In Praise of the Crutch-Makers

Stuart Vyse

Cover Image Caption: X-ray of the author’s left foot taken a day after the accident.

 


When I broke a bone in my foot, one of my first thoughts was of a cat I used to know. I was teaching at a small college, and I sometimes saw him lounging in the grass outside my office window. The cat, who was a beloved figure on campus, didn’t belong to anyone in particular, but the students and staff looked after him. His name was Tripod because he had only three legs.

Walking erect on two legs is a defining feature of hominids. Approximately 1.89 million years ago, a primate emerged with hips wide enough to provide lateral balance and a skull centered on top of the spine, allowing its head to be held upright. In The Descent of Man, Darwin suggested that bipedalism became a useful adaptation because it freed the hands and arms to do other things. According to this logic, Homo erectus and later hominids developed shorter arms that were no longer used for walking or tree-climbing.

Illustration from the frontispiece of Evidence as to Man’s Place in Nature (1863) by Thomas Henry Huxley, who was known as “Darwin’s Bulldog,” in recognition of his fierce defense of Darwinism. (Credit: Wikimedia.)

 

But quadrupeds retain one advantage over bipeds. Losing a leg doesn’t stop them. They can easily get around on the remaining three. Tripod had a distinctive jerky gate, but he roamed campus with little difficulty. It is only when a quadruped loses the use of two or more limbs that wheeled carts or other devices are needed to make independent movement possible. When hominids adopted bipedalism, they gave up this ready backup. Losing the use of a single leg forces us to go back down the evolutionary ladder and reengage our arms. Mirroring the developmental path of their species, most infant Homo sapiens begin as quadrupeds, crawling on all fours before mastering the art of walking on two feet, and when an adult Homo sapiens loses the use of a leg, they regress to quadrupedal crawling or walking with crutches. It is possible to amble along on one leg and one crutch, but it is tough going. Most people use two crutches and the remaining functional leg.

I had sustained a Jones fracture, a break near the top of the fifth metatarsal on the outside edge of my left foot. After sitting on the couch with my legs crossed reading a book, I got up suddenly. Unbeknownst to me, my left leg had gone to sleep, and the toes of my foot folded under as I moved forward. Before I realized my predicament, I put weight on the foot and heard a popping sound. When I got to the emergency room, X-rays confirmed that I’d broken my fifth metatarsal bone, and the doctor sent me home with crutches and a controlled ankle motion (CAM) boot. At a follow-up appointment with a foot doctor, I was told the bone should heal normally if I could avoid putting weight on it for six-to-eight weeks.

I was determined to approach my condition aggressively and not let it curtail my activities any more than necessary, so when I returned home — a new inductee to crutch life — I spent much of my first post-injury morning watching YouTube videos about every aspect of crutches. There was much to learn.

An Egyptian stele (1403–1365 BCE) showing what is thought to be a polio victim using an early form of crutch (Wikimedia).

Crutches are an ancient affordance. Egyptians were remarkably sophisticated physicians and are thought to have used crutch-like walking sticks 5,000 years ago. For most of their long history, traditional underarm crutches — fixed-length, T-shaped sticks — were the dominant style. In recent decades, a variety of crutch designs have been introduced, but today most people use one of the three primary designs: the classic underarm crutch, the forearm crutch, or the relatively new iWalk Free kneeling peg leg crutch.

Stereogram photo of John L. Burns, a hero of the Battle of Gettysburg, posing with his rifle and two classic T-shaped crutches (Library of Congress.)

 

Underarm or axillary crutches are the workhorses of crutch history. We have seen them in pictures of Civil War wounded and of polio victims in the years prior to the introduction of the Salk vaccine in the mid-1950s. The early single shaft T-shaped design has given way to the familiar triangular wood and aluminum models. I was issued an aluminum set of underarm crutches in the emergency room, but they were clumsy to use. The support at the top was uncomfortable and tended to catch on my clothes, particularly when I was wearing a coat or jacket. Based on the recommendations of my YouTube friends, I moved on to forearm crutches.

A British World War I–era poster for the Stick-Crutch Fund showing an example of Emile Schlick’s forearm crutch design (Imperial War Museum, London).

The forearm crutch was invented in 1915, by Emile Schlick, an engineer from Nancy, France, and it quickly became popular with wounded World War I soldiers. Schlick’s “walking stick” had a slanted top section that included a metal cuff to surround the forearm and a handle at the top of the main shaft.

