No Evidence that Children Have More Health Risks Running Long Distance Races Compared to Adults

Written testimony in opposition to Proposed Hawaii Senate Bill 2413 that would ban children under 18 from participating in long distance running events


I’m a Doctor of Physical Therapy who graduated from the U.S. Army – Baylor University Doctor of Physical Therapy Program (the top Orthopaedic PT Program in the U.S.) who has been practicing for ten years, and currently have been practicing that past 7.5 years in Hawaii. I’m a Board Certified Orthopaedic Clinical Specialist, a Certified Strength and Conditioning Specialist, and also specialize in slow motion video running form analysis/running form teaching. I have video analyzed over 6,000 runners (ages 11-60+) over the past six years and taught them how to properly run to put less stress on the body and run more efficiently. Furthermore, I’m a high school long distance running coach at Castle High School in Kaneohe. I have been a coach at the Aloha Cross Country Camp for the past seven years, where I have gotten to know hundreds of local Hawaii runners under age 18. I’m the coach and founder of Dr. Nate’s Champion Running Program that focuses on individual coaching for long distance high school runners on Oahu. I help prepare these athletes (14-17 years old) for their cross country and track seasons and for their college running careers. The pillars of my long-distance training program are injury prevention, training all at their individual levels, and teaching young runners how to properly train. As one of the most qualified subject matter experts in Hawaii, if I thought that there was any concrete evidence that those under age 18 are at a greater injury risk running distances over half-marathon, than the rest of the population; I would be the first to support SB2413. However, the subject matter experts in the world and the only studies/data we have regarding minors participating in marathons are in direct opposition of SB2413 and actually demonstrate less health events and risks than the adult population. This is one of many reasons why I’m opposing SB2413. Let’s look at what the top Pediatric experts currently say and then I’m going to give you what I know based on my running, clinical, and coaching experiences over my lifetime.

Section 1 of your bill claims that “the American Academy of Pediatrics’ Council on Sports Medicine and Fitness suggests that sporting activities should be geared to meet the developmental level of children and adolescents in regard to their physical abilities, cognitive capacities, initiative, and interest.” I reached out to one of the leading Sports Medicine Pediatricians in America, Dr. Chris Koutures, MD, FAAP who just completed a six-year elected term as a member of the Executive Committee for the American Academy of Pediatrics Council on Sports Medicine and Fitness, has written 20 professional articles, and is the co-author of the Pediatric Sports Medicine: Essentials for Office Evaluation textbook published by SLACK Incorporated in October, 2013 (see ">http://www.dockoutures.com/about-dr-koutures/ for his complete extensive bio). Dr. Koutures states, in regards to distance running for children: “The risks of injury and illness in distance running may be related to the total mileage and number of hours training per week. There is no agreement among sports medicine professionals about distance limitations for children. Until further data are available concerning the relative risk of endurance running at different ages, the American Academy of Pediatrics recommends that if children enjoy the activity and are free of injury or ailments, there is no reason to keep them from training for and participating in such distance events including marathons and half-marathons. Regardless of age, the 10 percent rule is an appropriate guide when designing a training program. - The variables include weekly distance, intensity, and number of training days per week. - Each week, one should only increase one of those three variables, and no more than 10 percent from the previous week.” https://chris-koutures.squarespace.com/running/
Dr. Koutures, like all good physicians, directed me to the best and only research articles and research studies on children running marathons. The studies actually demonstrate no evidence that distance running for those under 18 is harmful or poses a higher risk than the general population. The research shows less health incidents for minors than those over 18 running marathons. Here is the research:

Can Children and Adolescents Run Marathons? Sports Med. 2007;37(4-5):299-301.
https://www.ncbi.nlm.nih.gov/m/pubmed/17465593/

https://well.blogs.nytimes.com/2011/02/23/phys-ed-should-children-run-marathons/ (Link loads slowly, recommend copy/paste into web browser)

http://700childrens.nationwidechildrens.org/marathon-training-young-young/ (includes statement that American Academy of Pediatrics does not set age guidelines for distance events)

Pediatricians can help young runners stay healthy, avoid burnout. The Official Newsmagazine of the American Academy of Pediatrics. Aug 2013; Vol. 34: 8. (see attached and link: http://www.aappublications.org/content/34/8/18?sso=1&sso_redirect_count=1&nfstatus=401&nftoken=00000000-0000-0000-0000-000000000000&nfstatusdescription=ERROR%3a+No+local+token

