CHAPTER ONE

INTRODUCTION TO CRUTCHES

Walking aids are sometimes also referred to as ambulatory assistive devices. They are
devices that may be given to a patient to help them enhance their walking pattern, balance, or
safety when moving about independently. They can also be used to transmit weight from the
upper limb to the ground when it is preferable to reduce weight bearing via the lower limb.

There are walking aids to assist and provide independence to walk around with confidence,
whether you have limited mobility due to a disability or are recuperating from an accident or
surgery. Typical examples of walking aids include canes, walking frames, quadrupeds,
tripods, and crutches.

Definition of Crutches

Crutches are medical devices designed to aid in ambulation by transferring body weight from
the legs to the torso and arms (upper body). They are mainly used to assist individuals with
lower extremity injuries and/or neurological impairment for reasons ranging from short-term
injuries to lifelong disabilities. Indications for crutches are any temporary or permanent
condition where compromise of lower extremity balance and weight bearing exists with a
patient who has sufficient upper body strength and coordination to support and move their
own body weight.

Brief History of Crutches

The first evidence of their use dates back to the time of the Pharaohs, clearly visible in a
carving dating to nearly 3000 BCE. The earliest crutches were essentially a T-shaped design,
which slowly morphed into the more popular V-shape in use today. They were made from a
piece of hardwood cut to length and split near the top to create this V-shape. A wooden
underarm piece could then be attached for both underarm and handle use. Although
uncomfortable as they lacked cushioning, they proved effective.

In 1917, Emile Schlick patented the first commercially produced crutch, catering to the need
of wounded returning WWI soldiers; the design consisted of a walking stick with upper arm
support. Later, the first customisable crutches – they had a height-adjustable frame – were
designed by A.R. Lofstrand, Jr. Crutch mills soon became common throughout New England,

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some of which remain in production today, using production methods dating back to the Civil
War.

Years later, in the 1950s, another development in forearm crutches occurred. An American
polio sufferer named Thomas Fetterman changed the design of forearm crutches. He knew
firsthand how important forearm crutches were to those with mobility issues. He made
crutches with titanium and shock-absorbing rubber feet to improve forearm crutches. This
was an industry first and improved user comfort and paved the way for modern crutch design.

Over time, the design of crutches has not changed much, and the classic design continues to
be the most commonly used.

Indications for Crutches

Indications for crutches are any temporary or permanent condition where compromise of
lower extremity balance and weight bearing exists with a patient who has sufficient upper
body strength and coordination to support and move their own body weight. Some conditions
that might be beneficial to the use of crutches include; lower leg fractures, ankle sprain and
strains, torn meniscus, Achilles tendon rupture, tendonitis, and post-surgical procedures.

Contraindications for Crutches

Using crutches safely requires a moderate amount of strength, balance, coordination, and full
use of both arms. Going up and down stairs is even more challenging, and patients who are
permitted to do so must be carefully selected. Patients must also be able to understand
instructions and demonstrate the safe use of crutches after instruction.

Age is a common contraindication to crutch use. The very old and very young may not
possess the needed torso strength and coordination to use crutches successfully. Any
musculoskeletal or neurological condition that reduces mobility, strength, and sensation can
potentially be a contraindication to the short-term or long-term use of crutches.

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 CHAPTER TWO

TYPES OF CRUTCHES AND THEIR DIFFERENCES

There are different types of crutches available for use. However, there are four main types
that are most used and recommended. They are the Underarm, Forearm, Gutter, and
Hands-free crutches. They are available in different sizes, and each of the sizes is also
adjustable in length, so it is important to choose the right one.

The first thing that is important when choosing a pair of crutches is to ascertain how long you
will need the crutches and how far you intend to travel. The incorrect crutches can lead to
crutch palsy, which can damage the nerves beneath the arms and also result in weak forearm
muscles, wrists, and hands. The correct fitting crutches can help reduce complications and
provide safety.

