Bone Stress Injuries in Runners Using Carbon Fiber Plate Footwear

Abstract

The introduction of carbon fiber plate footwear has led to performance benefits in runners. The mechanism for these changes in running economy includes altered biomechanics of the foot and ankle. The association of this footwear with injuries has been a topic of debate clinically, but not described in the literature. In this Current Opinion article, illustrated by a case series of five navicular bone stress injuries in highly competitive running athletes, we discuss the development of running-related injuries in association with the use of carbon fiber plate footwear. While the performance benefits of this footwear are considerable, sports medicine providers should consider injuries possibly related to altered biomechanical demands affecting athletes who use carbon fiber plate footwear. Given the introduction of carbon fiber plate footwear into athletics and other endurance sports, strategies may be required to reduce risk of injury due to altered foot and ankle mechanics. This article is intended (1) to raise awareness on possible health concerns around the use of carbon fiber plate footwear, (2) to suggest a slow gradual transition from habitual to carbon fiber plate footwear, and (3) to foster medical research related to carbon fiber plate technology and injuries.

Full text

Vol.:(0123456789)
Sports Medicine (2023) 53:1499–1505
https://doi.org/10.1007/s40279-023-01818-z
CURRENT OPINION
Bone Stress Injuries inRunners Using Carbon Fiber Plate Footwear
AdamTenforde1 · TimHoenig2 · AmolSaxena3 · KarstenHollander4
Accepted: 31 January 2023 / Published online: 13 February 2023
© The Author(s) 2023
Abstract
The introduction of carbon fiber plate footwear has led to performance benefits in runners. The mechanism for these changes
in running economy includes altered biomechanics of the foot and ankle. The association of this footwear with injuries has
been a topic of debate clinically, but not described in the literature. In this Current Opinion article, illustrated by a case series
of five navicular bone stress injuries in highly competitive running athletes, we discuss the development of running-related
injuries in association with the use of carbon fiber plate footwear. While the performance benefits of this footwear are con-
siderable, sports medicine providers should consider injuries possibly related to altered biomechanical demands affecting
athletes who use carbon fiber plate footwear. Given the introduction of carbon fiber plate footwear into athletics and other
endurance sports, strategies may be required to reduce risk of injury due to altered foot and ankle mechanics. This article
is intended (1) to raise awareness on possible health concerns around the use of carbon fiber plate footwear, (2) to suggest
a slow gradual transition from habitual to carbon fiber plate footwear, and (3) to foster medical research related to carbon
fiber plate technology and injuries.
Key Points
The benefits of carbon fiber plate footwear have been
documented in the scientific literature and are well
accepted in the track and field and road racing commu-
nity.
Prior reports of injuries using this technology have
been observed clinically; these concerns have not been
documented in the literature and limit knowledge among
medical providers concerning possible association with
development of injuries.
This Current Opinion article including a case series of
navicular bone stress injuries after using carbon fiber
plate footwear is intended to raise awareness that health
concerns around use of carbon fiber plate footwear
should be considered when athletes adopt this new
footwear.
* Karsten Hollander
karsten.hollander@medicalschool-hamburg.de
Adam Tenforde
atenforde@mgh.harvard.edu
1 Spaulding Rehabilitation Hospital, Department ofPhysical
Medicine andRehabilitation, Harvard Medical School,
Charlestown, MA, USA
2 Department ofTrauma andOrthopaedic Surgery, University
Medical Center Hamburg-Eppendorf, Hamburg, Germany
3 Department ofSports Medicine, Sutter-PAMF, PaloAlto,
CA, USA
4 Institute ofInterdisciplinary Exercise Science andSports
Medicine, MSH Medical School Hamburg, Am Kaiserkai 1,
20457Hamburg, Germany
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1500 A.Tenforde et al.
