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The Eternal Debate

Ever since Walk Easy was founded back in 1991, we have always wondered why certain countries favor the underarm crutch (or axillary) over the forearm crutch (aka Lofstrand, elbow or Canadian).

Certain markets like the U.S. primarily recommend or administer underarm crutches for short-term use, as a result of a lower-limb sprain or fracture or as a post-operative rehabilitation aid following surgery. Typically, a person would use underarm crutches anywhere from 4 to 12 weeks, with doctors and therapists sometimes recommending a walker for the first few days.

For short-term crutch users, many factors play a determining role in the type of walking aid that is prescribed and used:

  1. 1) The physician's personal preference

  2. 2) The physician's exposure to global trends and continuing further education

  3. 3) The physical, occupational or rehab therapist's personal preference and overall familiarity with available walking aids and whether he or she has had training or education abroad

  4. 4) The patient's age, weight, agility and overall strength

  5. 5) The patient's personal preference

  6. 6) The hospital, medical facility or DME (durable medical equipment) shop's inventory of available walking aids

  7. 7) The brand reliability, purchase price and profit margin.
     

Over the past 26 years and for short-term patients, our best estimate is that the underarm crutch is prescribed 58:1 over the forearm crutch. Simply put, in the U.S. less than 2 people out of 100 are prescribed a forearm crutch for a period of use of 12 weeks or less.

Unfortunately, studies have shown that underarm crutches do not encourage correct posture due to frequent incorrect adjustment or use (leading to compression of the radial nerve, otherwise known as “crutch palsy”) and they offer limited gait types.

pivot point on underarm versus forearm crutchDue to the underarm crutch's pivot point (or fulcrum) being much higher, on average 62% higher than that of a forearm crutch, the axillary crutch requires more energy expenditure with each step – more acceleration and deceleration – and makes it much more difficult to walk up or down stairs or steps. Purely from a perspective of convenience, underarm crutches are also longer and more cumbersome than forearm crutches.

In an American Journal of Engineering Research paper (published in 2016), authored by Adnan Miski and entitled "Design Evaluation of Crutches from an Engineering Perspective," it was noted that a late 1970's study showed that "the percentage increase in heart rate from resting rate was about 20% higher for ambulation with axillary crutches compared to ambulation with elbow crutches." The author goes on to conclude that "We have found that forearm crutches are suitable for the majority as they have minimum disadvantages compared to other crutches."

While there are many more arguments in favor of forearm crutches, our research and past 26 years of experience talking to both types of crutch users, we have come across the following three “pros” in favor of underarm crutches:

  1. 1) When fatigued, users like to be able to rest their body weight on the underarm pads — which is exactly what they shouldn't do,

  2. 2) Short-term users perceive forearm crutches as being used only by those with a long-term physical challenge, hence want to avoid the stigma — the exact opposite perception exists in most other countries.

  3. 3) Forearm crutches require more upper body strength and more practice to master.

The USA predominantly prescribes the axilla crutch while the rest of world seems to prefer the forearm crutch.

Interestingly, in the UK and Europe, New Zealand, Australia or even Argentina, the forearm crutch prevails: “The USA predominantly prescribes the axilla crutch while the rest of world seems to prefer the forearm crutch” (posted on www.ResearchGate.net)

woman on a forearm crutch in supermarket

Over the past 25 years, we can confirm a gradual, albeit slow, acceptance of the forearm crutch as a superior walking aid even in the U.S. This shift can be seen with some of the country's most prominent and respected physicians prescribing forearm crutches after common medical procedures like hip replacement or arthroscopic knee surgery.

One of the strongest arguments in favor of the forearm crutch is also by far the most logical: doctors, therapists and patients agree that the forearm crutch is a superior walking aid for the vast majority of long-term crutch users. That argument alone should suffice in convincing anyone, especially short-term crutch users. With all due respect, that doesn't mean that there aren't specific cases or personal preferences among some users toward the axillary crutch.

Below is a compilation of excerpts from posts that we could find on the subject of underarm versus forearm crutches across websites, message boards, forums and blogs. This content, including images, is the property of its respective authors or copyright owners.

Posted on www.quora.com
(by a Quora member)

If you need a pair of crutches I can assure you that forearm crutches are much easier on your body than conventional (in the US) aka underarm crutches.

