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Dec 19, 2018

Can We Please Kill Off Crutches?

Let's ditch the crutches. (Photo: OSTILL/iStock)
Let's ditch the crutches.

Almost everyone who’s used underarm crutches agrees: they are terribly designed. They’re hard on your wrists, they cause falls, they cause nerve damage. This is why almost every country in the world has abandoned them—except the U.S., where if you go to the hospital with a leg injury, you’re most likely going to leave with adjustable aluminum crutches. In this third installment of our series exploring how gear gets made, we look at the fascinating history of why better designs for crutches haven’t caught on, and whether or not they ever will.

Podcast Transcript

Editor’s Note: Transcriptions of episodes of the Outside Podcast are created with a mix of speech recognition software and human transcribers, and may contain some grammatical errors or slight deviations from the audio.

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EPISODE BEGINS 

Outside Podcast Theme: From Outside Magazine and PRX, these are Dispatches, stories from our writers in the field. 

Peter Frick-Wright (host): About this time last year, we published a story about this one time when I managed to break my leg at the bottom of a canyon. And because it's not every day that the host of a survival podcast finds himself in a survival situation, it's actually one of our most downloaded episodes ever. I learned a lot from that injury and the following surgery, and one of the first things I learned was what it's like to spend six weeks not being able to put any weight at all on one of your legs. This is a situation that a lot of us find ourselves in at some point or another, and it turns out when you're on crutches and wearing an ankle cast, people just come up and tell you all about their former injuries. It feels like everyone has a story.

 But now that we're a year removed from the accident, there's one story that I haven't shared yet and it's not actually about me, but the gear that I was forced to use during my recovery crutches, there's a default option when you get hurt. So if you're like me, you probably figured that they're the best we can do, but it turns out I was wrong. They're really kind of terrible in a couple of different ways. So producer Alex Ward and I went looking for something better. 

Alex Ward: Yeah, so a few weeks ago I sat down with Peter to talk about crutches and kind of run me through everything he's learned about being hurt. And we're going to pick up from after his injury and the surgery is over and everything else, and he's finally back at home on the couch just staring at a pair of crutches. 

Frick-Wright: I should show you now because I remember when I got hurt, I was like, I made the mistake every other time of like, the first day on crutches, you just use them stock. You just use them straight from the hospital or wherever you get them. And they've got the little rubber things on there and nothing else. And this time I remember like before I had even used them one time, I'm putting pads on the top of these. I'm wrapping a cloth around here like I ain't nobody's fool. My armpits are going to be comfortable. 

Ward: (to Frick-Wright) So those are dish towels duct taped to the top of crutches. 

(voiceover) So on this journey towards less painful mobility, a thin layer of cloth was Peter's first step towards improving it. And by the way, the style of crutch with the crossbar in your armpits is called an axillary crutch. But adding more padding to the top of it doesn't soften the harsh truth about these traditional under the arm crutches that you and everyone else gets from the doctor. They are awful for you. 

Frick-Wright: Crutches are fine for two or three days, but lots of people are on crutches for a lot longer and they must have made some sort of adaptations that I've just had never bothered to look up and so that was where it started I just decided like I'm going to look these up and it just started with Google searches and looking for things that might be out there. And that actually kind of took me on this weird minor journey from the couch last summer. 

Ward: The problem with crutches is an ironic one and that you're actually pretty likely to get hurt while using that. 

Frick-Wright: The liabilities of crutches are crazy, like they are wobbly, they're unstable. If you look at the research studies that have been done on crutches, it's not a matter of like some people get nerve damage in their armpits. It's just like if you use crutches consistently, you will suffer this nerve damage. 

Ward: The fancy term is bilateral radial nerve compression, better known as crutch palsy or crutch paralysis. There's three main nerves in your arm that carry all the messages between the brain and the hand. And one of them, the radial nerve, runs right where the crossbar of a crutch goes in your armpit. And even though you're not supposed to put weight there when you're using these crutches, it's kind of like using Q-tips deep in your ear. It's medical advice we've all agreed to ignore. 

Frick-Wright: So the other crazy thing that you'd never think of is like one of the things that you're doing in rehab, like while you're still in crutches, is just trying to keep that leg that you're not using anymore a little bit stronger than it would be if you just completely stayed off of it. Like these things are in your armpits and you're just hanging like, you're putting a little bit of weight on your good leg, but the other leg is completely disengaged all the way down. And so it just, it atrophies. 

