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Association between the level of partial foot amputation and gait: a scoping review with implications for the minimum impairment criteria for wheelchair tennis
  1. Fábio Carlos Lucas de Oliveira1,2,
  2. Samuel Williamson3,
  3. Clare L Ardern4,5,
  4. Kristina Fagher6,
  5. Neil Heron7,8,
  6. Dina Christina (Christa) Janse van Rensburg9,10,
  7. Marleen G T Jansen11,12,
  8. Nikki Kolman12,13,
  9. Sean Richard O'Connor14,
  10. Tobias Saueressig15,
  11. Linda Schoonmade16,
  12. Jane S Thornton17,18,
  13. Nick Webborn19,20,
  14. Babette M Pluim9,21,22
  1. 1Faculty of Medicine, Université Laval, Quebec City, Quebec, Canada
  2. 2Research Unit in Sport and Physical Activity (CIDAF), University of Coimbra, Coimbra, Portugal
  3. 3English Institute of Sport, London, UK
  4. 4Department of Family Practice, The University of British Columbia, Vancouver, British Columbia, Canada
  5. 5Sport and Exercise Medicine Research Centre, La Trobe University, Melbourne, Victoria, Australia
  6. 6Rehabilitation Medicine Research Group, Department of Health Sciences, Lund University, Lund, Sweden
  7. 7Center for Public Health, Queen's University Belfast, Belfast, UK
  8. 8School of Medicine, Keele University, Staffordshire, UK
  9. 9Section Sports Medicine, Faculty of Health Sciences, University of Pretoria, Pretoria, South Africa
  10. 10Medical Board member, World Netball, Manchester, UK
  11. 11Toptennis Department, Royal Netherlands Lawn Tennis Association (KNLTB), Amstelveen, The Netherlands
  12. 12Center for Human Movement Sciences, University Medical Centre Groningen, Groningen, The Netherlands
  13. 13Knowledge Centre for Sport & Physical Activity, Utrecht, The Netherlands
  14. 14School of Psychology, Queen’s University Belfast, Belfast, UK
  15. 15Physio Meets Science GmbH, Leimen, Germany
  16. 16Medical Library, Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
  17. 17Department of Family Medicine, Schulich School of Medicine & Dentistry, University of Western Ontario, London, Ontario, Canada
  18. 18Department of Epidemiology & Biostatistics, Schulich School of Medicine & Dentistry, University of Western Ontario, London, Ontario, Canada
  19. 19IPC Medical Committee, Bonn, Germany
  20. 20School of Sport, Exercise and Health Sciences, Loughborough University, Loughborough, UK
  21. 21Amsterdam Collaboration on Health & Safety in Sports (ACHSS), AMC/VUmc IOC Research Center of Excellence, Amsterdam, The Netherlands
  22. 22Medical Department, Royal Netherlands Lawn Tennis Association (KNLTB), Amstelveen, The Netherlands
  1. Correspondence to Dr Fábio Carlos Lucas de Oliveira, Faculty of Medicine, Université Laval, Quebec, Quebec, Canada; fclud{at}


Objective This scoping review examines how different levels and types of partial foot amputation affect gait and explores how these findings may affect the minimal impairment criteria for wheelchair tennis.

Methods Four databases (PubMed, Embase, CINAHL and SPORTDiscus) were systematically searched in February 2021 for terms related to partial foot amputation and ambulation. The search was updated in February 2022. All study designs investigating gait-related outcomes in individuals with partial foot amputation were included and independently screened by two reviewers based on Arksey and O’Malley’s methodological framework and reported according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for scoping reviews.

Results Twenty-nine publications with data from 252 participants with partial foot amputation in 25 studies were analysed. Toe amputations were associated with minor gait abnormalities, and great toe amputations caused loss of push-off in a forward and lateral direction. Metatarsophalangeal amputations were associated with loss of stability and decreased gait speed. Ray amputations were associated with decreased gait speed and reduced lower extremity range of motion. Transmetatarsal amputations and more proximal amputations were associated with abnormal gait, substantial loss of power generation across the ankle and impaired mobility.

Conclusions Partial foot amputation was associated with various gait changes, depending on the type of amputation. Different levels and types of foot amputation are likely to affect tennis performance. We recommend including first ray, transmetatarsal, Chopart and Lisfranc amputations in the minimum impairment criteria, excluding toe amputations (digits two to five), and we are unsure whether to include or exclude great toe, ray (two to five) and metatarsophalangeal amputations.

Trial registration The protocol of this scoping review was previously registered at the Open Science Framework Registry ( and published.

  • Athletic Performance
  • Disabled Persons
  • Gait analysis
  • Sports medicine
  • Walking
  • amputee
  • disability
  • gait
  • Para sport
  • classification
  • partial foot amputation

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  • Twitter @fabiophysio, @clare_ardern, @KristinaFagher, @neilSportDoc, @seanoc_QUB, @janesthornton, @SportswiseUK, @docpluim

  • Contributors FCLO, SW, CLA and BMP contributed to the conception and study design. LS contributed to the search strategy. FCLO, SW and BMP conducted the data extraction, analysis and interpretation. TS performed the statistical analysis. FCLO, NH, CJvR, SW and BMP drafted the manuscript. All authors contributed to the manuscript with critical reviews and approved the final version of this paper.

  • Funding All authors thank the International Tennis Federation and the Royal Dutch Lawn Tennis Association (KNLTB) for supporting this research. We thank Dr Mohd Sameer Qureshi, MBBS, DNB Orthopaedics, for creating the illustrations.

  • Competing interests CA is Editor-in-Chief for JOSPT and JST is Editor for BJSM. At the time of writing, BMP was a classification consultant for the ITF, tasked to review the ITF minimum impairment criteria, and Chair of the ITF Classification Working Group.

  • Provenance and peer review Not commissioned; externally peer reviewed.

  • Supplemental material This content has been supplied by the author(s). It has not been vetted by BMJ Publishing Group Limited (BMJ) and may not have been peer-reviewed. Any opinions or recommendations discussed are solely those of the author(s) and are not endorsed by BMJ. BMJ disclaims all liability and responsibility arising from any reliance placed on the content. Where the content includes any translated material, BMJ does not warrant the accuracy and reliability of the translations (including but not limited to local regulations, clinical guidelines, terminology, drug names and drug dosages), and is not responsible for any error and/or omissions arising from translation and adaptation or otherwise.