Elsevier

Gait & Posture

Volume 69, March 2019, Pages 50-59
Gait & Posture

Review
Multi-segment foot models and their use in clinical populations

https://doi.org/10.1016/j.gaitpost.2019.01.022Get rights and content

Highlights

  • 65 clinical papers on multisegment foot kinematics used 9 different models.

  • Only few multisegment foot models have undergone validation studies.

  • These models have distinguished successfully pathological from control populations.

  • Severity of foot and ankle dysfunctions and surgical outcomes can be assessed.

Abstract

Background

Many multi-segment foot models based on skin-markers have been proposed for in-vivo kinematic analysis of foot joints. It remains unclear whether these models have developed far enough to be useful in clinical populations. The present paper aims at reviewing these models, by discussing major methodological issues, and analyzing relevant clinical applications.

Research question

Can multi-segment foot models be used in clinical populations?

Methods

Pubmed and Google Scholar were used as the main search engines to perform an extensive literature search of papers reporting definition, validation or application studies of multi-segment foot models. The search keywords were the following: ‘multisegment’; ‘foot’; ‘model’; ‘kinematics’, ‘joints’ and ‘gait’.

Results

More than 100 papers published between 1991 and 2018 were identified and included in the review. These studies either described a technique or reported a clinical application of one of nearly 40 models which differed according to the number of segments, bony landmarks, marker set, definition of anatomical frames, and convention for calculation of joint rotations. Only a few of these models have undergone robust validation studies. Clinical application papers divided by type of assessment revealed that the large majority of studies were a cross-sectional comparison of a pathological group to a control population.

Significance

This review suggests that there is sufficient evidence that multi-segment foot models may be successfully applied in clinical populations. Analysis of the currently available models allows users to better identify the most suitable protocol for specific clinical applications. However new models require thorough validation and assessment before being used to support clinical decisions.

Introduction

In standard clinical gait analysis, three-dimensional (3D) motion of large body segments, such as the thorax, pelvis, thighs, and shanks, is analysed under the rigid-body assumption thus kinematics can be estimated from the trajectories of three non-aligned skin markers attached to palpable bony landmarks. The foot, however, is made up of 26 small bones and presents few accessible landmarks therefore markers attachment to bony landmarks can be challenging. Over the last three decades several methods have been proposed to improve the kinematic analysis of foot segments. These have recently been termed multi-segment foot models (MFMs). There remains considerable debate over how best to group foot bones into segments, particularly in specific, clinical contexts.

The value of multi-segment, rather than single-segment motion tracking has been demonstrated by observing kinematic alterations at foot joints other than the ankle, in both typically developing and clinical populations [1,2]. Significant differences have also been reported [3] when the multi-segment Oxford Foot Model (OFM, see Table 1) and the Plug-in-Gait (single-segment foot) model were used to characterize normal-arched and flat feet. The additional value of multi-segment foot analysis has also been demonstrated with respect to traditional identification of anatomical deformities in static conditions [4]. Measurements are affected by the complexity of multi-segment foot modeling and intrinsic errors from motion of the skin markers with respect to the underlying bone, the so-called soft tissue artifacts. However, the alternative techniques used in routine clinical analysis have significant limitations. Video fluoroscopy and bone pins provide more accurate measures of foot joint motion but are also invasive. Inertial sensors [[5], [6], [7]] and marker-less dynamic 3D scanning [8] are less invasive, but anatomical accuracy is compromised.

A number of review papers on multi-segment foot models (MFM) have been published. Rankine et al. [9] reported a systematic analysis of twenty-five papers, where models were classified in terms of number of bony segments and types of joint rotations. Deschamps et al. [10] showed that some foot joint rotation measures are still unreliable and observed that MFMs have yet to be used to address clinical problems. According to Bishop et al. [11] this is the consequence of poorly described or flawed methodologies, preventing readers from replicating the analysis in real clinical settings. To overcome these limitations and to provide common platforms for sharing and comparing foot kinematic data, they proposed a number of standards for reporting MFMs. The association between foot posture and lower limb kinematics has been addressed in a review by Bult et al. [12]. Novak et al. [13] highlighted the strengths and weaknesses of the most widely used MFMs. A thorough recent survey of the MFMs can be found also in Leardini et al. [14].

The last few decades have seen the emergence of many different MFMs, but little has yet been done to determine their clinical relevance in terms of treatment planning and quantification of outcomes. The present paper aims at reviewing available MFMs, discussing major methodological and technical issues, with a special focus on clinical applications. This knowledge should provide the basis for the selection of the most appropriate model from the currently available techniques, according to the specific population and study hypotheses, and highlight which clinical questions have directly benefitted from utilization of these MFMs.

Section snippets

Material and methods

From January to September 2018 PubMed and Google Scholar were searched for papers on kinematics of human foot segments in-vivo, i.e. any model that included more than one segment. The search included the key words “gait”, “foot”, “kinematics” and “segment” or “model” and involved all relevant previous review papers. The search was extended to all those papers cited in this initial series. All papers were analyzed and categorized into primarily methodological ones or clinical applications of a

Results and discussion

39 papers presenting an original MFM and 65 clinical papers met the inclusion criteria; these are discussed respectively in Parts I and II.

Concluding remarks

A large variety of MFMs based on different marker sets is currently available in the literature (Table 1). Some of these are available to users via simple-to-use software programs, which save time and resources in writing ad-hoc programs. Also according to a recent review [11], the most widely used MFMs are those supported by papers providing exhaustive instructions on marker positioning, data smoothing, definition of the anatomical frames, and joint conventions. This has also enhanced

Conflict of interest

No conflict of interest has to be reported by the authors.

Funding

The Italian Ministry of Health funds for current research and the 5x1000 funds for health research (2018).

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