Ward: There's also the physiological problem of transferring all of your body weight to your wrists and shoulders, which can lead to further injuries and pain. Add in the inherent instability of crutches and the increased risk of falling, and it's like something specifically designed to work against your body and make it really difficult to get around. 

Frick-Wright: It turns out that replacing your legs with two pieces of metal doesn't quite do the trick. 

Ward: So why do we use these things? With all of the advances of modern science and technology, why are we settling for the bad design of axillary crutches? What would a world with better crutches look like? Because let's face it, we all need somebody or something to lean on. 

In Peter's case, it was only a few days before he started looking for something else. 

Frick-Wright: So that took me almost immediately to the knee scooter, which I can get out here for you. 

Ward: (to Frick-Wright)There is a story to this corner of your room (laughs). 

Frick-Wright: Yeah, I just piled all my rehab gear over there and it looks like I run some sort of physical therapy. (laughs)

So this is your standard four wheeled knee scooter. It's a taller model. I had trouble finding one that would fit my height. They're like 600 bucks and my dad found one for $45 on Craigslist. 

Ward: (voiceover) Peter's Craigslist scooter, AKA Nelson, according to the name written on it, is a classic beauty with a height adjustable handle and leg pad for eight inch rubber caster wheels and a detachable basket to carry things. And don't forget the high octane pulse pounding set of brakes. This baby can be driven right off the lot and down the hallway in style. 

Frick-Wright: It's pretty simple. You put your knee down to get the weight off your ankle, you have a little steering column upfront. So this is really nice. Especially in a house like we have, which is just one level, all of the space is sort of open. I can roll in and make a sandwich and roll all over the place. The hard part is like even one stair can be super problematic.

Ward: Not just stairs, but anything that's not a smooth level surface can trip you up. 

Frick-Wright: I went to physical therapy just like a block away from my house. I would scoot there on the scooter and there was one day that I'm scooting down the sidewalk and there's like a stick that's the exact same color as the sidewalk laying across. And my front wheels just jam into that stick and I go flying and I catch myself like on my good leg and I just sort of do one of those like hop, hop, sit down on my butt and roll onto my back kind of things. And like the wheels, my scooter's on its side and the wheels are still spinning and one car drives by and sees me splayed out like wearing a cast and they rolled down the window and they just go, idiot! (laughs) Like no sympathy for the fact that I am like hurt.  

Ward:  Mean people aside, the real problem with the new scooter is that when you have a non weight bearing injury, it's often because there's screws in your leg that can be ripped out if you put weight on them just once. So crashes are a big problem. And the other big problem is that even though there's been a lot of progress making public spaces accessible to wheelchairs, there's still a lot of stairs out there. 

Frick-Wright: This is still hard enough to use that the only place you go with the scooter is to your physical therapy. Like you don't go out for fun and that's kind of the standard for crutches or scooters or any of these other mobility devices is like are you going to go somewhere for fun or is the difficulty of going somewhere going to take most of the fun out of it?

Ward: We all get stir crazy if we're laid up around the house for too long and like Peter said earlier, muscles not in use will atrophy. Sitting around is bad for the body, so that's another plus for the new scooter is that it engages the hip and the quad muscles, but it's just balancing them on a little shelf, they're not really moving. What would be better for you is if you could somehow still replicate a walking motion while keeping weight off the foot. 

Frick-Wright: Which brings me to I think the coolest and weirdest crutch alternative, which is this guy, the iWalk. 

Ward: Axillary crutch alternative number two, the iWalk. It's a crutch that holds the knee and lower leg on a horizontal platform and straps to your thigh while an aluminum peg extends downward to where your foot would be. 

Brad Hunter: The best explanation I've come up with in the past, just that it's like a 21st century pirate leg in a way. 

Ward: This is Brad Hunter. He's the president of iWalk Free, inc., he company that makes this new age peg leg. He says that aside from the muscular engagement, the primary thing that differentiates it from normal crutches is that it's hands free. 