1 Background
The sport of running has seen recent changes in training
and competition with the use of an embedded carbon fiber
plate (CFP) within the midsole of footwear [1]. The CFP
spans and is embedded into the midsole inside a compliant
and resilient foam [1](see example in Fig.1). The early
prototypes were worn by elite marathoner Eliud Kipchoge
who ran a sub-2-h marathon using CFP footwear in arti-
ficial conditions including closed loop circuit and pace-
makers [2]. Concerns about fairness in sport were evalu-
ated by World Athletics and resulted in new rules stating
that the combination of a single CFP and responsive foam
midsoles was permissible for use if not exceeding 25mm
of sole thickness for track (≥ 800m) and 40mm for road
running (“Athletics Shoe Regulations”, effective from 1
January 2022) [3]. The footwear industry has continued
to incorporate this technology into running shoes. Since
the introduction of CFP shoes into competition starting
in 2016, every world record from 5000m to marathon
distance has been eclipsed by competitors using this new
technology [4]. Additionally, sports science has validated
the performance benefits of CFP combined with compres-
sive foam midsole compared to earlier footwear used for
training and competition [5–8].
2 Biomechanics ofCarbon Fiber Plate
Footwear
The use of CFP footwear during training and competi-
tion has been shown to introduce novel biomechanical
demands on the foot and lower extremities. The biome-
chanical differences between a novel CFP footwear com-
pared to standard competitive running footwear have been
previously evaluated in competitive male runners [9].
In this investigation, runners using CFP footwear were
observed to have decreased cadence and correspondingly
longer steps as well as a longer flight time [9]. Further-
more, peak vertical ground reaction forces and the verti-
cal impulse per step were higher in runners using CFP
footwear. No changes in knee or hip mechanics but differ-
ences in ankle and metatarsophalangeal joint mechanics
were observed in runners using CFP footwear [9]. The
authors also described thatpeak ankle dorsiflexion dur-
ing stance, and peak ankle moments were reduced and
lower negative and positive ankle work were observed in
CFP over standard competitive footwear during running.
These results suggest that more energy was stored in the
midsole and less in the muscles and tendons of the ankle
[9]. A biomechanical explanation of these findings is that
the CFP increases longitudinal bending stiffness of the
footwear and, thus, is associated with reduced dorsiflexion
of the metatarsophalangeal joints before take-off accom-
panied by an altered energy storage and return [9]. This
suggests CFP footwear may store and return more energy
compared to prior standard footwear. Observed improve-
ments in running economy may result from energy return
from compression of cushioning material and the lever
effects of the ankle mechanics considering the curve of
the CFP and a higher toe spring [9, 10]. The CFP has
been proposed to create a “teeter-totter effect” that moves
forces anteriorly in the foot during thepropulsive phase
[10]. Importantly, this is not supported by experimental
data, which show no difference in the center of pressure
progression [9]. The midsole cushioning may also con-
tribute to improvements in running economy, as shown in
earlier work [11]. However, the compressive foam would
be expected to contribute to a return of energy in the form
of vertical displacement and, thus, may be dependent on
the footstrike pattern [12].
Fig. 1 Lateral X-ray of a run-
ner's left foot in a carbon-plated
running shoe. Red arrows
outline the embedded plate. The
green arrow shows the fulcrum
point of the plate. Note the
relation of the curvature of the
plate to the metatarsal locations
(metatarsal phalangeal joints)
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1501
Bone Stress Injuries in Runners Using Carbon Fiber Plate Footwear
3 Biomechanical Inuences Associated
withBone Stress Injuries
The change in foot and ankle mechanics introduced by CFP
footwear may contribute to the risk of injury. Bone is an
adaptable tissue that responds to changes in demands includ-
ing those resulting from footwear. For example, a study
demonstrated that the gradual introduction of minimalist
footwear over 10weeks resulted in changes on magnetic
resonance imaging (MRI) concerning metatarsal bone stress
injury (BSI) in a population of runners previously habituated
to standard footwear [13]. By extension, the use of CFP foot-
wear could be expected to generate novel stress to bone. BSI
represents an overuse injury that is the result of localized
failure of bone from cumulative loading and can progress to
the development of stress fracture [14]. Navicular BSIs are
classified as a high-risk location for injury as some of these
injuries may not effectively heal with non-surgical meas-
ures [14]. While navicular BSIs are described in older pop-
ulations of collegiate and professional athletes [15], these
injuries have also been observed in youth athletes [16–18].