1. Underarm (Axilla) Crutches

Underarm crutches, also known as Axilla or Axillary crutches, are the most common types of
crutches. They are called Axilla crutches because they are made to sit just underneath the
axilla (armpit). They are what comes to mind when crutches are mentioned, and most people
see them as traditional or conventional crutches. Their ease of use makes them an excellent
option for most individuals. The design is intended to transfer most of the user's body weight
to the arms and torso. Axilla crutches are not ideal for individuals with wrist problems, weak
upper body strength, or impairment of coordination. Most healthcare facilities discharge
patients with axilla crutches for immediate use.

It is usually used after a short-term injury and is made up of either Wood, Aluminum, or
titanium alloy. They should be positioned with two fingers of distance (5cm) between the
axilla and the axilla pad with the elbow flexed between 20-30 degrees. Weight is transmitted
down the arm to the handpiece. The elbow is extended. Weight should not be taken through
the axillary pad as this could lead to neuropraxia of the radial nerve or brachial plexus.

Parts of an Underarm Crutches

The design includes an axilla bar (crutch pad), a handpiece, double uprights joined distally by
a single leg, and a rubber ferrule. They are adjustable in height; both the overall height and
handgrip height can be adjusted (adjustable approximately 48 to 60 inches / 12 to 153 cm).

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The adjustment of the handgrip is performed by adjusting the handgrip in predrilled holes in
the double upright bars using screws and wing bolts. The vertical posts and short horizontal
bars are made of different materials such as Wood, hard plastic, stainless steel, Aluminum
steel, and iron.

Fig 2.1. Parts of an Axilla Crutch

Adjustment of height of the axillary crutch and the handgrip is standardized in an inch
distance (2.54 cm). Adult axillary crutch ranges from 48 to 60 inches (122–153 cm). It is
available in Pediatric, youth, adult, and tall adult sizes.

Advantages of Underarm Crutches

 Underarm crutches are readily available for purchase

 They have the easiest learning curve among the other types of crutches
 They can be adjusted
 An axillary crutch is a better option and more manageable for people with poor
balance and weaker body strength.
 They are ideal for most types of injuries.
 It is used to improve lateral stability.
 It is relatively cheaper than other types of crutches.

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Disadvantages of Underarm Crutches

 They are uncomfortable and often painful to use.

 There is less freedom to walk on uneven surfaces like stairs.
 It permits a less upright posture
 It is longer and more cumbersome
 It can cause soreness and abrasion when used for prolonged periods and if not used
correctly.
 It can lead to potential damage to the axillary nerve causing crutch palsy
 Not ideal for people with weak upper body strength or wrist problems.

Measurement of Length for Underarm Crutches

Measurement of length It is usually carried out with the patient lying.

With shoes off, measure from the apex of the axilla to the lower margin of the medial
malleolus.

With shoes 5cm below the apex of the axilla to a point 20 cm lateral to the heel of the shoe.
This tends to be less accurate than the first method.

The measurement from the axillary pad to the hand grip should be taken with the elbow
slightly flexed (approximately 15 degrees) from a point 5 cm below the apex of the axilla to
the styloid process.

2. Forearm (Elbow) Crutches

The second option is forearm crutches, which can also be referred to as Canadian crutches,
Lofstram crutches, or elbow crutches. They have different mechanics than axillary crutches.
The user's body weight is not supported by the underarms but rather by the forearms, wrists,
and shoulders. There are a few advantages over axillary underarm crutches. The most
important benefit is they are less likely to damage your armpit nerves since the resting
pressure of your body weight isn't on your armpits. Depending on the user, forearm crutches
can put a lot of pressure on the wrists. The user's balance and weight are shifted forward,
which can put a consequential strain on the upper body.

It is used by inserting the arm into the cuff and holding the grip. The hinged cuff, most
frequently made of plastic or metal, can be a half-circle or a full circle with a V-type opening

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in the front, allowing the forearm to slip out in case of a fall. Individuals with long-term
disabilities looking to be more active or participate in sports may choose forearm crutches as
an option.

Parts of a Forearm Crutch

It has the following components a single forearm cuff (vinyl-coated, leather, plastic, or
rubber), a hand grip, and a single uprights vertical post (allow height adjustment) covered
with a rubber ferrule distally.