Hunter: I mean with conventional crutches like underarm crutches, or even forearm crutches which are more popular in Europe or Canada, you don't just lose the use of your leg, you also lose both of your hands and arms. So it's a three limb injury and anybody that's ever been on crutches and I had never been on crutches and I didn't realize just how debilitating they were until I was on them for like five minutes. And then immediately I realized all the things I couldn't do. I was trying to get through a door that was like slightly spring loaded and it was impossible. You know, I'd have to put the crutches in one hand, kind of balanced and stand on one foot, push the door open, try to get the crutches back under my arm and get through the door. By then it had slammed shut on me and it started there. 

Ward: (to Hunter) I’ve seen Peglegs depicted in cartoons and pirates since I was a kid. And it seems like something like this shit have come out a long time ago. 

Hunter: Well, actually it did in fact hundreds of years ago. If you there's old pictures of amputees with the pirate legs, but if you look, they're actually kneeling on it. It's not a socket that's stuck to the end of their leg, like you'd see on a pirate cartoon or something. So this was the way they've always done it -- the difference was it was a wood platform. It was held on with leather straps and it didn't function very well. But back then before prosthetics, what else were you going to do? So you may do with whatever you had. They weren't practical. There were certainly not practical for a non weight bearing injury for a person that wasn't an amputee. 

Ward: (voiceover)The prototype for the iWalk came about around the year 2000 when a farmer in Ontario, Canada broke his ankle. 

Hunter: He's having to tend to this farm, well how is he going to do that? He had livestock defeat and all kinds of things to do. A farmer’s life is tough. And so he's on these crutches and he can't do anything. And he found himself kneeling on this stool in order to shave in the morning and he realized, this works pretty good. If I had something like this instead of these crutches, I could probably get through my day. So he made the first one out of wood and it worked great and that's how the whole thing started. 

Ward: But at the time, this farmer, this guy named Lance, had just gone into his shop and built himself a custom one out of wood. Making it commercially viable would be difficult. But luckily the device was noticed by his doctors and Lance eventually patented the design alongside the Sunnybrook Health Science center in Toronto. They began manufacturing iWalks, but it was a tough sell at first. Nobody knew what it was or why they needed it. 

Hunter: And so it existed, but it sort of kind of didn't quite get off the launch pad. So for about 10 years it sort of was out there, but it really didn't go anywhere. It was heavy, it was expensive. There was a lot of limitations. It was difficult for a lot of people to balance on and to learn. And so for a variety of reasons, it just was never going to be commercially successful. 

Ward: Brad came into the picture around this time about eight years ago now, and he happened upon the iWalk by injuring his own ankle, jumping from a boat to a dock. He went on Craigslist to find a walking boot and when he went out to pick it up, the guy he bought it from just happened to have this other thing in the back of his garage that might work too. And it was one of the first generation iWalks and Brad was immediately taken with the product. 

Hunter: And I'm like, how is it possible that this is not the standard? Why are we still using sticks under arms? It makes no sense whatsoever. And I did a little research and kind of figured out where the company was and it's kind of my niche personally to find these great ideas and turn them into a viable commercial idea and a commercial venture. And here we are today. 

Ward: It was like the stars aligning. Before finding the iWalk, Brad had worked for a company that made high end bicycle wheels, specializing in designs that were lightweight, yet strong. So a lot of that design and manufacturing processes translated over to the iWalk production. And in 2013 they relaunched with the iWalk 2.0. 

Hunter: We needed to make it lighter, we needed to make it come in a smaller box. We needed to make it where you could assemble it quickly with no tools. So all of these things came into play and I could bore you to death with, okay, we've got this many ratchet teeth in the thigh support and the thumbscrew pitches, one point, blah blah blah. All that kind of stuff is just going to put you to sleep. But what we really wanted to do was make it so it worked better for a larger amount of people.  

Ward: (to Hunter) That seems to be the issue with conventional crutches is that they have to try and make them so that they can be adjusted to everybody. But it seems like that requirement is sort of what dooms traditional crutches. 

Hunter: I mean most traditional crutches have to come in three different sizes as far as height goes, because the way that the packaging of the product works, you just can't get the range of adjustment that you need in one crutch. 

So in the new design, we wanted to build in more adjustability that allowed people to do that so they could tailor it for their particular body geometry. For us, what we figured out was that, and we actually there's a thing called Natick tables and they're used by everyone from NASA to design the interior dimensions of say a space shuttle to clothing companies. And it's just human factors that have been measured over a huge population. So, what's the average length of legs versus height? What's the lower leg proportions? It's just proportions, proportions, proportions. 

