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The Answer to 'Natural Running?'

Adults may not decrease risk of injury by emulating how children run

By Bruce Wilk, PT, OCS, and Annmarie Garis, DPT

Sports Rehab

Barefoot and 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 injuries.

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

Major Difference

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

Archive ImageAA 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.


Importance of Observation

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 child.

No Consensus

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 to run.

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 participation.

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, Published Online.

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.

Using a Single-leg Arm Swing

Have the patient balance on one leg and hold upright posture so that, from each side, the ear, shoulder, hip, knee and ankle maintain a straight plumb line. From the front, the stance foot should be aligned forward directly under the knee and hip. The unweighted knee should be flexed into a straight kick-back position. Weight should remain evenly balanced through the foot, the hips should remain level and the trunk should remain stable. As the patient holds this posture, she maintains her elbows flexed at 90 degrees and reciprocally swings her arms forward and backward in the sagittal plane at the level of the hips in order to balance her body as she would during running.

Arm swing motion should occur at the glenohumeral joint-not the trunk. Have the patient maintain stability for several seconds while performing dynamic arm swing, and avoid lateral hip movement, trunk twisting, falling forward and arms crossing midline. She should then switch legs and repeat several times. This running-specific exercise should be practiced barefoot, shod and on uneven surfaces as the patient progresses.

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