Everyone I know who has used underarm crutches has reported significant pain due to incorrect use or fitting - allowing their weight to be supported by their underarms; this isn’t possible when using forearm canes. I suspect there is a correct way to use underarm crutches, my 98 pound wife, in her teens, managed to walk two miles two and from high school once she finally got them fitted right, but it took a lot of pain to get there.

I have used forearm crutches every day since 2011, for five or six years previously I used a cane, stopping when a talented rehab specialist saw me walk with the cane then strongly suggesting a pair of forearm canes.

Traveling in Western Europe, Chile, and Argentina I saw folks using canes and forearm crutches, I can’t remember anyone using underarm crutches.


Posted on forum.heathermills.org
(by a member)

I've used crutches for many years and now prefer to use forearm crutches. Years ago they would only give out underarm crutches because forearm crutches are not designed to take full body weight, so whatever you do, make sure they are the correct ones, ie. designed to take a persons full body weight.

By the way when I was taught to use underarm crutches I was told to take the weight on my hands, not under my arms, the idea is that you use your upper arms to grip the crutches to your body whilst taking the weight on your hands.


Posted on forum.roadbikereview.com
(by a member)

Since you're never really resting on your armpits, the forearm ones are as stable and IMO more comfortable. Unless, that is, you want to take a slouching rest on the crutch tops. I also like that they don't rub at all, even though I size them correctly and don't use tops to rest I too inevitably get some chaffing on the inner arms/ribs. Come to think if it, I really wish I'd sacked up and bought some of those last month instead of using the 'freebie' traditional crutches.


Posted on www.researchgate.net
(by a Purdue University student)

I would like to begin a forum to discuss which crutch prescription is best practice. The USA predominantly prescribes the axilla crutch while the Rest of World seems to prefer the forearm crutch. This query examines secondary injury, patient safety, range of mobility, ease of use, energy expenditure, and pain and fatigue associated with crutch-walk gait for all user types.


Posted on www.researchgate.net
(by Marshall B., in reply to the previous question)

I asked some US PT's why they still use the Axilla Crutch and the answer came back similarly that they are for temporary use. In New Zealand the hospital just gives you forearm crutches without the option of the axilla and people seem to be fine. I don't personally see the strength debate being a good reason to use the axilla crutch since if used correctly, the hands carry the full or partial weight bearing in either configuration.

Immediately after my accident I had to use the axilla crutch because my right arm was in a plaster cast at a right angle. So I know there is a place for the axilla crutch. But as soon as I could I switched to the forearm crutch.


Posted on www.enjoyingtheride.com
(by Mitch Sturgeon)

If you read my post on Judy the Physical Therapist, you may recall that when I visited her for the first time I was using a wooden cane to help with walking. One of the first things Judy did, in an act that I characterize as picking the low hanging fruit, was to grab a pair of demonstration forearm crutches, adjust them for my height, and let me try them out. Wow! What a difference.

image of a caneThese crutches were an improvement over the cane in two ways. Look again at the photo of my wooden cane. Notice that the connection to my arm exists only at my hand. This is not a very rigorous connection. It’s the weak point of the whole arrangement, kind of like that little piece attached to each leg on the underside of a folding table. If the piece is locked in position, then all is well. If you break that link though, the table leg folds, whether you want it to or not.

image of a caneNow look at the photo of the forearm crutches. They link up with my arm in two locations. My hand connects in a similar manner as with the wooden cane, but there's a second connection point further up on the forearm. So using even one forearm crutch is already much more stable than using a cane. The crutch feels like a natural extension of my arm.

Another nice feature of the forearm crutches is that you can let go with your hands and the crutch doesn't fall to the ground. This frees up your hands for whatever activity you need them to do.

The same day that Judy introduced me to forearm crutches I went to a medical supply store and purchased a pair. Initially I would often use only a single crutch, to leave my other arm completely free, and, well, frankly to appear less disabled. A person using a single cane or crutch has some difficulty. A person using a pair of forearm crutches is a cripple, or so I thought. Over time though, I naturally gravitated toward the added stability that came with using two crutches instead of one.

Read more about Mitch on Enjoying the Ride.