The adjustment of the handgrip and upright bar is made by using the push button mechanism.
The vertical bar is made of different materials such as Wood, hard plastic, stainless steel,
Aluminum steel, and iron.

Adjustment of height of the elbow crutch and the handgrip is standardized in an inch distance
(2.54 cm). Adult elbow crutch ranges from 29 to 35 inches (74–89 cm).

Fig 2.2. Parts of a Forearm crutch.

Advantages of Forearm Crutches

 It doesn't put pressure on the underarm area, which for a long time use, can prevent
possible nerve damage.

 It is often lightweight and sturdy, which can support greater weight.

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  It encourages upright posture

 It is shorter and less cumbersome

 Forearm crutches allow one to move easier in different terrains like stairs.

 Since the forearm crutches distribute weight equally to both hands, it reduces the risk
of side effects or injuries on our bodies.

 They are one of the best crutches for long-term use.

Disadvantages of Forearm Crutches

 They are not very adjustable

 Requires good upper body strength

 It can become very tiring over longer distances.

 While at first will be more comfortable compared to axilla crutches, it can shift the
pain and discomfort to a different muscle group.

Measurement of Length for Forearm Crutches

The best position to estimate elbow crutches length is the standing position. The
measurement is from the tip of the elbow crutch at 4–6 inches (10.2–15.2 cm) anterior and
lateral to the fifth toe of the ipsilateral limb to the greater trochanter. The elbow crutches
hand grip can be adjusted to allow elbow flexion of 20–30°. The forearm cuff is adjusted and
positioned close to the elbow joint distally (proximal one-third of the forearm).

Differences Between Underarm Crutch and Forearm Crutch

The differences will be discussed in various categories;

o Indications: The axillary crutch is indicated for patients with short-term injuries or
disabilities, especially patients recovering from surgeries and patients who have
injuries due to RTA. While the forearm crutch is indicated for patients who have
long-term disabilities, especially people who cannot make use of their legs, amputees,
etc.

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o Design: The Axillary crutch is designed with an axillary bar that supports the axilla, a
hand grip that the user holds onto while using the device; it has a double upright
which is joined distally by a single leg, and a rubber keel distally. While the Forearm
crutch is designed with a forearm cuff where the forearm rests, it also has a hand grip
that the patient holds on to and a single upright.

o Their other names: The Axillary crutch is also called the UNDERARM CRUTCH
because of where it is placed while in use. In contrast, the Forearm crutch is also
called the ELBOW CRUTCH or the LOFSTRAND CRUTCH.

o Materials they are made of: The Axillary crutch can be made from Wood or an
alloy of Aluminum and titanium. At the same time, the Forearm crutch can be made
from an alloy of Aluminum and titanium.

o Pivot point: The Axillary crutch has a pivot point of more than 60%; because of this
high pivot point, it requires more energy when a user makes use of it, and it tends to
be uncomfortable. In comparison, the Forearm crutch has a low pivot point and is
very easy and comfortable to use.

o Ability to navigate difficult terrains: Because of the high pivot point of the Axillary
crutch making it require more energy while in use, it is not feasible to be used to
navigate difficult terrains such as staircases. In contrast, the Forearm crutch, which
has a low pivot point, can be used to navigate difficult terrains like staircases.

o Arm strength required: The Axillary crutch requires less arm strength when
compared to the Forearm crutch, which operates in a way that weight is transferred
from the legs and distributed to both hands; therefore, the hand receives all the
weight, and the device is used effectively, one must have the good arm strength.

o Posture: People who make use of the Axillary crutch tend to slouch while using the
device because of the high pivot point of the device; therefore, long-term use of this
device can cause a dent in the posture of the user. While, to a large extent, the
Forearm crutch enhances the posture of the user, users are always in an upright

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 position because of the low pivot point of this device, and it is the best crutch in terms
of posture.

o Complications: In terms of complications, long-term use of the Axillary crutch could

cause SORES, ABRASIONS, and CRUTCH PALSY. Crutch palsy is a condition where
the nerve which supplies the axilla is damaged; this damage can be a result of the
patient subconsciously pressing the axilla on the axillary pad when tired. If this is
done continuously, the nerve can get damaged. In comparison, the Forearm crutch has
little or no complications.

