind be at your back .

Good luck to all AMAA Boston runners, their friends, and families.  See you for the post race beer.


See you at the start!                                                                                      Mark Cucuzzella MD