Related Terms

• Axillary artery thrombosis, axillary crutch, axillary nerve dysfunction, bilateral ulnar neuropraxia, biomechanics, brachial plexus, Canadian crutch, crutch palsy, crutch paralysis, crutches, elbow crutch, forearm crutch, gait, gutter crutch, Lofstrand® crutches, Lofstrand®-type crutch, physical therapy, platform crutch, radial nerve dysfunction, radial nerve paralysis, Strutter®,ulnar nerve.

Background

• A crutch is a walking aid that a patient who is injured below the waist uses. Through the use of its hand grips, crutches reduce the weight an injured portion of the lower body must bear by transferring part of the burden to the arms and upper body.

• Crutches, canes, and walkers are used to provide stability, augment muscle action, and/or reduce the weight an injured area needs to bear.

• The U.S. National Institute of Arthritis and Musculoskeletal and Skin Diseases reports that immobilization is a common treatment for sports injuries. Immobilization limits mobility in the injured area, thereby helping to prevent more damage. Slings, splints, casts, and leg immobilizers are used to prevent motion. Mobility aids such as crutches, canes, or walkers may be needed if the area to be immobilized is in the lower extremities.

• Experts recommend that crutches be used in pairs to foster stability and ensure the best possible sequence and manner of moving the legs, or gait. When an individual's ability to withstand weight with the affected limb improves, some experts recommend using a single crutch on the side opposite the injury. When used in such a manner, the injured leg and the crutch move at the same time, and the crutch still offers a degree of weight-bearing assistance.

• Crutches may be made of wood, steel, aluminum alloys, titanium alloys, carbon-fiber composites, or glass-fiber composites. Titanium is a metal with high rust resistance and the highest strength-to-weight ratio of any metal. Aluminum also is highly rust-resistant, and both metals are combined with other metals to form alloys, which provide additional strength, durability, or both. Carbon fiber consists of carbon atoms that are arranged into parallel threads of carbon crystals during fabrication. The alignment of the crystals makes carbon fibers very strong for their size. Glass-fiber composites consist of very thin extruded glass fibers embedded in plastic.

• Crutches have ancient origins. The entrance to an Egyptian tomb said to be constructed in 2830 BC shows an individual using a crutch-like staff for support. Important modern advances include the invention of a walking stick with upper-arm support by Emile Schlick in 1917 and the invention of crutches that could be adjusted to fit the patient by A. R. Lofstrand Jr. in 1945.

• Advances in crutch design and fabrication continue. Modern materials such as carbon-fiber and glass-fiber composites allow new designs for the two most important points of contact for a crutch: the hand grip and the crutch tip. Ergonomically designed hand grips may allow better control and less fatigue. Better contact with the ground may provide more stability, reduce the chance of slipping, and allow the patient to use less energy for a given level of stability. In addition, advances are being made to add mechanical shock absorbers to crutches, which may reduce stress on the back, shoulder, arm, and elbow.

Technique

• Health care professionals recommend that a patient recovering from a fracture rest the limb as much as possible to promote healing. When a cast or splint is used to immobilize the fracture site and foster healing, crutches provide mobility.

• Crutches may also be recommended for certain nonfracture conditions, such as sprains or strains, and joint, tendon, or muscle pain.

• Types of crutches: There are two principal types of crutches: axillary crutches, which incorporate a crutch pad near the top that should be positioned just under the armpit, and the shorter forearm crutch, which transfers weight to the arm and upper body through a forearm cuff and hand grips. Forearm crutches are used almost exclusively in Europe, where axillary crutches are uncommon. In the United States, those with long-term disabilities often use forearm crutches. Forearm crutches are also called Lofstrand® crutches and Canadian crutches, taking the name of a key patent holder and a major crutch manufacturer, respectively. Both axillary and forearm crutches have hand grips and adjustment mechanisms to accommodate a range of body sizes.

• To maximize grip and minimize slipping, crutch tips are usually made of rubber. Most crutch tips are flat or convex (curved inward). Convex tips flatten when weight is applied. Round-bottom crutch tips are also available. Since they are made of rubber, crutch tips flex when the patient pivots on the crutch, thus remaining flat on the floor for as long as possible. Some crutch tips are designed with extra flex, and others are designed with small dimples to enhance grip.

• A Strutter® is an enhanced axillary crutch on which the standard rubber tip has been replaced with a wider flat surface, providing greater stability as the patient walks.

• Those with problems gripping may use a platform, or gutter, crutch, which provides a platform on which the patient's forearm rests for support. The forearm is usually strapped onto the platform. Although they are designed for those with problems gripping, platform crutches nonetheless have a hand grip. The angle of the platform/grip may be adjusted to suit the patient's strength and gripping ability.