Youth Marathon Runners and Race Day Medical Risk Over 26 Years. Dr. William O. Roberts et al. Clin J Sports Med. 2010; 20 (4): 318-321. (See attached link for abstract https://www.ncbi.nlm.nih.gov/pubmed/20606519).
Dr. Roberts is currently doing further research on runners, under 18, running marathons.
Dr. Roberts’s research shows less health events in minors’ versus adults’ during/after a marathon and this research is further supported with a larger sample size of 846 under 18 running in the 2017 Honolulu Marathon. James Barahal, MD, CEO and Founder of the Honolulu Marathon and President for 27 years states: “I have never even seen a kid in the medical tent. I am a practicing clinician who has seen over 100,000 patients of all ages, although I am not a medical director of the marathon, so it is possible kids have been seen but no one on our medical report team has ever reported an incident with a child running. EVER. Not once (Written conversation 3 February 2018).”

My Statement:

As I outlined above, there is no scientific evidence or studies published that specifically demonstrates that those under 18 have higher risks of injury or heath consequences running marathons. All claims that there is a higher risk of overuse injuries and health complications for those under 18 running marathons are assumptions ‘not’ based on any studies looking directly at under 18 distance runners. Furthermore, the studies and claims cited in section 1 of SB2413 are not conclusive and are not direct research data on children running marathons. I cross referenced the studies in the International Medical Marathon Directors Association (IMMDA) advisory statement and they are outdated articles and textbook commentaries from 1976, 1981, and 1983; not studies looking at children and long distance running. There is no evidence that young long-distance runners have a higher occurrence (than other sports) of osteochondritis dissecans, Osgood-Schlatter disease, or Sever’s disease. I have run long-distance and participated in all the team sports since age 9 and I have NEVER met a young runner or treated a young runner that had osteochonritis dissecans or Sever’s disease. “No studies have linked distance running by young children to potentially serious overuse injuries like growth-plate disruptions or knee arthritis,” says Dr. William Roberts, professor of family medicine and community health at the University of Minnesota and medical director for the annual Twin Cities Marathon (https://well.blogs.nytimes.com/2011/02/23/phys-ed-should-children-run-marathons/). Furthermore, after a through literature review on knee osteochonritis dissecans and athletes, the incidence is less than 0.025% and the consensus is “the cause is unknown, many theories exist.” (https://www.sciencedirect.com/topics/immunology-and-microbiology/osteochondritis-dissecans).

Additionally, I’ve only met and treated two distance runners in over 25 years that had Osgood-Schlatter’s. Osgood-Schlatter’s is a normal occurrence for ANY young competitive athlete that has to run/jump/squat/lunge repetitively in their sport and that are going through a large growth spurt. Osgood-Schlatter’s will resolve once the young athlete stops growing or sooner. Sever’s disease will resolve after about two months of rest and once again will completely resolve and will not return after the young athlete stops growing.

In regards to the studies that you are referencing that claim children absorb less impact than adults and that their running mechanics may contribute to a diminished ability to absorb shock…these are tremendously flawed studies. First, the article from the Journal of Athletic training that the SB2413 references: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2865964/ concludes, “We do not know how these shock attenuation characteristics are related to overuse injuries.” The study sample size was small n = 18, the age of participants were extremely young 8-11 years old, did not test children that ran long distance races, and most importantly there was no standardization on the type of shoes that the children ran in during the study (the children were allow to us their own shoes, which could have been any type of shoe and worn out). From scientific research we know that a shoe loses it’s ability to absorb impact/shock and actual individual foot strike also matters. For example, runners that heel-strike absorb most of their initial ground shock in their heel (if the shoe has good heel cushion), but if there is not a good shoe heel cushion, then impact forces go up to shin and knee first (increasing injury risk in ALL distance runners). Forefoot and mid-foot strikers absorb most of their initial ground shock in their arch and Achilles tendon (which act as natural springs/shock absorbers).

I read the studies that SB2413 indicates children run with different mechanics, have shorter legs in relation to their body size, and thus ‘may’ have a diminished ability to absorb impact.
A Description of Shock Attenuation for Children Running. 1996. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2865964/

Is Running Economy Different Between Adults and Children? 1996
http://www.humankinetics.com/acucustom/sitename/Documents/DocumentItem/12361.pdf