3. Gutter Crutches

They are also called adjustable arthritic crutches and forearm support crutches. These are less
common and used by those with poor hand or grip strength due to arthritis, cerebral palsy, or
other conditions. The forearm rests on a horizontal platform and is usually strapped in place
with velcro-type straps that allow the platform or trough to release in case of a fall. The hand
holds an angled grip which, in addition, should allow adjustment of length from trough to
grip and side-to-side sway depending on the user's disability.

Gutter crutches are most commonly used by rheumatoid patients. The forearms of gutter
crutches are softly padded and very comfortable. Gutter crutches distribute weight equally
and maintain balance. These crutches are mainly designed for arthritis patients or patients
with impaired grip. The handgrip is adjustable, and the handle rotates 360 degrees.

The platform allows the user more stability than the axilla and forearm crutches, but it has
less maneuverability. They are intended for long-term use. Individuals with long-term
disabilities from severe neurological impairment of their lower extremities with decreased
stability may choose this as an option.

They are made of metal with a padded forearm support and strap, an adjustable handpiece,
and a rubber ferrule.

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Fig 2.3. Parts of a Gutter Crutch

Measurement of Length for Gutter Crutches

Measurement of length If the patient can stand, it is better to assess the required length in this
position from the elbow to the floor. Measurement can be carried out with the patient lying
with shoes on and is taken from the point of flexed elbow to 20 cm lateral to the heel.

4. Hands-free Crutches

Hands-free crutches are known as knee crutches. Due to the adverse effects of underarm
crutches, a lot of people opt for hands-free crutch. It is mainly used for support for lower leg
surgeries and injuries. Some knee walkers act as leg extensions and make movement easy and
comfortable. Some of the hands-free crutches have a knee pad and straps to the thigh that
provide more support and stability to the user.

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A wheeled knee walker is another type of hands-free crutch. It comes with a set of wheels
and is easy to move around without much physical strain.

They function by strapping the affected leg into a support frame that simultaneously holds the
lower leg clear of the ground while transferring the load from the ground to the user's knee or
thigh. This style of crutch has the advantage of not using the hands or arms while walking. A
claimed benefit is that upper thigh atrophy is also reduced because the affected leg remains in
use. Unlike other crutch designs, these designs are unusable for pelvic, hip, or thigh injuries
and, in some cases, for knee injuries also.

Fig. 2.4. Parts of a hands-free crutch

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Other less common types of crutches include;

 Bariatric Crutches

Bariatric means patients who have been identified/classified as having obesity, i.e., a heavy
body mass index BMI, as such, having challenges in gait. They help provide ease and
comfort and can also be used to move, assist and aid bariatric patients.

These crutches are best for patients with a larger build. Built of steel, these heavy-duty
crutches support up to 550 pounds. They were designed with strength and durability in mind.
Additionally, armpit pads and hand grips have extra thick latex padding to provide additional
comfort. They are made of extra sturdy metals so as to allow for more reliable weight
bearing.

 Millennial Crutches

These crutches are equipped with adjustable handles intended to keep hands and wrists in
their natural position to reduce the risk of developing carpal tunnel for its users.

They are suitable for both adults and children but are only intended to be used as a short-term
crutch (no more than four weeks).

Some models have a shock-absorbing underarm section to alleviate the pain and potential
axillary nerve damage of standard underarm crutches.

