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Introduction ⬇

Crutches improve balance, assist propulsion, and remove weight from one or both legs, enabling patients to support themselves with their hands and arms. Typically prescribed for the patient with lower extremity injury or weakness, or one who has undergone a surgical procedure on a lower limb, crutches require balance, stamina, and upper-body strength for successful use.1 Crutch selection and walking gait depend on the patient’s condition. The patient who can’t use crutches may be able to use a walker.

Two types of crutches are currently prescribed by practitioners: axillary and nonaxillary. Patients with a sprain, strain, or cast should use axillary crutches, which are made of standard aluminum or wood. The primary advantage of axillary crutches is that they allow transfer of most of the patient’s body weight.2 Axillary crutches provide better trunk support than nonaxillary crutches.

Nonaxillary crutches include forearm crutches and platform crutches. These crutches are intended for long-term use.2 Forearm crutches transfer the weight of the patient to the upper arms and are indicated for patients with good upper-body strength who have generalized weakness in the lower extremities, such as patients with paraplegia or cerebral palsy.2 An aluminum forearm crutch has a collar that fits around the forearm and a horizontal handgrip that provides support. A wooden forearm crutch resembles wooden axillary crutches that end proximally with a closed leather band that can be situated around the proximal portion of the forearm. A platform crutch transfers the weight of the patient to the forearms.2 It includes a platform placed on the top level of the crutch, a vertical handgrip placed at the distal end of the platform, and Velcro straps applied around the patient’s forearm. This type of crutch is indicated for a patient with a painful wrist or hand condition (such as arthritis), a weak handgrip because of pain or deformity of the hand or wrist, or elbow contractures.

Equipment ⬆ ⬇

Equipment

Crutches with axillary or forearm pads, handgrips, and rubber suction tips ▪ Optional: gait belt, full-length mirror.

Preparation of Equipment ⬆ ⬇

Preparation of equipment

After choosing the appropriate crutches, adjust their height with the patient standing or, if necessary, recumbent. (See Fitting a patient for crutches.)

Implementation ⬆ ⬇

Implementation
  • Consult with the patient’s practitioner and physical therapist to coordinate rehabilitation orders and teaching.
  • Determine the patient’s weight-bearing status to help determine which gait to teach the patient.
  • Perform hand hygiene.4,5,6,7,8,9
  • Confirm the patient’s identity using at least two patient identifiers.10
  • Provide privacy.11,12,13,14
  • Explain the procedure to the patient and family (if appropriate) according to their individual communication and learning needs to increase their understanding, allay their fears, and enhance cooperation.15
  • Place a gait belt around the patient’s waist, if necessary, to help prevent falls. Tell the patient to position the crutches and to shift his or her weight from side to side.
  • Place the patient in front of a full-length mirror, if available, to facilitate learning and coordination.
  • Teach the four-point gait to the patient who can bear weight on both legs. Although this is the safest gait, because three points are always in contact with the floor, it requires greater coordination than other gaits because it requires constant shifting of weight. Use this sequence: right crutch, left foot, left crutch, right foot.2 Suggest counting to help develop rhythm, and make sure each short step is of equal length. If the patient gains proficiency at this gait, teach the faster two-point gait. (See Crutch gaits.)
  • Teach the three-point gait to the patient who can bear only partial or no weight on one leg. Instruct the patient to advance both crutches 6′ to 8′ (15.2 to 20.3 cm) along with the affected leg. Then tell the patient to bring the unaffected leg forward and to bear the bulk of the weight on the crutches, but to put some on the affected leg, if possible and ordered.2 Stress the importance of taking steps of equal length and duration, with no pauses.
  • Teach the two-point gait to the patient with weak legs but good coordination and arm strength. This is the most natural crutch-walking gait because it mimics walking, with alternating swings of the arms and legs. Instruct the patient to advance the left foot and right crutch simultaneously, followed by the right foot and left crutch.2
  • Teach the swing-to or swing-through gaits—the fastest ones—to the patient with complete paralysis of the hips and legs. Instruct the patient to advance both crutches simultaneously and to swing the legs parallel to (swing-to) or beyond (swing-through) the crutches.2
  • To teach the patient to get up from a chair, tell the patient to hold both crutches in one hand, with the tips resting firmly on the floor. The patient should then push up from the chair with the free hand while supporting the body with the crutches.
  • To teach the patient to sit down in a chair, instruct the patient to reverse the process of getting up. Tell the patient to support the body with the crutches in one hand, place the other hand on the chair, and then slowly lower the body into the chair.
  • To teach the patient to ascend stairs using the three-point gait, tell the patient to lead with the unaffected (“good”) leg and to follow with both the crutches and the affected (“bad”) leg. To descend stairs, the patient should lead with the crutches and the affected (“bad”) leg and follow with the unaffected (“good”) leg. The patient may find it helpful to remember the phrase, “up with the good; down with the bad.”
  • Have the patient provide return demonstrations using the appropriate gait, using a chair, and negotiating stairs.
  • Remove the gait belt, if used
  • Perform hand hygiene.4,5,6,7,8,9
  • Document the procedure.16,17,18,19