These studies are both old, small sample size, and nowhere in the studies do the authors conclude that their findings may contribute to diminished ability to absorb shock or that their findings could result in health outcomes that you are claiming in Section 1 of SB2413. The Bill is making assumptions based on zero date or supportive literature. Fact, the running economy study demonstrated that the children had a higher stride rate, which is actually a good thing for injury prevention. The higher the stride rate, the less ground impact time, then less time the body has to absorb impact and stabilize. Higher stride rate improves running mechanics and causes less over-striding and less heel striking, leading to less impact on the tibia bone, knees, and lower back. The assumptions are similar to how the medical community has assumed for 40 years that those that run will have a higher incidence of knee and/or hip arthritis. We now know that recreational runners, which make up 99.999% of runners, have significantly less knee and hip arthritis than sedentary people. A systematic review of 17 studies with a total of 125,810 people, published in 2017 by the Journal of Sports and Orthopedic Physical Therapy found that: “…only 3.5% of recreational runners had hip or knee arthritis; this was true for both male and female runners. Individuals in the studies who were sedentary and did not run had a higher rate (10.2%) of hip or knee arthritis. Most of the studies the researchers evaluated that showed an increased risk of arthritis from running focused on runners who were at the elite, ex-elite, or professional level [elite running make up only approximately 0.00075% of the running population and they ran over 57 miles/week for years]. These professional or elite athletes or individuals who participated in international competition had the highest rate of knee or hip arthritis at 13.3%.” https://www.jospt.org/doi/full/10.2519/jospt.2017.0505?code=jospt-site
(Copy and paste, link does not work directly).

None of the other studies that you cite in your reasoning for SB2413 look at injury rates in under 18 distance runners or take into account what we know now about running form and the forces on your body based on where and what part of your foot strikes the ground relative to your hip joint. It was not until around 2009 that good and conclusive running form and impact studies began to be published. It is my experience doing video analysis, when I compare the recent literature on efficient running mechanics and running form, that younger children generally have better mechanics, and less over-striding (which is directly linked to overuse injuries) than the rest of the population. It is not short legs that lead to injury or diminished impact, but it is first and foremost training too much – to fast (overtraining by increasing running volume greater than 20% per week for consecutive weeks). If you want to link running mechanics/running form to overuse injury, than over-striding (landing greater than 2 inches in front of your hip) and what part of your foot initially strikes the ground first (heel striking) is the most important factor that can contribute to injury if ANY long distance runner is over-training and progresses their running volume >20% per week for over three weeks in a row.

Let’s now address the International Marathon Medical Directors Association (IMMDA) advisory quoted in SB2413 as a reason to prohibit those under 18 to participate in a marathon. The IMMDA explicitly states that “currently there is no scientific evidence that supports or refutes the safety of children who participate competitively in marathons.” However the meeting where they made this statement was in 2008 and they voted to approve their advisory March 2009. This was before Dr. Williams Robert’s full 26-year study was published in 2010 that demonstrated the safety in children participating in marathons. They also completely disregarded Dr. Robert’s preliminary study that was published in 2007 that demonstrated children had less medical events in marathons than adults. As I outlined above, there is much more data and a greater number of children participating now in marathons then there was pre-2008 and it consistently proves the safety of those under 18 running marathons. The IMMDA also quotes, in their advisory, the American Academy of Pediatrics (AAP), “there is no reason to disallow participation of a young athlete in a properly run marathon as long as the athlete enjoys the activity and is asymptomatic.” The two doctors that wrote the IMMDA advisory paper, then go on to directly contradict the consensus of 64,000 Pediatric doctors that are part of the AAP.

I thoroughly read the entire IMMDA advisory statement on children and marathon running. The statement focuses on children that would specialize in marathons as a competitive marathoner and perform specific marathon training year round. If a child was to do this, it would include running over 70 miles per week consistently, which is typical competitive marathon training. However, NO child under 18 in the State of Hawaii is doing this and does this! There is no child marathon clubs or school sports programs or teams for competitive marathon participation. Thus, the ‘burnout’ physically, psychologically, or emotionally that these two doctors are claiming can happen with specializing in a competitive sport year round, is NOT a risk.

In conclusion, since there is scientific and medical evidence that directly opposes SB2413 and absolutely zero scientific and medical evidence that supports SB2413; I once again state my opposition to SB2413. Let the children run!

