natural running advocates tell us to observe
children running barefoot so that we may learn
to run "naturally" in order to avoid and manage
our own running-related injuries. However, such
statements are inherently flawed. As physical
therapists, we know that children also get
injured while running. In fact, recent studies
show that there has actually been an increase in
the number of children's running injuries.1
This increase is likely due to the fact that
more children are participating in organized
sports but rarely receive proper running
instruction. In reality, children are different
than adults, and they are plagued by their own
unique set of risk factors for running-related
Because children's bodies are
still growing and have not fully developed, they
are susceptible to running injuries that most
adult runners never encounter. Thus, the
incidence and type of running injuries children
suffer from are very different from the injuries
we see in adults.2
One major difference between
adults and children, for example, is that
approximately one-third of children's running
injuries are due to falls. Younger children with
little running experience are particularly prone
to traumatic fall injuries when running.3
However, running-related injuries due to a
specific trauma are actually rare for adults,4
and those that do occur are most often the
result of an isolated incident.
Children's increased risk for
falling is not only because their bodies are
different but is also attributed to their
limited proprioception and body awareness. In
fact, children's brains function differently
than adults' brains. One review demonstrated
that adults approach the same physical task very
differently than children do, and adults are
better able to mentally coordinate, anticipate,
adapt and orient their bodies in a more fluid
manner than children when ambulating.5
Adults have more
proprioception and body control because they
have more mature, developed sensorimotor systems
and access higher-level brain functions to
perform physical activities when compared to
children. Before puberty, children primarily
show activity in subcortical regions of their
brains during physical tasks, while adults
primarily rely on the more sophisticated
cortical regions of the brain to direct and
integrate movements for the same task.5,6
lack of body awareness and "clumsiness" are the
most likely reasons that children, specifically
small children, are prone to fall injuries while
running. And while children are at greater risk
for falling during running than adults, they are
by no means exempt from the non-traumatic
running injuries adults face. They are still
susceptible to the strains, sprains and
tendonitis to which adult runners are prone.2,3
So arguments that adults
should try to run "naturally" like children in
order to manage and treat injuries are invalid.
Children's bodies are different, the way they
control movement is different and their injuries
are also different. There is nothing "natural"
about an adult trying to run like a child. In
fact, as physical therapists, we should not
watch children run so that we can learn about
natural running. In contrast, we need to observe
children running in order to recognize and
identify the signs and symptoms of running
injury in the children themselves and help them
progress into healthy running as they mature.
Certain observations are
critical to correctly identifying a running
injury. Children are not always forthcoming
about pain or difficulty when running,
especially when it's part of an activity or
sport they love. Like adult runners, children
too can have a great fear of losing the ability
to run, so we need to carefully observe for
signs of injury and ask specific questions in
order to recognize the red flags.
While the child runs, look
for pain that alters running stride. Note
antalgic gait, asymmetrical strides, aberrant
movement patterns, and excessive twisting,
rotating or lateral movement. All of these signs
can be indicative of injury.
We must also observe the
child when he is not running and identify pain
that interferes with everyday activities. Signs
of an injury will likely include limping,
avoidance and often an inability to negotiate
stairs properly. With more severe injuries,
children will often verbalize complaints about
pain at rest or pain that interferes with sleep.
Furthermore, always keep in mind that taking
medication for pain and inflammation due to
running automatically indicates a running
injury. Under no circumstances should a child be
taking any medication, injected or oral, in
order to run with a painful injury.7
Proper rehabilitation must
address aberrant movement patterns and teach the
child balance, proprioception and body control.
Rehabilitation exercises should be implemented
so that the child can achieve several
running-specific goals, such as maintaining
stability over an aligned foot, controlling
dynamics of arm swing to achieve a balanced
body, progressively controlling weight-bearing
through the first ray and maintaining stable
posture with a straight kick-back.8
An example of a running-specific balance
exercise and its progression is given in the
sidebar. Children should practice and learn
these running balance exercises both barefoot
and shod; however, protective training shoes
should be worn when they initially return to
actual running. Running without proper
protection can be dangerous for an injured
As a profession, we currently
have no consensus whether or not going barefoot
or wearing barefoot-simulated shoes reduces
non-traumatic running injuries. However, recent
reports have shown that they do actually
increase the risk for serious running injuries.9
An injured runner is already at risk for
developing further injury. Thus, having an
injured patient run without protection will only
put that person at greater risk to suffer a more
complex injury and completely lose the ability
Additionally, children are
required to wear shoes in physical education
class, USA Track & Field events, cross country
and almost all organized sports that require
running. Therefore, children must learn to run
in shoes. An injured child should initially use
a more protective shoe to return to running and
may "shoe down" for performance once he has
progressed and recovered from injury.
Return-to-run programs should be tailored to
meet each child's activity-specific goals for
Barefoot, young children are
not "natural" runners; like adults, they too are
at risk for running injuries. As physical
therapists, we need to observe them and guide
them, not for our own benefit but for theirs. We
need to be able to recognize the signs and
symptoms of injury, help them develop
proprioception and body control, and progress
them through a proper return-to-run program.
We teach our children who
participate in track and field to run in
performance-enhancing track spikes. What can be
more unnatural than that?
1. Soprano, J., & Fuchs, S.
(2007). Common overuse injuries in the pediatric
and adolescent athlete. Clinical Pediatric
Emergency Medicine, 8, 7-14.
2. Seto, C., Statuta, S., &
Solari, I. (2010). Pediatric running injuries.
Clinical Sports Medicine, 29, 499-511.
3. Mehl, A., Nelson, N., &
McKenzie, L. (2011). Running-related injuries in
school-age children and adolescents treated in
emergency departments from 1994 through 2007.
Clinical Pediatrics, 50(2), 126-132.
4. O'Connor, F., & Wilder, R.
(2001). Textbook of Running Medicine. New York,
NY: McGraw-Hill Professional Publishing.
5. Quatman-Yates, C.,
Quatman, C., Meszaros, A., Paterno, M., &
Hewett, T. (2011). A systematic review of
sensorimotor function during adolescence: A
developmental stage of increased motor
awkwardness? British Journal of Sports Medicine,
6. Thomas, K., Hunt, R., et
al. (2004). Evidence of developmental
differences in implicit sequence learning: An
fMRI study of children and adults. Journal of
Cognitive Neuroscience, 16(8), 1339-1351.
7. Wilk, B., Nau, S., &
Valero, B. (2009). Physical therapy management
of running injuries using evidence-based
functional approach. Journal of American Medical
Athletic Association, 22, 5-6.
8. Wilk, B., & Muniz, A.
(2011). An Evidence-based Approach to the
Orthopaedic Physical Therapy Management of
Functional Running Injuries. APTA Combined
Sections Meeting Conference Presentation. New
Orleans, LA, February 10, 2011.
9. Giuliani, J., Masini, B.,
Alitz, C., & Owens, B. (2011).
Barefoot-simulating footwear associated with
metatarsal stress injury in two runners.
Orthopedics, 34(7), 320-323.
Bruce R. Wilk is director
of Orthopedic Rehabilitation Specialists, Miami,
FL, president of The Runner's High, and head
coach of the Miami Runners Club. Annmarie Garis
is a physical therapist at Orthopedic
Rehabilitation Specialists and member of the
Miami Runners Club.