Prior studies on biomechanical risk factors associated with
navicular BSI are retrospective and include reduced ankle
dorsiflexion and subtalar range of motion [18], higher peak
rearfoot eversion and range of motion [19], both cavus and
planus foot types [20], and plantar displacement of navicular
and cuneiforms with narrowing of the medial aspect of the
talonavicular joint [21]. The navicular bone receives une-
qual forces from the first and second metatarsocuneiform
joints [22] that create shear stress over the central third of
the bone, corresponding to a region of reduced blood supply
[23], and a common site for navicularBSI. A grading system
of navicular BSIs developed by Saxena and Fullem is com-
monly used to guide evaluation and management based on
CT findings and inform surgical decision making [20, 24].
4 Case Series ofNavicular Bone Stress
Injuries inRunners Using Carbon Fiber
Plate (CFP) Footwear
This case series reflects clinical observations in five patients
presenting with foot pain and diagnosis of navicular BSI
who were using CFP footwear at the time of injury. Given
the high rate of adoption of CFP footwear in track and field,
understanding potential associated health concerns is impor-
tant for athletes and healthcare providers.
4.1 Case 1
A 17-year-old male junior elite steeplechase runner was
using CFP shoes for interval sessions on the track prior to
a race. The athlete felt severe midfoot pain directly after a
3000m steeplechase race. He had no relevant history of BSIs
and had been using different types of carbon-plated shoes
for 2years (completing approximately 1000km of total run-
ning in this footwear). Plain radiographs were performed
immediately after the race and the athlete was cleared to
continue sports participation. Due to persistent pain over the
following 5weeks, he presented at an outpatient clinic and
was diagnosed with a navicular stress fracture. The injury
was managed by sports restrictions (no cast immobilization,
no weight-bearing restrictions). Six weeks later (at 11weeks
after the inciting race), a follow-up MRI was obtained and
did not demonstrate visible bony consolidation (Fig.2a–c).
However, the athlete was pain free and was allowed a grad-
ual return to sports. However, with persistent non-union of
the fracture, he was transferred to a specialist with advanced
knowledge in foot injuries and sports medicine. A weight-
bearing CT revealed a stable Type III navicular stress frac-
ture [20] with the absence of bony consolidation (Fig.2d–f).
After an interdisciplinary case conference with the patient,
shared decision-making was applied, and he completed a
gradual load buildup on an anti-gravity treadmill at 75% of
body weight, and he ultimately returned to land-based run-
ning. Despite a follow-up CT scan revealing that the fracture
line was still present, the athlete continued to run without
pain.
4.2 Case 2
A 17-year-old female junior elite middle-distance runner
was using CFP shoes exclusively for interval sessions on
the track. She had been using carbon-plated shoes for about
6months over 100km. She experienced pain in the midfoot
after a track session wearing CFP shoes. The runner had a
previous history of a navicular BSI in the same foot 2years
earlier that was treated conservatively. On evaluation, she
was noted to have bilateral pes planovalgus. An MRI after
the inciting event revealed a Type 0.5 (“stress reaction”)
of the navicular bone [20]. She was initially treated with
6weeks of non-weightbearing in an AirCast. Repeat MRI
obtained 6weeks after the initial diagnosis showed a reduc-
tion of edema but still a stress reaction leading to 2 more
weeks of non-weightbearing. After a total of 8weeks of
non-weightbearing the athlete started cross-training on an
Alter-G treadmill (initially with 70% of body weight) and
was back to normal and pain-free training 15weeks after
the initial diagnosis.
4.3 Case 3
An 18-year-old female elite 3000m steeplechase runner was
racing a 10km road race in CFP racing shoes. The race was
the first time that she had used the new CFPshoes. The
Content courtesy of Springer Nature, terms of use apply. Rights reserved.

1502 A.Tenforde et al.
week after the race she experienced foot pain localized at the
forefoot with associated minimal swelling and was unable to
walk pain-free in the following days. Without medical con-
sultation, she went back to running and experienced trauma
from acute supination in the same foot leading to medical
consultation. Resulting from this consultation at 4weeks
after the race and 1week following trauma, an MRI was
obtained that revealed a navicular BSI, and a subsequent
CT scan confirmed the presence of a Type III navicular
stress fracture (Fig.3). She was subsequently treated with
non-weightbearing for 4weeks in a walker. Afterwards, she
initiated strength exercises and cross training on a cycle
ergometer. Seven weeks from thetime of CT, she attempted
to run but experienced pain at level 4/10 on a numeric rating
scale. Following one additional week off from running, she
was able to return to running pain-free.