So we designed the 2.0 version of iWalk to fit what's referred to as the 95th percentile. So 95% of the world adult population can wear an iWalk. 

Ward: So why do people still use conventional crutches? 

Hunter: Because they don't know. Once you know about that there's something better than you wouldn't use it anymore. It would be like having a rotary dial phone in your car and calling your friends. You just wouldn't do it if you knew that, Hey, I can use a smartphone. It's just changing a paradigm of thought is probably our biggest challenge. You know, crutches have a 5,000 year headstart. 

Ward: (voiceover) So, that’s the iWalk, an excellent, ingenious alternative to crutches that's actually catching on. But the problem is that it only really works for lower leg injuries. If you hurt your knee or your hip or you can't put weight on one side of your body for some reason, you're still stuck with crutches. So Peter started looking not at crutch alternatives but at the very best crutches out there. 

Frick-Wright: So I got one more set of crutches and these were supposed to be like the best crutches. They're called the smart crutch and they are super customizable, super adjustable. Your hands go in, lickety split, they sit under your elbows, your forearms, rest on them, and then you have like molded handles to help kind of guide everything. And these are just like the best crutches that are still crutches, they're not something else. You can get them in whatever color you want, which is a nice feature. They disengage from your arm if you fall. They are incredibly comfortable. 

Ward: This is the third and final alternative to axillary crutches, the forearm crutch, and they're sort of in a different realm altogether than the others because in some form they've been around just as long as axillary crutches and they're better in every way. There's more control, better weight disbursement and less risk of nerve damage. But here in the U.S. you just don't see them very often and yet almost everywhere else in the world forearm crutches are the standard, not the underarm ones. So to find out why we wanted to talk to someone with a different perspective on crutches entirely. Someone who spent their entire life on them. 

Thomas Fetterman: My name is Thomas Fetterman and I'm the crutch guy. I have spent many years developing crutch and crutch tips and technology that's more human friendly. It'sa very important thing. If you're a runner, a long distance runner, you want to make sure you have the good footwear. If you're mountain biking, you want the best mountain bike. Well, I want the best crutches on the planet. 

Ward: Thomas contracted polio in the 50s when he was just eight years old. If you don't know, polio is an infectious virus that can affect the central nervous system resulting in the paralysis of one or more limbs. And the polio epidemic hit its peak in 1952 when nearly 60,000 children were infected in the U S and although a vaccine to eradicate polio would be developed before the decade was over, it couldn't reverse the effects of the virus. Thomas had to spend six months in a polio ward with other children. And during the rehabilitation, they were outfitted with an early version of forum crutches that were developed by an Australian nurse named Sister Kenny. 

Fetterman: And that's called a Kenny crutch, named after her course. And that's what I used for probably 10 years or so, the Kenny crutch, as did all the other people that I associated with afterwards that had polio. And you know, it was kind of called the polio crutch. 

Ward: The Kenny crutch looks like a regular crutch up until the top. Imagine if you cut off the top 10 inches of the underarm crutch and instead fitted a leather band that strapped around your arm. 

Fetterman: And it was very good, uh, especially for kids because we were very active and we would fall all the time. I mean, that's a big part of  walking on crutches is falling. And we were actually, we had nuns who took care of us in abbotts and everything back in those days. And one of the things that they did was they took us into the room with the gym mat on the floor and they would come up behind us and literally kick the crutches out from underneath. 

Ward: (to Fetterman) Was this was this to like harden you up? 

Fetterman: Well, it was to teach us how to fall. And it was a great lesson because I've calculated I’ve fallen probably more than 500 times in my life. And yet I like to say I never chipped a tooth, I mean, that was always the goal is not let your head hit the ground or what. It was a great life skill that I felt I never thought I needed.

Ward: (voiceover) Keep in mind that at the time wheelchair accessibility wasn't anywhere near what it is today. Crutches could navigate around stairs and curbs, and so Thomas knew he wanted to say upright whenever possible. He says he learned early on that stature is universally important and that people would literally talk down to him when he was in a wheelchair. So despite the polio, he got good at being vertical, which meant mastering crutches. And from a young age, he was fixing and maintaining his own crutches because unlike the temporary users, a lifelong user is going to be consistently wearing out crutches. 