Fig 2.5. Millennial Crutches

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Ambulation with Crutches

The walking style a user of a crutch will adopt is dependent on the medical condition, trunk
control, balance, coordination, muscle strength, endurance, weight-bearing status, functional
capacity, and learning ability. Prior to ambulation using crutches, the following safety and
precautions should be checked:

 All the push buttons should be made visible and at the same level.
 The ferrules should not be loose or worn out.
 The handgrips should be attached sturdily and not move when pressure is applied.
 None of the components in the crutch should be loose.
 There should be no dents, cracks, or irregularities on the crutch.
 The following instructions should be given to the users before usage:
 Users should maintain good posture (hyperflexion of the head, neck, and trunk should
be avoided).
 Users should avoid resting (i.e., bearing body weight) on the axillary pad.
 Users should avoid moving the crutches too far away during ambulation. The distance
the crutch should be moved should be within arm's length.
 Axillary pads should be close to the chest wall to improve lateral stability.
 Users should avoid pivoting when turning around; rather, a short circle movement
should be used.

Walking Pattern (Gait) For Crutches

There are several different walking patterns an individual using crutches may adopt,
including:

 Two-point crutch gait: In a two-point crutch gait, the crutches and the non-weight
bearing / affected limb (due to fracture, amputation, joint replacement, etc.) make up
one point, and the uninvolved leg makes up the other point. The crutches and affected
limb are advanced as one unit, and the uninvolved weight-bearing limb is brought
forward to the crutches as the second unit. This gait pattern is less stable as only two
points are in contact with the floor. Thus, good balance is needed to achieve a two-
point crutch gait. The sequence is a right crutch with the left leg and then a left crutch
with the right leg.

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 Two-point gait: the right foot and left crutch are advanced simultaneously, followed
by the left foot and right crutch. There are two points in contact with the floor at any
one time. Those who can tolerate partial weight bearing on both legs but require less
support than a four-point gait usually use the two-point gait. The sequence is a right
crutch with the left leg and then a left crutch with the right leg.
 Three-point gait: this gait pattern is used when one of the lower extremities (LE) is
unable to fully bear weight (due to fracture, amputation, joint replacement, etc.).
There are three points of contact with the floor. The crutches serve as one point, the
involved leg as the second point, and the uninvolved leg as the third point. Both
crutches move forward, and the affected limb then steps up to the crutches. This is
followed by the weight-bearing limb, which steps through, beyond the crutches. There
are always three points of contact with the floor at any given time.
 Four-point: this gait pattern is used when there is a lack of coordination, poor
balance, and muscle weakness in both LE. This is because it provides a slow and
stable gait pattern with four points of support. Point one is the crutch on the involved
side, point two is the uninvolved leg, point three is the involved leg, and point four is
the crutch on the uninvolved side. The crutches and limbs are advanced separately,
with three of the four points on the ground and bearing weight at any given time.
 Step-to: the fractured/injured limb is advanced, and then the intact limb is brought to
the same position. When the weight-bearing status is restricted to partial, toe-touch, or
as tolerated, crutches or a walker are necessary. They help the patient step to the
fractured/injured limb by pushing down with the upper extremities, thus transferring
weight from the fractured/injured limb to the assistive device.
 Step-through: the intact leg is advanced, and then the fractured/injured leg is
advanced past it. With restricted weight-bearing, crutches are used instead of the
injured limb; the patient steps past the crutches with the weight-bearing lower
extremity. Thus, the gait assumes a two-point or three-point pattern.

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Fig 2.6. Types of gait for crutches

Standing from lying position with crutches

When in bed, the user first moves to a sitting position and maintains balance. The user then
inches forward to the edge of the bed or the chair (users can also first transfer to an armless
chair). The user picks up the crutches with the upper limb of the affected side. Both axillary
crutches are then placed upright and same side as the injured side. Using the armrest of the
chair and the crutches handgrips as support, the user slowly moves the injured leg forward,
moving out of the chair and rising up on the uninjured leg and the crutches. The user then

15
positions the crutches properly and then balances up in preparation to move, using any of the
available weight-bearing statuses that can be accommodated based on the user's condition.

Sitting and Standing with crutches

 Only patients who are strong and agile and have good balance should use crutches on
stairs without assistance. Ideally, a sturdy handrail is available.
 The patient stands close to the bottom step.
 The patient places both crutches under the arm opposite the handrail.
 The patient supports himself by holding both crutches in one hand and the handrail in
the other hand.
 The patient leans on the crutches and grasps the handrail for support while stepping
up one step with the foot on the uninjured side.
 After stepping up, the crutches are lifted and placed onto the same step that the patient
now occupies.
 The patient should reposition the supporting hand higher on the handrail to prepare
for the next step.
 To take additional steps up the stairs, the process is repeated.