• According to the American Physical Therapy Association, special tools and devices such as crutches, braces, treadmills, prosthetics, compression garments, hot or cold packs, computer-assisted feedback, lasers, and ultrasound may be used during physical therapy. The goal of physical therapy is to improve mobility, restore function, reduce pain, and prevent further injury by using a variety of methods, including exercises, stretches, traction, electrical stimulation, and massage.

• In addition to their role in allowing a patient to get around while keeping the injured area from moving or bearing weight, crutches are used to provide partial support during a patient's recovery, when the patient should begin moving and placing weight on the injured area so that both muscle strength and bone density increase.

• Learning to use crutches: When using crutches, patients should use techniques directed by medical professionals or physical therapists to walk or manage day-to-day activities. Incorrect use of crutches, particularly allowing the weight of the lower extremities to be borne by the underarm instead of the hands and forearms, may result in damage to the upper extremities.

• Training for crutch use may work better in an inpatient setting, where physical therapists may be available, than in an emergency room, where appropriate staff may not be assigned. Often in emergency care settings, nurses or doctors rather than physical therapists provide the training.

• Adjusting crutches: Axillary crutches are available to fit patients ranging in size from three feet, two inches (child) to seven feet, 7.75 inches (extra tall). Adjustments should be made with the patient standing erect and wearing normal footwear. The height of an axillary crutch is adjusted so that the crutch pads are 1.5-2 inches below the armpits with shoulders relaxed. When using crutches, the hands should absorb the weight, not the armpit. The hand grip of an axillary crutch should be adjusted so that it is even with the hip line, with the elbow slightly bent to 15-20 degrees when holding the grip, to allow full extension of the arm when the crutch tip is moved forward.

• Forearm crutches are available in sizes ranging from child (three feet, two inches) to tall (six feet, six inches). Forearm crutches should be adjusted so that the hand grips are at the crease of the patient's wrist, with the arm extended and the patient standing. When the crutch is gripped with the hands, the patient's elbow should bend at about 30 degrees. The cuff should be adjusted to a position 1-2 inches below the bend in the elbow. The cuff should be widened or narrowed to allow a secure fit around the arm. Forearm crutches have a collar that secures the cuff, preventing it from rotating during use.

• Standing and sitting with crutches: Ohio Health in Columbus, Ohio, has published detailed instructions on how to use crutches. To stand, the patient places both crutches together and holds them in front by their hand grips, using the hand on the injured side. The injured leg is extended forward, and the uninjured leg is positioned beneath the patient. The patient uses his or her free hand to reach back to a chair arm, bed, or other supportive surface and then pushes up with both hands and the uninjured leg. Once the patient is standing, he or she takes a crutch in each hand.

• To sit, a patient backs up to the chair until he or she can feel the chair with the back of the legs. Then the patient holds the hand grips of both crutches with the hand on the side with the injured leg. The patient shifts the injured leg forward slightly and crouches down while reaching back to find support with the free hand. The arm holding the crutches, the free hand, and the uninjured leg work together to lower the body slowly to a seated position.

• Walking with crutches: The basic at-rest standing stance when using crutches is the tripod position, with the tips of both crutches resting on the floor forward of each foot by 2-4 inches and slightly to the side of each foot. The patient's weight should rest on the uninjured, or weight-bearing, foot.

• When a patient can bear some weight on both legs, a four-point gait (sequence and manner of walking) is used. From an at-rest position, the patient moves right crutch forward and then the left foot forward. Next, the patient moves the left crutch, followed by the right foot. The four-point gait is the slowest gait, but it consumes the least energy.

• Like the four-point gait, the two-point gait is recommended for patients who can bear some weight on both limbs. The patient moves the right leg and left crutch forward, followed by the left leg and right crutch.

• When a patient should not place any weight on the injured leg, a three-point gait is used. To walk, a patient should place the crutches about one foot ahead, leaning forward slightly. To step, the patient moves the injured leg forward as if it were to be used. As the injured leg goes in motion, though, weight is shifted to the crutches instead of the injured leg. The patient then swings his or her body through the crutches, with the uninjured leg landing even with or slightly ahead of the crutches. When the uninjured leg returns to the ground, the patient should be ready to take the next step.

• Patients whose lower extremities are paralyzed or in braces may use the swing-to gait. From an at-rest position (as mentioned above, with the crutches slightly ahead of the feet), the patient swings both legs toward the crutches, coming to rest between the crutches. Then the patient moves both crutches together forward to a point about six inches ahead of the feet in preparation for the next step.

• A swing-through gait is similar to the swing-to gait, except with the swing-through gait, the patient's legs land ahead of, instead of even with, the planted crutches. The swing-through gait is the fastest gait pattern, but it also consumes the most energy. Also, patients need good upper-extremity strength to use the swing-through gait.