Very Respectfully,

Dr. Nathan H. Carlson, DPT, OCS, CSCS

Doctor of Physical Therapy Tripler Army Medical Center
Orthopaedic Clinical Specialist
Certified Strength and Conditioning Specialist
Major U.S. Army Reserves and Bronze Star Recipient for work as a physical therapist for one year in Iraq serving over 30,000 and saving the U.S. millions through treating injuries
Founder and Coach of Dr. Nate’s Champion Running Program for high school runners
2-time 1st Hawaiian Resident Finisher and 1st American Finisher Honolulu Marathon
2011 Maui Half-Marathon Champion and 3rd best finishing time ever
Member of the All-Army Elite Cross Country and 10-Miler Teams
33rd place in the 2012 U.S. Cross Country National Championships
Saint Martin’s University Sports Hall of Fame Member for Cross Country and Track
Saint Martin’s University 2004 Assistant Cross Country Coach
2005 NCAA All-American 1500m (8th at the National Championships)
Competed in three NCAA National Track and Field Championships in the 1500m and Mile races.
9-Time Academic All-American (Cross Country, indoor track, outdoor track) and ESPN the Magazine 1st Team All-American
2005 Great Northwest Athletic Conference Sportsman of the Year and Academic Athlete of the Year
Saint Martin’s University record holder 1 mile, 1500m, and distance medley relay
1998 Washington State High School State Champion 1600m and 800m
Husband of 2020 Olympic Marathon Trials qualifier and 4-time Honolulu Marathon 1st Hawaii resident champion: Polina Carlson

Last Speed workout before the Honolulu Marathon this Thursday. Let's take action and stay focused on the prize!

Champion Running Group! We will meet this Thursday at 5:30pm at Ala Moana Beach Park behind the tennis courts (mountainside, diamond side). We will start with a dynamic warm-up and then go into a 41 minute countinuos Farlek speed workout where you will Alternate between 2 minutes hard and 3 minutes hard for 41 minutes with a 1 minute jog rest between each hard iteration of running. Finish w/ a 9 minute cool-down jog. The Word for the day is the TAKE ACTION! In life, in training, and in racing; decide to not settle for comfortable compromise. Instead, take Critical Action and put the success of the mission ahead of personal comfort and convenience! Daniel Kolenda, in his book, "Live Before You Die," says: "Critical action almost always involves putting “boots on the ground,” taking risks and interacting with people in a way that makes one vulnerable. Critical action will almost always mean paying some price and sticking your neck out in some way. The comfortable compromise, on the other hand, always consists of more talking than walking. It allows us to stay safe, makes us feel good about ourselves, and keeps us busy, but it produces very few actual results. Simply put, the comfortable compromise is an action that serves as a substitute for the critical action. It is a cheap imitation, a second-rate alternative; an easy way out. I say that comfortable compromise is more problematic than procrastination because when we procrastinate, at least we know that something is still lacking. But the comfortable compromise allows us to pacify our conscience, feeling as though we have fulfilled our obligation though in reality we have accomplished only a fraction of our potential, or perhaps none at all." The scriptures remind us to take action: "What good is it, my brothers, if someone says he has faith but does not have works? Can that faith save him? If a brother or sister is poorly clothed and lacking in daily food, and one of you says to them, “Go in peace, be warmed and filled,” without giving them the things needed for the body, what good is that? So also faith by itself, if it does not have works, is dead." James 2:14-17 And again: "Little children, let us not love in word or talk but in deed and in truth." 1 John 3:18 "Whatever you do, work heartily, as for the Lord and not for men, knowing that from the Lord you will receive the inheritance as your reward. You are serving the Lord Christ." Colossians 3:23-24 I hope this blog finds you healthy and inspired to take action in life and in your running goals. - Dr. Nate

Come Over for a group Workout in Kailua This Thursday Night, or at Ala Moana Beach park too!

Champion Running Group to meet this Thursday in Kailua for the first time at 5:30pm in the community park right next to the Times Supermarket (across the street from the new condos in the ball-fields). All are welcome for a group easy run of 6-7 miles and then stay afterwards for the Kailua town night market that has food venders and fresh fruits and vegetables. Please message me and respond if you are coming. If you cannot make it to Kailua, the group is still going to meet Thursday in Ala Moana beach park at 5:30pm (behind the tennis courts, Mountainside) for a moderate 50 minute run (about 30 seconds slower than marathon goal pace). Please post if you are going to be at Ala Moana. - Coach Nate

Tomorrow Night reverse pyramid speed interval workout, read blog for full details