Special Considerations ⬆ ⬇

Special considerations
  • Consult with the physical therapy department during crutch use training20 because, at a minimum, training should include aerobic conditioning exercises, coordination and balancing exercises, and range-of-motion and muscle strengthening of the upper and lower limbs. Also, teach the patient two gaits if possible—one fast and one slow—because the patient can alternate between them to prevent excessive muscle fatigue and to adjust more easily to various walking conditions.
  • Encourage the patient to remove rugs and clutter from the floor to decrease the risk of falls.20
  • Have the patient wear shoes with nonskid soles, such as tennis shoes or other flat rubber-soled shoe, to avoid slipping.20
  • Instruct the patient not to move too fast or to swing the leg too far forward while using crutches, because this could cause a loss of balance.
  • Check the wing nuts or locking mechanisms on the crutches daily to make sure theyre tightened securely.

Patient Teaching ⬆ ⬇

Patient teaching

Instruct the patient and family (if applicable) to contact the practitioner about any questions regarding the use of crutches or if the crutches don’t fit, break, or are lost. Also instruct the patient to notify the practitioner if blisters, rashes, painful calluses, or skin breakdown of the hand, forearm, or underarm develops. Advise the patient to avoid habitually leaning on the crutches. Explain that the patient’s weight should rest on the hands, not the underarm supports.21 Instruct the patient to seek immediate care if sudden numbness of the hand or arm develops.

Complications ⬆ ⬇

Complications

When used by a patient with a chronic condition, the swing-to and swing-through gaits can lead to atrophy of the hips and legs if appropriate therapeutic exercises aren’t performed routinely. Prolonged pressure on the axillae can damage the brachial nerves, causing brachial nerve palsy. Crutch use can also lead to blisters, rashes, painful calluses, and skin breakdown of the hand, forearm, and underarm.

Documentation ⬆ ⬇

Documentation

Record the date and time of training, the type of gait, the amount of assistance required, the distance walked, and the patient’s tolerance of the crutches and gait. Document teaching provided to the patient and family (if applicable), their understanding of that teaching, and any need for follow-up teaching.

References ⬆

  1. EdelsteinJ. (2019). Canes, crutches, and walkers. In WebsterJ. & MurphyD. (Eds.), Atlas of orthoses and assistive devices (5th ed.). Philadelphia, PA: Elsevier.
  2. WareesW. M., et al. (2021). Crutches. StatPearls. https://www.ncbi.nlm.nih.gov/books/NBK539724/
  3. American College of Foot and Ankle Surgeons. (n.d.). Instructions for using crutches. https://www.acfas.org/footankleinfo/crutches.htm
  4. The Joint Commission. (2021). Standard NPSG.07.01.01. Comprehensive accreditation manual for hospitals. Oakbrook Terrace, IL: The Joint Commission. (Level VII)
  5. Centers for Disease Control and Prevention. (2002). Guideline for hand hygiene in health-care settings:

    Recommendations of the Healthcare Infection Control Practices Advisory Committee and the HICPAC/SHEA/APIC/IDSA Hand Hygiene Task Force

    . MMWR Recommendations and Reports, 51(RR-16), 1–45. https://www.cdc.gov/mmwr/pdf/rr/rr5116.pdf (Level II)
  6. World Health Organization. (2009). WHO guidelines on hand hygiene in health care: First global patient safety challenge, clean care is safer care. https://apps.who.int/iris/bitstream/handle/10665/44102/9789241597906_eng.pdf?sequence=1 (Level IV)
  7. Centers for Medicare and Medicaid Services, Department of Health and Human Services. (2020). Condition of participation:

    Infection control. 42 C.F.R. § 482.42

    .
  8. Accreditation Association for Hospitals and Health Systems. (2020). Standard 07.01.21. Healthcare Facilities Accreditation Program:

    Accreditation requirements for acute care hospitals

    . Chicago, IL: Accreditation Association for Hospitals and Health Systems. (Level VII)
  9. DNV GL-Healthcare USA, Inc. (2020). IC.1.SR.1. NIAHO accreditation requirements, interpretive guidelines and surveyor guidancerevision 20.0. Milford, OH: DNV GL-Healthcare USA, Inc. (Level VII)
  10. The Joint Commission. (2021). Standard NPSG.01.01.01. Comprehensive accreditation manual for hospitals. Oakbrook Terrace, IL: The Joint Commission. (Level VII)
  11. The Joint Commission. (2021). Standard RI.01.01.01. Comprehensive accreditation manual for hospitals. Oakbrook Terrace, IL: The Joint Commission. (Level VII)
  12. Centers for Medicare and Medicaid Services, Department of Health and Human Services. (2020). Condition of participation:

    Patient’s rights. 42 C.F.R. § 482.13(c)(1)

    .
  13. Accreditation Association for Hospitals and Health Systems. (2020). Standard 15.01.16. Healthcare Facilities Accreditation Program:

    Accreditation requirements for acute care hospitals

    . Chicago, IL: Accreditation Association for Hospitals and Health Systems. (Level VII)
  14. DNV GL-Healthcare USA, Inc. (2020). PR.2.SR.5. NIAHO accreditation requirements, interpretive guidelines and surveyor guidancerevision 20.0. Milford, OH: DNV GL-Healthcare USA, Inc. (Level VII)
  15. The Joint Commission. (2021). Standard PC.02.01.21. Comprehensive accreditation manual for hospitals. Oakbrook Terrace, IL: The Joint Commission. (Level VII)
  16. The Joint Commission. (2021). Standard RC.01.03.01. Comprehensive accreditation manual for hospitals. Oakbrook Terrace, IL: The Joint Commission. (Level VII)
  17. Centers for Medicare and Medicaid Services, Department of Health and Human Services. (2020). Condition of participation:

    Medical record services. 42 C.F.R. § 482.24(b)

    .
  18. Accreditation Association for Hospitals and Health Systems. (2020). Standard 10.00.03. Healthcare Facilities Accreditation Program:

    Accreditation requirements for acute care hospitals

    . Chicago, IL: Accreditation Association for Hospitals and Health Systems. (Level VII)
  19. DNV GL-Healthcare USA, Inc. (2020). MR.2.SR.1. NIAHO accreditation requirements, interpretive guidelines and surveyor guidancerevision 20.0. Milford, OH: DNV GL-Healthcare USA, Inc. (Level VII)
  20. CravenR. F., et al. (2021). Fundamentals of nursing:

    Concepts and competencies for practice

    . (9th ed.). Philadelphia, PA: Wolters Kluwer.
  21. American Academy of Orthopaedic Surgeons. (2015). How to use crutches, canes, and walkers. https://orthoinfo.aaos.org/en/recovery/how-to-use-crutches-canes-and-walkers