• Navigating stairs: To climb a staircase, health care professionals generally recommend that a patient hold the handrail with one hand and hold both crutches with the upper arm and/or armpit of the other hand. With weight shared between the handrail and the doubled-up crutches, the patient takes the first step with the uninjured foot, leaving the crutches and the injured limb on the step below. Then the patient straightens the uninjured leg to lift the injured leg and crutches. When descending, the patient moves the crutches and injured foot down first, followed by the uninjured leg.

• Patients with more strength and coordination may climb stairs with the crutches in their usual position, one on each side of the body. The patient pushes down on both hand grips to raise the body enough so that the good leg can flex and move up to the first/next step. Then the patient straightens the uninsured leg, allowing the crutches and the injured leg to move upward. To descend, the patient places the crutches on the next step first and brings the injured leg forward as if to begin a step. Then the patient takes a step down with the uninjured leg while placing weight on the crutches through the hands.

• A third way to ascend stairs is to sit on the stairs backward (facing downstairs) with the injured leg extended and the uninjured leg pulled up close to the step. The patient places both crutches together and holds them flat against the stairs with one hand. The other hand and uninjured leg work together to lift the body, step by step. Descent is made much the same way, starting by sitting on the first step facing downstairs, with the injured leg extended and the uninjured leg tucked up, with the foot of the uninjured leg resting on the two steps down. Then the free hand and the uninjured foot lift the body, and the patient shifts his or her bottom down one step.

• Single crutch: When a patient's ability to withstand weight with the affected limb improves, some recommend using a single crutch. Experts recommend that a single crutch be used on the side opposite the injury. When used in such a manner, the injured leg and the crutch move at the same time, and the crutch still offers a degree of weight-bearing assistance.

Theory/Evidence

• There is some evidence that suggests that mobility aids such as crutches, walkers, and canes often are prescribed without a detailed understanding of the devices, which may lead to detrimental consequences. The research suggests that medical practitioners should understand mobility aids and their modifications, correct fitting, gait patterns, and patient physiologic demand.

• Researchers at the University of Pittsburgh state that the phase of rehabilitation during which the patient reacquires limb functionality must be preceded by traditional physical therapy given in phases to ensure normal healing and restoration of motion, strength, and endurance.

• In a study using oxygen consumption to measure energy expenditure, researchers encountered some evidence that forearm crutches have an energy-consumption advantage over axillary crutches. The authors also mention that those using forearm crutches avoid the risk of axillary artery thrombosis and crutch palsy. Axillary artery thrombosis is a blood clot (thrombus) in the axillary artery. Crutch palsy, also called radial nerve dysfunction, may be caused by pressure from the crutch cushion on the radial nerve in the underarm. The radial nerve travels down the arm and controls movement of the triceps muscle in the upper arm.

Safety

• General: Sports medicine experts recommend that patients receive instruction on crutch use and practice using their crutches.

• The crutch tip needs to stay in place on the ground as the patient takes steps. If the standard tips are not sufficiently slip-resistant, they may be replaced with specialized crutch tips, such as tips with a larger surface or a surface with dimples for enhanced grip. Crutch tips wear with use and should be replaced as they wear to maintain maximum slip-resistance.

• Reducing risk of falling: Eliminating hazards in the home that may increase the risk of falling is important. The American Academy of Orthopaedic Surgeons (AAOS) recommends that patients remove potential hazards such as scatter rugs and electrical cords.

• Medical professionals recommend that patients using crutches place nonskid mats near sinks and in their bathtubs. Those who expect to use crutches long term may consider installing grab bars in their bathrooms.

• Proper footwear is important: patients using crutches should wear sturdy, rubber-soled shoes and avoid wearing socks alone, slick-soled shoes, or high heels.

• The AAOS recommends that patients with crutches use backpacks, fanny packs, aprons, or other types of bags to carry items in order to leave their hands free to operate the crutches.

• Crutch palsy: Radial nerve dysfunction, or crutch palsy, may result if crutches are improperly adjusted; that is, adjusted in a way that causes the patient's weight to transfer to the crutch via the underarm and shoulder pad instead of the hands. The condition may also occur if the patient uses properly adjusted crutches in a way that places weight on the shoulder pad.

• The radial nerve travels down the arm and controls movement of the triceps muscle in the upper arm. The radial nerve extends to the wrist and hand, where it controls extension of the wrist and assists in movement and sensation of the wrist and hand. Pressure from improperly used or adjusted axillary crutches most often damages the brachial plexus in the axilla (underarm). The brachial plexus is a network of nerves in the back of the neck that extends through the axilla and connects to the nerves in the arm. The ulnar nerve is the next most frequent area of nerve injury from improper adjustment or use of axillary crutches. The ulnar nerve passes through the inner arm near the elbow, serving the hand and parts of the forearm.

