Going Toe to Toe With Peripheral Arterial Disease (PAD)

Rebecca taught me how to wake up my toes, and now it’s paying big dividends for my calf pain.

Some of my blood vessels are too big (abdominal aortic aneurysm, AAA) and some too small (peripheral arterial disease, PAD). Just wish they could get together, and work this thing out. These vascular events are due to the genetic cards I was dealt (no complaints), which included severe dyslipidemia (Loads of fat in my blood). I managed to continue Ironman training with the AAA, but PAD turned out to be tougher. It kills my run, due to calf muscles locking up (claudication) and numb feet within a few hundred yards of fast running. But I need to continue Ironman training, as it clearly extends my life, and I love not being dead for as long as possible. Life is just too much fun.

So I study the problem, which is basically a plumbing problem. In fact, most biological challenges we face turn out to be plumbing problems. Trust me! I’m a pathologist. Pathology is the study of the nature of disease, and both AAA and PAD are genetically-related progressive plumbing diseases.

My approach to the delights of overcoming peripheral arterial disease, include, so far:

(1) Optimizing a low impact stress running style, (2) Steady conditioning using regular hill repeats, because weak muscles are tight muscles, and tight muscles don’t perfuse well, (3) Running with my whole body, to take the load off my legs, for which water running helps a lot, and (4) Wearing minimalist shoes that allow my feet to talk to the road, which create their own problems due to severe foot load issues (answer? conditioning).


While run/walking the other day, on encountering a hill, my calf started to lock up as usual, and I thought, “There must be a way to help the blood flow through those calf muscles, and through my feet”

Then I vaguely remembered the role of muscle contraction in venous return. It works because veins have valves. My thinking went like the picture below:

Pretty crude image (purchased with copyright from ShutterStock), but it gets the message across.

But are there any data to support this idea? Later, I went off to PubMed, and I found just the thing. A study in rats that explored the role of muscle contraction in venous return (blood flowing back to the heart). This would encourage arterial flow into the muscle. For calf muscles, as for a cup of tea, you have to empty the teacup before you can put more tea in it (Old Zen story).

The article I found on PubMed is entitled, “Effects of muscle contraction on skeletal muscle blood flow: when is there a muscle pump?” What’s good enough for rats, is good enough for me, as we only separated, evolutionarily, about 80 million years ago, just the blink of an eye in geological time. The conclusion of the article, was, “The muscle pump contributes to the initial increase in blood flow at exercise onset and to maintenance of blood flow during exercise.”

Anyway, I was on a hill, not in PubMed, and it turns out they got that right. I played with developing muscle pumping in my calf, while maintaining a low impact style. I did this by gently flexing my toes (think picking up a towel on the floor with your toes). I focused on the toes that were linked to the painful calf muscle. I just reached down, flexed my toes, and found the ones that worked best. Then, back to hell running. Did I say hell running. Sorry, I meant hill running. Freudian slip!

And it really worked. I got up that hill without having to stop and refill my calf muscles with blood (which hurts like hell, normally, but not with toe flexion pumping!) Research began. I tested contraction strength. Gently stroking the ground with each stride worked best. I then tested contraction frequency, for clearing calf claudication at rest, where slow steady contractions worked best, reducing the refill pain significantly.

A few days later, I went on a 10-mile training walk, which usually involves my having to stop for calf refill on most of the hills. No need, as long as I kept up those gentle toe flexions going, as I walked the hills. Why walking for Ironman training? Two reasons, (a) to toughen my feet, for long distance run/walking in minimalist shoes (Nike Frees), and (b) you end up walking some of the run at my age, whatever you do, so you’d better be a solid walker if you want to finish the race within the 17-hour time limit.

I’ll keep this site posted, as I explore toe flexion for PAD claudication. I bet there are other things I can do, too. Any ideas?

If it works, I use it. Arizona Ironman isn’t far away.

Never give up.

By the way, you can sign up for my weekly newsletter, if you so desire, at this link, and you’ll get a free ebook, if you want it.

Remember, “A life without risk, is no life at all.”

-kev aka FitOldDog

peripheral arterial disease
Grey is muscle, white is fat, clear ring around the central white spot (bone marrow) is the femoral bone. Note the loss of both muscle and bone mass in the sedentary guy.


  1. Robert Levin says

    Do you have any regret no being on statins?

    • Hi Robert, not at all. I tried them for two months, mild effect, then needed a higher dose. Then a colleague walked into my office, in Glaxo, and said, “Take a look at this, Kevin.” I put the microscope slide on my scope, and said, “It looks like rhabdomyolysis. I’ve seen it in horses, but it doesn’t look like equine muscle.” This condition destroys skeletal muscle.

      My colleague said, “Rat soleus, on a statin.”

      Never touched them again. Ironman training did a great job, which is why I’m still alive at 78.


  2. Robert Levin says

    Thanks. You’re my inspiration and one for the reasons I stopped my statins. I also have PAD . I have never run an Ironman, but have done loads of marathons. With my active lifestyle, I never expected PAD. Guess it is the luck of the draw.
    I might get a stent in my leg to make running my tolerable.

    • Hi Robert, my vascular surgeon, who I trust, advised me against a stent in my popliteal artery. He said it comes with the risk of losing my foot. This intense exercise has kept it at bay for about five years, but I won’t be running Boston again.

      It really is a challenge, hang in there, and enjoy what you can do. It’s remarkable that we even exist.



      • ROBERT G LEVIN says

        One last comment and questions. My vascular surgeon gave me no such warning but I will ask more questions. I am not the usual person they do an angiogram on. Non smoker, athlete, not over weight.
        Have you found any diet that has served you well?

  3. Robert Levin says

    Thanks. I love your attitude and hope it rubs off on me.
    Best of luck and never give up.
    Keep writing, it is of great value to others.

  4. Thanks for the tip, Kevin, I am inspired to walk to the library while flexing my toes. Roger

  5. No Statins? After being diagnosed with PAD, I went to a Cardiologist and he immediately changed my cholesterol med and added one due to PAD and family history!

  6. Robert Levin says

    Carol: Yes, that seems to be the standard of care for PAD. That is why I think Kevin’s view is so interesting and Kevin is not alone in being anti-statin.

  7. Hi Robert, sorry for the delay. Got busy. Diet is an interesting thing. I’m largely vegan, with a few of my chicken’s eggs per week. But we are each biochemically a little different. Listen to your body, is my advice. I’m sure some need some meat, most don’t. Largely plant-based, is my recommendation. Before eating anything, ask yourself, is this good for me? Is it good for the planet? And you won’t go far wrong. -kev

  8. Robert Levin says

    Kevin, I appreciate you taking the time to reply. I was curious about your diet because we do have much in common. We both take running seriously, are both in our 70’s, and both suffer from PAD. You do have a scientific background which I lack.
    The questions you pose are interesting but many times difficult to answer because nutrition information is confusing. I have tried to eat real food, as unprocessed as possible. However, I probably should be more plant based and I plan on doing that. I have resorted to eating 2 meals a day in an 8 hour window which I question is the best move. I also try to stay away from foods that will spike my blood glucose even though I am not a diabetic. Again maybe something I should ignore.
    Thanks again.

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Disclaimer: As a veterinarian, I do not provide medical advice for human animals. If you undertake or modify an exercise program, consult your medical advisors before doing so. Undertaking activities pursued by the author does not mean that he endorses your undertaking such activities, which is clearly your decision and responsibility. Be careful and sensible, please.