Fetterman: I always seemed to be pretty inventive or handy with tools and hand tools and whatnot. And I think partly because of this early exposure to taking care of my gear. And then when I finally went to university, I went to industrial design. And so I looked at my crutch and I said, this could be done a lot better than it is 

Ward: After college, Thomas and his wife got married and went traveling and they traveled like crazy. First he and his wife ended up immigrating to Australia in their twenties. 

Fetterman: And after a year and a few months, we packed it up and went to Bali and lived in Bali and in Java and Singapore and Malaysia. And we did that for three and a half years. 

Ward: Hang on, it doesn't end there. 

Fetterman: Germany and down to Yugoslavia and Greece and then up to Turkey and over the Turkeyish Alps to Iran and across Iran to Mashad. And then from there over to Herat and then Kandahar and then cobbled down the Khyber Pass into Pakistan, Basharward, Jalalabod, and then into India. And all that time I had to maintain my equipment. I had no access to crutch tips and that was the biggest problem because you couldn't get crutch tips anywhere. I mean, I could in Singapore and places like that, but not when you're in Sumatra, by the way, don't ever go there looking for crutch tips. You're not going to find them. 

Ward: Eventually it was in Colombia that Thomas found a structural improvement that he could make for his crutches. He was on a long walk on the beach where the sand was particularly grainy and loose. 

Fetterman: And the crutches, they sink in six inches with every step. It's really a schlog trying to walk on soft sand on crutches. And by the end of this long walk that I took across the beach, my shoulders ached and I had never really experienced -- that's always been my strength, my shoulders, my upper body developed to be pretty strong. So, I thought, geez, I better start mitigating this impact force that my shoulders and cartilage and or all absorbing now and see if I can get some kind of mechanical relief. 

Ward: Thomas took a spongy rubber ball and cut out a half inch section of it and he sliced off the tread of the crutch tip, slid the rubber ball piece in there and reattached the tread. 

Fetterman: And I found, wow, this is really nice. I could definitely feel it was a lot more comfortable. The walking on that hard rubber. So that was the real innovation that I made. The crutch tip is the most important aspect of any crutcher cane.

Ward: Thomas took his crude solution and continued refining the idea, eventually getting a patent for a crutch tip with shock absorption technology. And before this story, I had never considered the bottom tip of the crutch as the thing that needed to change. But it makes sense. If the bottom weight bearing part doesn't work, nothing else matters. 

Fetterman: I mean, the way it engages the ground is everything. And what it does during that engagement is very, very important to long-term crutch users. Now they're the majority, the greater majority of crutch users, are short term users. Probably like Peter, I mean six weeks is a long time, but still it's not 50 years mind you. The axillary underarm crutches, which this country insists on continuing to issue,  they are like cash cows in the medical system. 

Ward: I looked into the numbers on crushed distribution in the U.S. and the best estimates have axillary crutches being prescribed roughly 60 to one over forearm crutches. They've been the standard for so long that they're just part of the medical system's DNA. But this has been the case for a long time. I mean there's ancient Egyptian drawings that depict the use of an underarm walking stick and I'll bet they just put up with it too. The basic design of the crutch hasn't evolved much since then. But the times we do see change is for the same reason lots of technology changes: war. In the U.S. for example, there was a boom in crutch production during the Civil War when soldiers were losing limbs left and right, be it by battle or disease. The hardwood trees of the North provided plentiful and reliable wood for crutches and soon crutch mills began producing them in large quantities. 

Fetterman: Most of them were pretty down and dirty and they were for the infantry people. But if you were an officer, you got a crutch called the sling top crotch, which was rather sophisticated and that really pushed -- by 1916 the crutch tip industry started to really move forward. Based on all these disabled people who are now getting older from the civil war. So I mean, it's amazing how war drives all this stuff. 

Ward: The mass production of crutches continued through WWI and WWII and was soon followed by the polio epidemic. And perhaps it's here that we find the answer as to why we still use bad crutches. The increased number of children with polio meant that a better solution for crutches was more dire. So it didn't take long for something like Kenny crutches to come around and make long term mobility easier for a child that couldn't walk again. But with that innovation came stigma. Suddenly the forearm crutch was associated with permanent disability. Even the president at the time recognized this. Franklin Roosevelt had polio, yet he chose to be sitting down whenever appearing in public rather than walking with crutches. 