Champion Running Group: please meet at Ala Moana Beach Park behind the tennis courts (mountainside/Diamond) this Thursday night at 5:30pm. Those that have been coming for the past year, please print out this workout and put everybody through the following…. Before main workout perform at least an 8-10 minute jog followed by a dynamic warm-up with drills and 4 x 100 meter stride out accelerations. Main workout is a Reverse Pyramid Interval Speed workout of: 6:00 min – 4:00 min – 3:00 min – 2:00 min – 1:00 min – 2:00 min – 3:00 min – 4:00 min – 6:00 min. Rest should be slow 3-minute jog between each hard interval. Cool-down with a slow 8-10 minute jog and 10 minutes of static stretching (holding each stretch 30 seconds). Once again, I will not be at the workout due to being in Kailua. Please let me know if you are going to be at the workout and if you have any questions about training; since many are in full marathon training and racing mode. Good news! I’m training consistently again and prepping to race a 5k in 2.5 weeks and a 10k in Japan at the end of the month. Been running with and training Polina a lot lately and she is pushing me, which is great! All the workouts I give you this month are geared for anybody that is racing distances from 10k up to Half-Marathon. The workouts will increase to more volume in October. Good luck in your training and racing the rest of the week and this weekend! Windward Half and 20k coming up! Thought for the Day: For what purposes do you run and live life? If your joy is completely tied up in what you do or in someone else, your joy can be taken away in an instant. However, if your joy is tied up in what Jesus Christ has done for you and that He has created you for a purpose and that He loves you no matter what…then you will always have joy! The Scriptures remind us: “…do everything to spread the Good News and share in its blessings. Don’t you realize that in a race everyone runs, but only one person gets the prize? So run to win! All athletes are disciplined in their training. They do it to win a prize that will fade away, but we do it for an eternal prize. So I run with purpose in every step. I am not just shadowboxing.” 1 Corinthians 9:23-26. - Dr. Nate

Workout tomorrow night 5:30 at Ala Moana Park: 30 minute tempo run. Important info about the group in this blog! Please read!

The Champion Running Group will continue to meet...unfortunately I will no longer be able to make it to Ala Moana Beach Park for the group due to now living in Kailua and conflicting work and commuting schedules. I have been trying to make it work for the past 3 months but it is not working for me during the week. I will continue to post the entire workout every week. Please continue to meet at the same time and place. I am hopeful that at least one time per month we can all meet in Kailua as a group on a Thursday night so I can be there and coach and help everyone out! Plus, Thursday night Kailua has an awesome night farmer's market with lots of food vendors! This Thursday Night's workout 5:30pm at Ala Moana Beach Park (behind tennis courts, mountainside) is a dynamic warm-up consisting of walking high knee pulls, walking lunges, running butt-kicks, running high knees. Then perform 6 reps (50 meters) of progressive stride-out accelerations to get the leg turnover going. The main workout is a 30 minute hard sustained tempo run at half-marathon goal pace. Finish the workout w/ a slow 10 minute cool-down jog and 10 minutes of static stretching (hold each stretch 30 seconds). This workout is great to prep for the 20k or the Windward Half-Marathon next weekend! I will be on the course biking around to cheer people on during the Windward Half-Marathon. Hope to see a few of you there! Polina is running the Half. I am proud of everyone that comes out to the Champion Running Group every week and runs hard. Everyone has improved so much and I enjoy meeting new people too! It pains me to not be there to encourage and direct the workouts but this is for the better and hopefully we can start doing more in Kailua soon. Inspirational word for the day: Whatever you do, do it with all your heart, working for the Lord God and not for the approval of Men. Honor God with your talents and your running, He has blessed you with abilities and talents. You can live your whole life trying to please others but you never will please everybody. However, God is already pleased with you because He created you and accepts you for who you are no matter what you have or have not done. Take the pressure off yourself to gain approval from others and live for an audience of ONE (God). - Dr. Nate

Thursday night Run Group: Dynamic warm-up followed by 12 x 400-meter repeats with 1 minute rest between each. End with 10-16 minute cool-down. Everyone is welcome to come out for a speed workout as a final tune-up before the Great Aloha Run. Meet at 5:30pm at Ala Moana beach park behind the tennis courts (mountainside/Diamond). - Coach Nate

Champions are Birthed in the Mind

“If your thoughts are filled with a fear and worry, your life will be unstable, anxious, and insecure.  If you think only of the bad things that can happen, the good things will pass you by.  If you think you don’t deserve to win, you’ll never come in better than second.  And you won’t enjoy even that…Go for the gold, and don’t be surprised when you get it.” 

- Dr. Tim Storey

Champions imagine success before it happens!

“…whatever is true, whatever is noble, whatever is right, whatever is pure, whatever is lovely, whatever is admirable—if anything is excellent or praiseworthy—think about such things (Philippians 4:8, NIV).”

UH Sunrise Series Track Meet This Saturday is Open to Everyone

This Saturday University of Hawaii Track and Field team is hosting a track meet for all-comers.  Open to children and adults.  Entry is free but donations are encouraged.  Must register 30 minutes prior to your event.  Meet starts around 8am and goes quickly.  There is a 1500 meter, 800meter, and 3000 meter.  Come out and test your speed and set a new PB!  I hope to run the 1500m and 800m.
Click on the link for more information: http://hawaiiathletics.com/documents/2012/12/12/2013_Sunrise_Meet_Information.pdf