Thoughts on a Proper Child’s Shoe

By Mark Cucuzzella MD FAAFP

As a family physician, I firmly believe that children should play in their bare feet or in activity shoes that complement natural foot development and proper biomechanics of movement. Runners, walkers, coaches, and the medical community are all awakening to the benefits of allowing proper natural foot motion to occur in all of our daily activities.  Leaders in the running mechanics, sports medicine, dancing, and yoga/tai chi communities all understand that the smartest design that will ever be developed for human movement and injury free activity is the human foot itself. Running shoe companies are slowly hearing this message and adapting their product lines to create footwear that allows your foot to behave like a foot, but most have only applied this new thinking to adult models.  Unfortunately, the modern shoe industry and its marketing machine effectively convince parents that when running, a child should wear miniature versions of traditional adult running shoes; almost all of which have elevated heels, extreme cushioning, and some form of motion control technology.  Many dress shoes for children are also stiff and overly supportive.  Personally, as a doctor I firmly believe that the strongest support for a child is a strong foot that is flat on the ground.

Here’s an important point to keep in mind – a child’s foot is not a miniature version of an adult’s foot. In early development, a child’s foot is widest across the toes. If our population wore shoes that were designed with this functional shape from birth, most adults would also have feet with the widest part across the toes, and the toes would be perfectly aligned with the metatarsals (long bones in midfoot). Most of a child’s developing foot is composed of cartilage, which is gradually replaced by bone. If the cartilage is deformed by badly shaped or rigid shoes, the bones will take on the deformed shape. More than 80% of foot problems, bunions and injuries are a result of misshaped and inflexible shoes. It’s vital that kid’s shoes allow enough room for natural growth, until the foot bones mature. This doesn’t happen until ages 18-19 for girls and 20-21 for boys. Simply put; inflexible, poorly shaped shoes are potentially harmful – they restrict the natural movement and development of the foot.

Images Barefoot children: notice the foot is widest at the toes and toe spacing

Research and education efforts from places, people, and organizations like the University of Virginia SPEED Clinic, Dr. Daniel Lieberman of Harvard University, and Chi Running are together allowing runners and walkers to re-look at old concepts related to form an footwear. More importantly, innovative shoe manufacturers such as Newton Running, Terra Plana Vivo Barefoot, Vibram, Kigo and newcomers Altra and STEM are now producing foot-friendly shoes that people can use to more effectively apply new concepts in their own self-experiments. It is hard to find a single one of the now thousands of runners and walkers who have made proper changes in their gait, and complemented this with footwear void of elevated heel/motion control features, who wants to return to the old way of heel crash pads and inefficient gait.

Currently, almost every running shoe company has products in development supporting natural running, and we are beginning to see the very first steps by many of them away from heavy cushioning and elevated heels. Again though, most of these new shoes are being made solely for adults. Outside of a few select brands, with Terra Plana Vivo Kids being the model, a void exists in the development of proper youth footwear, where natural foot function and development are perhaps most critical.  Without any supporting evidence, the President of the American Academy of Podiatric Sports Medicine (AAPSM ) David  Davidson made this comment when asked about children’s footwear by Running Times Magazine “Kids should not be running in minimalist footwear at all, and as in other shoes, should be wearing brand name running shoes with good motion control, cushioning, etc…”

I believe the opposite. I feel children should run barefoot as much as possible, and when they need a shoe, they should wear one that allows the young foot to develop its natural strength, support, and function.  Parents should think twice before heeding the message that their children need “sturdy” or “supportive” shoes. As Dr. Lieberman demonstrated so well in his landmark paper in Nature (Jan 26, 2010), footwear can have a large influence on natural gait.

I find it highly unusual and there are no supporting documents to the APMA (American Podiatric Medical Association) parent flyer which states that parents should “Select a shoe that’s rigid in the middle. Does your shoe twist? Your shoe should never twist in the middle.” Curiously, right below that piece, and written in fine print, there is this accurate statement: “Step three does not apply to toddlers shoes. For toddlers, shoes should be as flexible as possible.” I’m left wondering “So at what time does a toddler become a child and we bind their feet up?”

As a parent and physician I believe that the APMA statements could cause harm in a developing child’s foot. A foot builds its own intrinsic support via communication with the ground, building strength and stability through proprioception, and allowing normal force loads to be applied to the areas that nature intended. If you change anything from what is normal in a developing child, then you proceed at your own peril. For example, when I was a child the APMA suggested bracing as a treatment for intoeing (feet that turn inward instead of pointing straight ahead) – fortunately this practice has been banned. The results were extreme tibial rotation and for me, I wound up needing patellar tendon realignments at age 13 due to completely misaligned tibia and patellas (kneecaps)….I missed a large portion of my high school running due to this.

Dr. Mark’s Children Leo, Lily and dog Cocoa in Vivo Barefoot kids

A parent will always do what the experts say is best for their children, and the APMA statement that is mentioned above is one that I would challenge. Do I have studies for this….unfortunately, not good ones.  Conceptual and evolutionary evidence is the best we have here. For one example, we see many high school runners with hallux valgus — “big toes pointed in.” Hallux valgus is generally caused by ill-fitting shoes with a pointed toebox. Furthermore, most runners, both young and old, cannot stabilize and balance on one foot. To run properly, you must be able to do this.