4.4 Case 4
A 38-year-old male elite triathlete competed in a half-
marathon (13.1 miles/21.1km) in CFP shoes. The shoe he
wore had not been used in any significant training or rac-
ing prior. Towards the latter portion of the race, he expe-
rienced midfoot pain, and upon completion, was unable to
walk pain-free. He had minimal swelling, pain localized to
the “N-spot” and experienced throbbing at night. He had a
previous history of a navicular BSI in the same foot, treated
non-operatively 18years prior as a collegiate steeplechaser.
He also had a history of a navicular BSI in the contra-lateral
foot treated operatively 6years prior. He had a stable foot
structure and normally did not wear foot orthoses. Due to his
prior history, a CT scan was obtained, which revealed a Type
II navicular BSI, and the patient underwent open reduction
and internal fixation, and went on to successful healing.
4.5 Case 5
A 36-year-old male elite triathlete ran a 22-mile training
run in preparation for a marathon race 4weeks later. He had
only run in the CFP shoes two to three times prior and for
much shorter distances. He developed midfoot pain imme-
diately after the inciting run, with similar symptoms to the
Fig. 2 Images from Case 1. Sagittal (a), coronal (b), and long axis
(c) on T2 fat-suppressed sequences on magnetic resonance imaging
demonstrate vertically oriented stress fracture. Corresponding views
on CT visualize the fracture orientation (d–f) and classify as navicu-
lar Type III stress fracture [20]
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1503
Bone Stress Injuries in Runners Using Carbon Fiber Plate Footwear
case above (limping, pain at the “N-spot”, throbbing at night),
but no swelling. He had no prior history of a navicular BSI.
The athlete normally wore custom foot orthoses but did not
use these in his racing shoes. Due to the short time-span of
his upcoming race, a CT scan was ordered and was negative
for a fracture. He was diagnosed with a Type 0.5 navicular
BSI (“stress reaction”) and treated with a below-knee boot,
focused extracorporeal shockwave therapy (at 0.40mJ/mm2
for 2000 pulses at the “N-spot”) and electromagnetic transduc-
tion therapy (9000 pulses at power level 8, 8Hz). This treat-
ment was repeated 1week later, and since he was pain-free,
he discontinued the boot. He was allowed cross-training on
a stationary bike and swimming after diagnosis. He started
training on an anti-gravity treadmill 10days after initiating
treatment at 70% body weight. He was able to run on land
approximately 12days prior to his marathon, and he completed
the marathon pain-free.
5 Discussion
The purpose of this Current Opinion article is to describe
both running performance benefits and potential associa-
tions of BSI in runners using CFP footwear. We illustrate
this with a series of navicular BSIs in two discrete cohorts
including a population of junior elite track and field ath-
letes in Europe and two older athletes competing in endur-
ance events in North America. In all cases, athletes devel-
oped acute pain during or after running in CFP footwear.
Differences in time to diagnosis and management reflect
the relative experience of the healthcare providers who
initially evaluated each athlete. A prior study related that
the time to reach an accurate diagnosis for navicular stress
injuries is almost 9months [20]. Recognizing possible
associations of navicular BSI in runners presenting with
vague midfoot or ankle pain who use CFP footwear may
Fig. 3 Images from Case 3. Long axis (a), sagittal (b), and coronal
(c) on T2 fat-suppressed sequences on magnetic resonance imaging
demonstrate vertically oriented stress fracture. Corresponding views
on CT visualize the fracture orientation (d–f) extending through both
plantar and dorsal cortices and classify as navicular Type III stress
fracture [20]
Content courtesy of Springer Nature, terms of use apply. Rights reserved.

1504 A.Tenforde et al.
be important to identify this high-risk injury. A previous
study of 139 elite tennis players reported stress fracture
incidence of 12.9%, of which 27% were located in the
tarsal navicular [25]. A previous article reports navicular
stress fractures to be 35% of all stress fractures [26]. The
true incidence may be hard to estimate since many of these
injuries go undiagnosed for long periods (on average over
8months, as data from a large series and a systematic
review suggest [24, 26]).
