Going the Distance


26.2 miles take a toll on the body

Hector Cruz refused to quit. Hector Cruz refused to quit.
By Elizabeth Cooney
Globe Correspondent / April 19, 2010

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Today’s the day. For many of the nearly 27,000 runners in the 114th Boston Marathon, simply getting to the starting line is an accomplishment. Crossing the finish line will be monumental — and, for some, painful.

Just ask Hector Cruz. Last year he had to stop at mile 17, hobbled by hammerlocking cramps that seemed to travel from one calf to the other. A half-hour of massage in the medical tent near the Newton fire station didn’t help, so the medics suggested he accept a ride to the finish line.

Cruz, running his first marathon at age 46, would have none of it. “That was not my nature,’’ he said.

After 15 more minutes, he was able to walk, and at mile 23, he began running again. Long past his projected time, he set a new goal of crossing the finish line in under six hours.

“My determination just pushed me to the end,’’ he said. “And I finished in six hours and one second.’’

Cramps like Cruz’s are just one of the calamities small or large that can befall a marathon runner. Months of preparation can bring amateur and professional athletes alike to a peak of fitness, but training can also take a toll on muscles and minds — after several hundred miles of training, about 30 percent of runners already have weathered injuries, many from overuse. Cap that with 26.2 miles of leave-it-all-out-there exertion — or so runners hope — and the next job is recovery.

There’s a reason that, for all but elite runners, weekly long training runs build up to around 20 miles over the course of four months and then ease off for the last few weeks. The regimens typically don’t include the actual race length.

“Justifiably so,’’ said physical therapist J. Alex McKinney of Marathon Physical Therapy and Sports Medicine in Norton. “You break down so much. If they ran 26 miles before the race, it would take them too long to recover.’’

What breaks down is muscle tissue in the legs. Running for long distances creates “microtears’’ in the muscles. And past about 20 miles, all the energy from glycogen stored in muscle has been converted. If the glycogen has not been replenished by high-carb feeds along the way, muscles will shut down. Heat makes matters worse, as the body works harder to cool itself.

The nature of the Boston course, which overall is modestly downhill despite its well-known Newton hills, can worsen the physical toll. Instead of the body absorbing three to five times its weight with every foot strike on level ground, the impact goes up to five to seven times body weight when running downhill.

Runners get in trouble if they start out too fast. As the road dips down from the start in Hopkinton, “you feel great,’’ McKinney said. “However, your muscles need to absorb more of the impact.’’

Although injuries are more likely to crop up during training, some do occur on race day, said Dr. Pierre d’Hemecourt, director of primary care sports medicine at Children’s Hospital Boston and co-medical director of the Boston Marathon. Runner’s knee and tendinitis can flare up. He’s even seen a few cases of stress fractures — tiny fissures in bone — turning into full breaks during the race.

About 2 to 3 percent of runners end up in the MASH-like medical tent in an average year, so that would mean about 500 to 800 out of this year’s field of some 27,000. On hot and humid days, that number swells to 10 percent because of dehydration and overheating. Not drinking enough fluids to replace what is lost through sweat can send body temperatures soaring as high as 102 degrees, d’Hemecourt said. Hyponatremia, or a fluid imbalance from drinking too much water, can also be a problem on hot days, especially for runners out on the road for more than four hours.

The most alarming medical emergency is sudden cardiac death, striking about 1 in 50,000 runners. “We always worry about that. People run with cardiovascular risk factors they may not be aware of,’’ d’Hemecourt said.

The International Marathon Medical Directors Association recently issued recommendations for runners to avoid a heart attack on race day. Some research has shown that endurance events like marathons cause the body to release enzymes that can then lead to more blood clots and potential blockages in the arteries leading to the heart. The result is a heart attack. The guidelines say runners should take one baby aspirin (81 mg) the morning of the race unless they have a medical reason not to; drink no more than one cup of coffee; and consume salt in drinks, gels, or food during the race.

Far more common in the medical tent are blisters and damaged toenails. Friction is the culprit in both cases, from the foot sliding in the shoe or banging against the front of the shoe, said Dr. John Giurini, chief of podiatry at Beth Israel Deaconess Medical Center. Losing a toenail “is almost an occupational hazard for runners,’’ he said.

Once it’s all over this afternoon, the recovery begins. Professional runners, who may have been clocking 120-plus miles a week, are not immune from the after-effects of a marathon, newbies may be pleased to know. Khalid Khannouchi, who won the first marathon (Chicago) he entered and has set world marathon records, says he’s no different.

“You have a lot of damaged muscles so you feel sore for two or three days,’’ he said by phone from Mexico, where he was training, but not for Boston. “Everyone feels the same way, if they finish in two hours or six.’’

Immediately after the race, runners should reload protein and carbohydrates, even if they don’t feel hungry, and then return to a normal diet, according to Michael Pieroni, head coach of the Boston Athletic Association.

Recovery means taking a rest from strenuous running for a week or two, Khannouchi said, with stretching or light jogging starting sooner. Co-medical director d’Hemecourt said that if runners have a lot of muscle pain, they should cross train before resuming running, maybe on a bicycle to let damaged muscles repair their microtrauma. “It takes a big toll on the body.’’

And on the mind, says Jeff Brown, author of the new book “The Winner’s Brain’’ and a sports psychologist affiliated with McLean Hospital. “Every runner out there knows that this is a mental performance as well as a physical performance.’’

When Brown first began working in the Marathon medical tent, his job was to spot the mental confusion that can signal dehydration or hyponatremia. He has since found that injured athletes may need help processing their disappointment, whether they were chasing a certain time or just completion in honor of a lost loved one. “I tell them, ‘This is not the single defining performance you have.’ ’’

For Hector Cruz, who feels better prepared this year, his plan today was to enjoy the race. “Just soak it up,’’ he said, remembering the crowd support last year. “The people out there are unbelievable, still out there [after] five hours. Not as deep, but they were still cheering those of us that were struggling.’’

Elizabeth Cooney can be reached at