The next time you are in a park, watch a child run barefoot.  Notice the relaxed movement and foot placement. They lean slightly forward and their legs fall out behind them.  They do not strike hard on their heels. Then watch the child with the highly cushioned or supportive shoe.  The difference is easy to see.

So what are the important features to look for in a child’s shoe?

• Ultra-thin soles to allow proper proprioception, neuromuscular activation in the entire kinetic chain, and to complement the body’s natural ability to absorb ground forces.
• Low, flat to the ground profile – shoes should allow all play activity that involves climbing, running, and jumping. Shoes should enhance lateral movement since the foot will not be up on a platform or have a slope from heel to forefoot.
• The materials should be soft and supple, thereby allowing natural foot function. The shoe should bend easily at the toe joints – this is where a foot is designed to bend to recreate the arch on takeoff.  See the TR Treads website on Footwear Education for more on this.
• The toebox should be wide enough to allow natural toe spread (Runblogger’s note: check out this video of running toe splay on ground contact in my 5 year old daughter). Foot support is created by the natural arch of the foot with the great toe stabilizing the arch.  When the heel is elevated and great toe deviated toward the second toe (a common design flaw in many shoes which come to a point), this stability is compromised. The foot produces the most leverage when the toes are straight and aligned with the metatarsals. A child’s foot is widest at the ends of the toes (as should an adult’s be if they have been in proper shoes or barefoot).
• A single piece midsole/outsole allowing protection on unnatural surfaces (concrete, asphalt) and natural rough surfaces (rock,trail) while allowing proprioception and natural dissipation of ground reaction forces.
• Upper material should be soft, breathable, and washable.
• Get over the notion that shoes need “traction.” In a moving child the more stickiness and grip, the more heat produced in the foot and braking moments on running activity.
• Discourage the use of thick, heavy socks as these interfere with foot proprioception.
• All efforts should be made to use recycled materials in the construction of the shoe.
• Shoes should be a good value and of comparable price to other children’s shoes.
• Design and colors should inspire fun and play.
• And critical is proper fit. For tips see the Two Rivers Treads Shoe Fitting Guide in their expansive Footwear Education section.
• For another great resource on children’s footwear, read this article by Dr. William Rossi DPM.

Why do I care so passionately about this?  The most important reason is that I am a parent and want to do what is best for my children and not be influenced by marketing claims or trends.  I have been a competitive distance runner my entire life and am personally involved in multiple projects and grants involving both youth and adult physical fitness.  If we can teach proper approaches to pain free activity throughout life then the daily walk or run will be sustainable.

I had both of my feet operated on 10 years ago at age 33 for severe arthritis caused by a combination of improper gait mechanics, lots of hard miles as a collegiate and post collegiate runner, and the negative influence of new trends in footwear such as elevated heels and crash pads. The foot instability this created and greater impact in the great toe joint caused this joint to deteriorate. I had the joints fused in both feet and instead of taking the standard doctor’s advice of not running anymore, I chose to relearn how to run. I also got heavily involved in footwear design and function for runners and children. Read my story here on zero-drop.com.

I have watched my own children (ages 5 and 7) dramatically change their movement patterns after discarding the heavy, inflexible “Sketchers with lights” and getting them into slip-on Vivo Barefoot kids shoes. They will not put anything else on their feet now when they need to have shoes. We gave away 180 pairs of Vivo Barefoot kids shoes at Freedom’s Run for our kids run thanks to the combined generosity of Two Rivers Treads and Terra Plana. See story….scroll down.  Dozens of moms and kids have thanked me for the discovery they have made (Runblogger’s note: as do I – Mark was kind enough to send me a pair of Vivo Barefoot Kids Pally’s for my 5 year old daughter, and she and I both love them).

The beauty of this field is that it is evolving rapidly, we are all discovering new things, there is no one correct answer, and as a field we are doing the needed research. My personal results as a study of one give me the authority to say that you can retrain how you move, and that footwear does have an influence.  I began running barefoot at the beach when I was 12. This was the beautiful movement that I can still remember. Thirty-one years later, I finished in the top 10 for runners over age 40 at the 2010 Boston Marathon in a time of 2:34.  I’ve run under 2:35 for a marathon 22 of the last 24 years, with misses only during my medical intern year and in 2009 when I ran a 2:37. My training miles are minimal now for these efforts. Knowledge and application of gait principles and use of optimal footwear allows effortless movement to occur.  It’s “no pain…thank you” instead of “no pain…no gain”.

It all starts with the children. Adults make their own decisions but children cannot. We need to see further collaboration among many fields – as Dr. George Sheehan so eloquently stated in 1975:

“If athletes were given less care and more thought, the doctors might come up with some original ideas on why illness persists, why injury doesn’t clear up.  If more non-physicians – podiatrists and physiotherapists for instance – could be induced to lend their ideas and talents, we might see a completely new approach to sports medicine.  If the athlete had to wait longer for surgery, he might have time to recover from his ailments.”

Footwear designers are a critical part of the future of preventive sports medicine, and they need to start thinking more about our children.

Long may you run…

-Mark Cucuzzella MD FAAFP