The next advance in forearm crutches was made by Anders R. “Rudy” Lofstrand Jr. Lofstrand’s father, Anders Sr. was a Swedish immigrant and owner of Washington, D.C.’s iconic Old Ebbitt Grill, but after graduating from college, Lofstrand Jr.  announced that he didn’t want to go into the restaurant business. He wanted to start a manufacturing firm instead. Lofstrand Sr. invested $13,500 in his son’s first shop in Silver Spring, Maryland, and Lofstrand Jr. returned the favor by inventing a machine for washing restaurant glasses—the first of the Lofstrand Company’s many successful products. Eventually, Lofstrand Sr. sold the restaurant and joined his son in manufacturing. During World War II, the Lofstrand company secured a number of government contracts, and in 1945, Lofstrand Jr. filed a patent application for an adjustable version of Schlick’s forearm crutch.

In the early 1950s, Lofstrand Jr. served as a Republican state senator representing Montgomery County, Maryland, and in 1951, he filed patent US2711183A for a crutch design that allowed both the main shaft and the forearm section to be adjusted to fit the user. Sadly, Lofstrand’s patent was not approved until June 1955, three months after his death from cancer at the age of forty-two. Nonetheless, the forearm crutch is now sometimes called the Lofstrand crutch or the Canadian crutch, and it is the most popular style of crutch in Europe and Canada. In the United States, the underarm crutch remains more popular, in part because it is stereotypically associated with a temporary disability. For reasons that are unclear, forearm crutches suggest a permanent condition.

The diagram accompanying Anders R. Lofstrand Jr’s 1955 patent for an adjustable forearm crutch. (Google patents.)

If there is a Stradivarius of crutch-making, it is Thomas Fetterman of Philadelphia, who has used crutches since contracting polio in 1953. After getting a degree in design, Fetterman took on the challenge of constructing the best forearm crutches possible. He makes custom titanium crutches and has invented specialized shock-absorbing rubber tips. Fetterman’s prominence grew substantially in 1997 when President Bill Clinton had knee surgery and ordered a pair of Fetterman crutches that he jokingly described as the “product of B-2 technology.”

The iWalk Free is a newer product that is less a crutch than a peg leg designed for injuries below the knee. The user kneels on a padded platform with the affected leg, and a shaft below the knee is fitted with a rubber shoe. The beauty of the iWalk is that it provides a form of bipedal transportation. Once it is strapped on, you can lumber around with hands-free, which is no small thing given that standard crutches make the simple act of carrying a cup of coffee almost impossible.

I bought an iWalk based on positive testimonials on YouTube. Although it worked fairly well, I used it almost exclusively around the house. The iWalk makes it much easier to cook, do dishes, and carry things, but it’s bulky. Because your leg is bent at the knee and always extends backward , you need to go downstairs backward to avoid catching the trailing foot on the stairs behind you, and the device must be unstrapped and removed to sit down.

There are many other designs of crutches, walkers, and kneeling scooters, but, to me, most of them seemed too elaborate or impractical. So, after a few days of deliberation, I became committed to forearm crutches. Using Lofstrand crutches requires a bit more wrist and forearm strength than underarm crutches, but they don’t jab your ribs and are easier to wield. In addition, the rubber-tipped shafts are perfect for picking up dropped socks or reaching to flip light switches.

A 1924 photo of Franklin D. Roosevelt using underarm crutches. He had contracted polio three years earlier. The man on the right holding a hat is Al Smith, Governor of New York. Roosevelt would succeed him in 1929. (Wikimedia.)

 

Because I had sacrificed much of my prehensile abilities to the business of quadrupedal locomotion, I employed several marsupial workarounds to carry things. Out of the house, I strapped on a backpack or a messenger bag to hold shopping items, books, and laptops. For use inside the house, I purchased a simple waitperson’s apron equipped with three pockets. If I poured my coffee into a tall travel cup, I could easily transport it — and other things — in the apron. Stairs are a challenge on any kind of crutch, but I learned the standard technique of transferring both crutches to one hand and hopping up and down while holding the rail. Once you learn the correct form, it isn’t too difficult.