• Symptoms of crutch palsy include weakness of elbow extension, difficulty flexing the elbow (elbow flexion), forearm supination, thumb abduction, and wrist and finger extension. Some patients with crutch palsy experience reduction in sensation in the region of the dorsal forearm (back of the forearm). The location of the injury is most often in the axilla, but the location of the injury for some patients is in the radial groove of the humerus (the bone in the upper arm).

• Other researchers observe that, although crutch palsy often appears in the literature, the condition is rarely seen in clinical practice. Their paper reports on a case of crutch palsy with nerve dysfunction that resolved itself spontaneously in eight weeks. Researchers at the Mount Sinai Medical Center report that most cases of crutch palsy occur in children, and most cases resolve themselves spontaneously in 8-12 weeks.

• Other safety issues: Other side effects of using crutches may include bruising the ribs if the crutches are gripped inward toward the chest, blistering or soreness of the hands due to holding the hand grip, and carpal tunnel syndrome if the hands are used incorrectly for weight bearing. Carpal tunnel syndrome is caused by compression of the median nerve (the nerve connected to the hand that controls some muscles that move the thumb). When pressure is placed on the median nerve, numbness and pain occur, which eventually may lead to hand weakness.

• Researchers have found that using crutches for mobility causes the upper extremities to do more work. Since upper-extremity muscles and joints are not functionally designed for supporting the body's weight, they may become fatigued more rapidly than the lower-extremity muscles and joints. Therefore, crutches may not be appropriate for patients with reduced upper-body strength or upper-body joint instability.

• Those using crutches expend more energy, so crutches might not be suitable for patients with cardiac and long-term respiratory conditions. Epidemiologic specialists have learned that physical exertion, emotional stress, anger, and extreme excitement may trigger a heart attack and sudden cardiac death, particularly with cardiac patients who are not normally active. Since the respiratory system is responsible for maintaining healthy oxygen and carbon dioxide levels in the patient's blood, those with respiratory conditions who exert themselves while using crutches may reduce the amount of oxygen supplied to the body's organs, such as the heart and brain. These depleted oxygen levels may damage tissues and result in death.

• The AAOS advises that axillary crutches tend to fall over when they are stored on their tips, so they recommend that patients lean their crutches upside down, with the crutch pads on the floor. Falling crutches may injure the patient or someone nearby. Furthermore, the patient may have difficulty retrieving the crutches.

Author Information

• This information has been edited and peer-reviewed by contributors to the Natural Standard Research Collaboration (www.naturalstandard.com).

Bibliography

Natural Standard developed the above evidence-based information based on a thorough systematic review of the available scientific articles. For comprehensive information about alternative and complementary therapies on the professional level, go to www.naturalstandard.com. Selected references are listed below.

1. American Academy of Orthopaedic Surgeons. orthoinfo.aaos.org

2. American College of Foot and Ankle Surgeons™. www.acfas.org

3. Dounis E, Rose GK, Wilson RS, et al. A comparison of efficiency of three types of crutches using oxygen consumption. Rheumatol Rehabil. 1980 Nov;19(4):252-5. View Abstract

4. Faruqui SR, Jaeblon T. Ambulatory assistive devices in orthopaedics: uses and modifications. J Am Acad Orthop Surg. 2010 Jan;18(1):41-50. View Abstract

5. Lephart SM, Henry TJ. Functional rehabilitation for the upper and lower extremity. Orthop Clin North Am. 1995 Jul;26(3):579-92. View Abstract

6. Magee JA, Kenney DM. Use of strutter orthoses for an adolescent with myelodysplasia. Pediatr Phys Ther. 2008 Spring;20(1):81-8. View Abstract

7. Natural Standard: The Authority on Integrative Medicine. www.naturalstandard.com

8. OhioHealth. Instructions for using crutches. www.ohiohealth.com

9. Poddar SB, Gitelis S, Heydemann PT, et al. Bilateral predominant radial nerve crutch palsy. A case report. Clin Orthop Relat Res. 1993 Dec;(297):245-6. View Abstract

10. Potter BE, Wallace WA. Crutches. BMJ. 1990 Nov 3;301(6759):1037-9. View Abstract

11. Raikin S, Froimson MI. Bilateral brachial plexus compressive neuropathy (crutch palsy). J Orthop Trauma. 1997 Feb-Mar;11(2):136-8. View Abstract

12. Reisman M, Burdett RG, Simon SR, et al. Elbow moment and forces at the hands during swing-through axillary crutch gait. Phys Ther. 1985 May;65(5):601-5. View Abstract

13. Slavens BA, Sturm PF, Bajournaite R, et al. Upper extremity dynamics during Lofstrand crutch-assisted gait in children with myelomeningocele. Gait Posture. 2009 Nov;30(4):511-7. View Abstract

14. U.S. Department of Education, National Institute on Disability and Rehabilitation Research. www.ed.gov

15. U.S. National Institutes of Arthritis and Musculoskeletal and Skin Diseases (NIAMS). www.niams.nih.gov