Posted on www.mybrokenleg.com
(by a member)

I am someone who has suffered problems from being on underarm crutches.

My spine is slightly curved from using them for so long as well as constantly leaning on them when tired. I have blown out my wrist numerous times from being on them because of the way the weight is distributed compared to forearm crutches. I was told after my first surgery that I should have been put on forearm crutches once I went past three months by the PT at the hospital. I guess it depends on how long you are on them for, I was on them for 9 months the first time, 8 months the second time, 2 months the third time, 2 months the fourth time and 3 months when I injured my knee.

It's hard to say what you should do, your OS will know what is best from an ortho perspective, if it will ruin your posture and stuff like that. However I think that the PT is worried about the amount of work you would have to do for the muscles that adjust to the ways of walking on those types of crutches. Go on the advice of your PT or OS or if you are not comfortable using forearm crutches or it is unsafe when you try, then stick with underarm crutches.


Posted on the previous Walk Easy Message Board
(by a crutch user)

I have done much research on the two crutches as a user myself. The axilla (underarm) crutch WILL cause crutch palsy (Google it) after any duration of use. The extent of the crutch palsy will differ from person to person and mostly from duration of use. The urge to rest your armpits on the pads is too great especially when balance challenged and fatigued. This is why you will RARELY find a full time user of crutches using axilla crutches but instead will use the height adjustable, hinged v-cut full cuff, round handle, forearm crutch, the most common world-wide made by many different manufacturers costing between $20 to $500.

Forearm crutches are not less expensive, they are generally more expensive than underarm crutches. To further, the only country in the world to use the axilla crutch widely is the US and large manufacturers refer to the forearm crutch as the "rest of world" crutch knowing full well that axilla crutches cause crutch palsy. This is an oversimplification but go to the NIH.gov websites for more in depth research on crutches.

For the guest that wrote that they find the axilla more stable, I have found persons in your condition to prefer the custom height set (fixed height), heavy gauge tubing, soft round handle, hinged v-cut full cuff (this allows your arm to break out of the crutch in case of a fall to shield yourself). Please try this configuration and learn how to use them correctly before use. You may find you have more mobility and more use of your hands when standing static such as pushing an elevator or street crossing button. However each persons condition differs and the axilla crutch may be the best option for you.


Posted by Walk Easy
(in reply to the following question)

In England when you go to the hospital with a leg injury, the hospital will give you forearm crutches, but in America they give you underarm crutches, even though they are the same injuries. Anybody know why this is?

After 12 years in business, the forearm versus underarm debate continues to surprise us! As you accurately mentioned, forearm crutches are dispensed in the UK but also in most other Western countries worldwide.

In our opinion, there are 4 main factors which continue to influence the much greater adoption rate of underarm crutches in the U.S.:

  1. 1. Education and training of orthopaedic surgeons, physical therapists, rehab therapists and everyone else who prescribes crutches. They have little exposure to forearm crutches, not only as a viable alternative but in many cases a superior alternative.
  2. 2. A general mindset among the North American population that forearm crutches are for long-term physically challenged individuals only. Ask any short-term user and they'll reply "but I will only be using the crutches for a few weeks/months so I don't need forearm crutches."
  3. 3. Potential lawsuit problems arising from incorrect forearm crutch training. Underarm crutches are perceived by everyone as being simple to use. However, they are very bulky, restrictive and frequently cause axillary radial nerve compression. Going up or down stairs with underarm crutches is quite an undertaking!
  4. 4. The higher price of forearm crutches. However, this is due not to the complexity of manufacturing but to economies of scale. There are on average 46 pairs of underarm crutches sold for each pair of forearm crutches.

From www.physio-pedia.com

Axillary crutches is a misnomer because they should not be placed in the axilla at all. They should actually be positioned about 5cm below the axilla with elbow slightly flexed,15° approximately.


From www.physiotherapy-treatment.com

Weight should not be taken through the axillary pad as this could lead to a neuropraxia of the radial nerve or brachial plexus.

Have you used either or both types of crutches for any length of time? We would love to hear your thoughts.

Please join in this discussion by leaving your comments below. Remember that to avoid "spam" you must be logged in to comment.

COMMENTS (1)

  • Anna M.
    May 29, 2018

    why didn't FDR use forearm crutches?

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