Walking down Stairs with Crutches

 The patient stands close to the bottom step.

 The patient places both crutches under the arm opposite the handrail.
 The patient supports himself by holding both crutches in one hand and grasping the
handrail with the other hand.
 The patient leans on the crutches and grasps the handrail for support, then moves the
crutches down to the step below.
 The patient moves down to the step where the crutches are using the foot on the
uninjured side.
 The patient repositions the supporting hand lower on the handrail to prepare for the
next step. If no handrail is available, patients can descend steps using normal crutch
walking, but only if they have excellent strength, agility, and balance.
 Patients not capable of descending stairs using crutches may be able to descend stairs
by sitting down and then lifting and then lowering themselves to reach the stair below
one stair at a time.

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 CHAPTER THREE

MATERIALS USED IN THE FABRICATION OF CRUTCHES AND

THEIR MECHANICAL PROPERTIES

Crutch Types Materials used

1. Forearm (elbow) crutch Made of durable, lightweight metal (e.g., Aluminum).
Aluminium has a low density and thus a low weight,
making it mobile and easily maneuverable. It also has high
strength so that the crutch will support the full weight of a
person without bending or buckling. Aluminium is also
easy to machine and corrosion-resistant to ensure a long
life.

 The shaft (usually Aluminum) should be in two

parts, telescopic in nature, and height-adjusting
mechanisms should be made of stainless steel
(high strength, low deformation, high abrasion
resistance).
 Handgrip: usually made of durable plastic or
rubber with pistol-type handgrips. The plastic
provides more wear resistance and durability, but
the rubber is more comfortable and can also absorb
more shock. The handle should be covered with a
durable material (e.g., Nylon 6/6) that has good
abrasion and hydrocarbon resistance to handle the
repeated friction and contact with skin when
walking. It also has high strength and stiffness to
provide sufficient support to the user.
 Height adjustable areas (via a clip or push button-
the pin should be made of stainless steel (high
strength, low deformation, and high abrasion
resistance)
 Tips or ferrule: non-slip and replaceable/

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 interchangeable, usually made of durable rubber.
The rubber provides plenty of grip and stability to
prevent slipping when walking. It also has good
shock absorption to dampen the shock of walking.
2. Underarm (axilla) Made of Wood or Aluminum. For wooden axilla crutches,
crutches high-strength laminated timber is required. High-density
rubber horizontal bar, cushioned, fitting
under the axilla.
3. Gutter crutches Made of durable, lightweight metal (e.g., extruded
anodised Aluminum);
The aluminum shaft should be in two parts,
telescopic in nature. Molded plastic and vinyl padded
forearm with hook and loop velcro
Handle: Adjustable, ergonomically designed, firmly
connected to the main frame, immovable, injection-molded
grey plasticised PVC
Height & forearm adjustable height: stainless steel pin
locking mechanism- single or double spring-loaded pins
(spring clips) on each foot piece.
Spring clips: Double pin type, at least 6 mm in diameter,
electroplated to prevent corrosion.

CHAPTER FOUR

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 CONCLUSION

Crutches are safe and promote users' ability to function in activities of daily living when the
right ambulatory device is prescribed, and accurate measurements of users are obtained prior
to usage. It also reduces the burden of care and burden on caregivers. Trial and error methods
of prescribing and assessment should be avoided to prevent injury to the users.

Safety precautions should be observed by users, and clinicians should always educate users
on guidelines for ambulating with the devices and care of the devices.

It cannot be determined whether it is better to use Axillary crutches or other types of

crutches. However, researchers have discovered that forearm crutches are acceptable for the
majority since they have the majority since they have fewest drawbacks when compared to
other crutches. Nonetheless, when experimenting with crutches, people should explore
numerous options and examine many criteria in order to make the best decision.

Furthermore, crutch makers should incorporate customer input while developing and
improving their product design.

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