Fetterman: Because there's a stigma that we carry being long term disabled people, and people who have a short term need, they don't necessarily want to be seen as a long-term cruthc user. 

Ward: This perception has not only lasted this long, but has been fortified over the years through the media. Think of Jimmy from South Park or Walter Jr and Breaking Bad, both prominently displayed on forearm crutches. Meanwhile, you'll find underarm crutches in the logo for Jackass, which is basically a reckless laboratory for short term injuries. There's no question that crutches in all forms are way better than the walking sticks and the leather straps of old. But that doesn't mean we should just settle for a bad crutch. We just need to overcome an old stigma and the medical system that's set in its ways. Axillary crutches are the cheapest for them since they make so many. So the demand just needs to shift, and hopefully we don't need disease or war to change our behavior going forward. In fact, Thomas's latest project is called Peace Tips. 

Fetterman: I carved peace sign in the tread piece. So everywhere you walk, you're leaving these peace signs. 

Ward: It's part of a program to supply better crutch technology to places that wouldn't otherwise get it. Places where there's a lot more long term crutch users because of civil violence, old minefields, natural disasters, or just less healthcare access. They even supply soccer teams in the amputee World Cup. Not bad for a kid that lost his ability to walk at age eight. 

Fetterman: What my disability told me loud and clear when I was like 18 years old --I realized that that time in my life when I was 18, that I had limited mobility in my life, that I had a finite amount of crutching that I was going to be able to do in my lifetime and stay vertical and so on and so forth. That realization really lit a fire under my spirit and there we go. And that was propelled by this desire to see the world and do all the stuff while I still could. 

Ward: (to Fetterman)You feel like you've used that time as well as you can. 

Fetterman:Yeah. I feel like I've jammed at least two lives into my life already. Maybe I'm working on a third, you know what I mean? I mean, we do a lot and I have to say that the crutches have been an integral part of that. When I was traveling, I still had not driven across the United States. I left that. I've never been to Hawaii for instance. I've saved a lot of stuff for my wheelchair scooter days, which I've entered into now at 74. I'm a lot less mobile than I was, but still I had this vision when I was a kid. This is the way my life was going to unfold and I think I was was right. 

Ward: (voiceover) I have no idea who I'd be if I'd lost my ability to walk as a kid, but I hope it'd be like Thomas. Something I picked up on talking with him is that he really feels for anyone who suddenly has to use crutches, even if it's temporary. There's no bitterness that he's had to do this as whole life, and now you know what it's like. He simply offers you a leg up, which speaking of Peter is going to need again. Ge's going back into surgery in a couple of months to clean up some cartilage in his ankle that was damaged when he broke his leg. 

(to Frick-Wright) You have another period of crutches looming on the horizon. How are you feeling about it? 

Frick-Wright: I mean it's dark. I'm not excited about it. There's pretty much nothing that I'm looking forward to in terms of having this surgery again. 

Ward: (voiceover) It turns out even the best crutch alternatives don't keep an injury or surgery from taking over your life. You can still do a lot of things, but it's going to take a lot of extra work. It's going to be inconvenient, but at least there's some other options. 

Frick-Wright: Crutches are like a seeing eye dog, but just like a really bad dog (laughs) doesn't follow your commands. Like sometimes walks you out into traffic stuff. 

Frick-Wright: That's Alex Ward and me talking about crutches. We produced and edited this piece together. Music by Robbie Carver. This piece was brought to you by Adidas and their all new line of Terrex outdoor gear. The outside podcast is a production of Outside Magazine and PRX. We're taking a break until January. We'll be back on the eighth with a story about the craziest endurance competition we've ever heard of.

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Outside’s longstanding literary storytelling tradition comes to life in audio with features that will both entertain and inform listeners. We launched in March 2016 with our first series, Science of Survival, which was developed in partnership with PRX, distributors of the idolized This American Life and The Moth Radio Hour, among others. We have since expanded our show and now offer a range of story formats, including interviews with the biggest figures in sports, adventure, and politics, as well as reports from our correspondents in the field.