Each case presented involved the use of CFP footwear
with a compressible foam midsole designed to improve run-
ning economy. The mechanism for injury in each case cannot
be determined due to limitations of a case report format and
lack of studies to describe the changes in lower extremity
biomechanics between forms of training and racing foot-
wear in both sexes [5].The athletes include a mix of sex,
age, use of CFP footwear and primary competition events.
Use of custom orthotics and prior history of BSI in athletes
could influence injury risk. Two athletes competed in the
steeplechase event and prior work has demonstrated higher
vertical ground reaction forces with hurdling and water jump
landings compared to treadmill running [27].
Based on prior studies describing risk factors for navicu-
lar BSI [18, 19, 22], it is plausible that shoes with a com-
pressive foam midsole may allow for increased plantar
displacement of the navicular and cuneiform bones and
modified forces to the hindfoot. As discussed earlier, multi-
ple biomechanical variables may change using CFP footwear
compared with other types of competition shoes. Behav-
iors of the athlete in their use of these shoes for training
and competition may also explain novel demands on the
foot, including training at faster velocities, which would be
expected to increase skeletal loading [28].
Currently, sports governing bodies permit the use of CFP
footwear, and many runners are using these shoes with the
aim of enhancing performance. Our case series is the first
published cohort to document the potential associated risk
of navicular BSI using this new footwear. Athletes choosing
to wear CFP footwear should recognize the development
of pain, particularly over the navicular bone, anterior ankle
or midfoot region, which may represent a more significant
injury that requires further evaluation to guide correct treat-
ment. Based on prior evidence of maladaptation following
rapid adoption of minimalist footwear use with metatarsal
BSI [13], one potential behavioral strategy for runnersmay
be to incorporate CFP footwear gradually into training and
competition.
While this is the first report to describe bone stress inju-
ries in association with novel CFP footwear, there are clearly
limitations to this work. The development of BSI is often
multifactorial [14] and retrospective chart review limits
understanding mechanisms for injury. The cases are from
two separate cohorts of junior and senior elite from different
geographic locations, and it is unclear whether similar inju-
ries have been observed in other populations. The diagnostic
testing is described using the Saxena and Fullem classifica-
tion to provide consistency in descriptors of injury [21].
6 Conclusion
This Current Opinion discusses a possible association of
BSIs with CFP footwear while recognizing the perfor-
mance benefits that have been described. Advances in the
evaluation and management of BSIs have been extensively
published, and highlight the need to identify multiple risk
factors for BSIs including those that are modifiable. We
recommend further research to better understand whether
the association of BSIs with CFP footwear is unique to the
described runners in this case series or applies to other
running populations. Prior experience with metatarsal BSI
with minimalist footwear led shoe companies to develop
a more gradual program for transitioning to minimalist
shoes; it is plausible that similar advances could be devel-
oped by shoe companies, researchers and clinicians to pro-
mote safety in sports when using CFP footwear. Further
discussions are expected, and both sports industry and
sports federations have a duty to respect the guidance and
advice of medical professionals. The excitement surround-
ing this new technology due to faster running times is pal-
pable for both athletes and the sports medicine community.
We hope this article helps to guide better recognition of
medical issues related to CFP footwear, appropriate use of
this new technology, and safety for our athletes.
Acknowledgements We would like to thank the runners who allowed
us to present their cases in this Current Opinion article.
Funding Open Access funding enabled and organized by Projekt
DEAL.
Declarations
Funding No funding has been received in relation to this work.
Conflict of interest Adam Tenforde, Tim Hoenig, Amol Saxena, and
Karsten Hollander declare that they have no conflicts of interest rel-
evant to the content of this article.
Ethics approval Not applicable.
Consent to participate and publication All patients consented to the
use of their case for this purpose.
Availability of data and material Not applicable.
Author contributions All authors contributed equally to writing this
Current Opinion article. All authors read and approved the final manu-
script.
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Bone Stress Injuries in Runners Using Carbon Fiber Plate Footwear
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