The human body has limited regenerative abilities. Once lost, most organs do not grow back. Eyes, ears, stomachs, and livers, as well as hands and feet, are gone for good. The neural tissue of our brains has some ability to regenerate and form new connections to compensate for neurons lost to injury or disease. But bones, the basic superstructure of our bodies, have a remarkable ability to create something from nothing. My Jones fracture had produced a clear separation of the two remaining pieces of my fifth metatarsal. As a result, healing would require filling the gap with bone that did not exist at the time of the break. If all went well, the process would proceed in several phases.

Immediately after the injury, my foot would become inflamed and swollen, and the area around the injury would fill with blood, forming a hematoma. Specialized cells would move in to clean away loose bits of bone and dead tissue, and stem cells, which have the ability to turn into various kinds of tissue, would be recruited from the marrow of the broken bone and from the surrounding soft tissue. To stabilize the bone, the stem cells would form a callus made of cartilage-like material in the gap between the broken ends. This callus would also serve as a scaffolding to build the new bone tissue on. Eventually, bone cells and blood vessels to feed them would grow over the callus, and as the new bone hardened, the callus itself would disintegrate and be swept away.

I have glossed over many aspects of the process, but even this greatly oversimplified description sounds like a biological miracle. A remarkable adaptation to repair the calcium girders of our bodies.

For several weeks I was a visitor in crutch world. Despite achieving a reasonable level of independence during my convalescence, I got an eye-opening introduction to life with a disability. As a wounded quadruped, all the activities of daily life took longer than usual. Bathing, doing laundry, setting the table for dinner, shopping, and simply walking down the street took more time, effort, and planning than they did before. Suddenly, topography that had never been a concern — high curbs, slanted surfaces, and stairs without railings — became a problem and, in some cases, an impossibility.

Despite my efforts at independence, I often found myself taking advantage of the available adaptations. When offered special seating at a theater, I took it, and while traveling through Union Station in Washington, D.C., I accepted the help of a Red Cap to board the train. I refused the great majority of offers from friends, but on occasion I accepted. Especially in the early days when my foot was tender and I was unaccustomed to crutch life, I was grateful when people brought things to me, carried loads, or helped me in and out of cars.

Throughout my sojourn with disability I found myself going back to YouTube to hear from a group of permanent residents in the world of broken limbs. YouTube is home to lots of nasty, banal, and pointless material, but it has also emerged as a valued educational institution. Whether you want to know how to jumpstart a car, install drywall, apply makeup, or create an excel spreadsheet, knowledgeable amateur instructors are standing by to help you. 

What I did not anticipate was that much of the advice I got came from a group of amputees—young YouTubers who appear to be comfortable with their damaged bodies and are using social media to share their experiences and help others facing similar challenges. For example, much of what I learned about using crutches came from Josh Sundquist, a comedian, author, and motivational speaker who lost a leg above the knee to cancer. He uses Thomas Fetterman forearm crutches, and in one video he visits Fetterman in his workshop. Other prominent amputee helpers include Jo Beckwith (“Footless Jo”), who lost a foot subsequent to a horse riding accident, and Kristie Sita, a young Canadian dancer and actress who lost a hand in a boating accident.

Although each of these YouTubers has a different kind of amputation, they have one thing in common. They all have prosthetics, but from what I can tell, they rarely use them. Sundquist appears to never use his prosthetic leg — except as a prop for practical jokes. Sita uses her prosthetic hand primarily at the gym, where it makes it easier to grasp equipment and lift weights. Otherwise, she goes without. Beckwith is relatively new to her amputation and is still evaluating the usefulness of a prosthetic foot. For several of these amputees, prosthetic technology has not advanced sufficiently to provide a reliable adaptation. None of them does anything to hide their missing limbs, and they regularly display their “stumps.” They all have a kind of millennial openness about their bodies that seems very healthy. In addition, their ambivalence about the available prosthetics stands in contrast to the simple usefulness of crutches. Crutches have survived so long because they are dependable. They provide new bones for those who need them, and they work.

In the theater world, there is an expression, “Break a leg.” It’s meant to be a bit of reverse psychology — a ploy to avoid the jinx that might come from a conventional good luck wish. Of course, no one considers a broken leg — or arm, or foot — good luck. But in everyday non-theatrical life, we often employ our own version of reverse psychology. We take an objectively bad event — a broken bone or a lost limb — and turn it into a blessing. Whether rational or not, this seems like an adaptive response. If there is no other way around an obstacle, perhaps it is better to be satisfied or even happy with the cards we’re dealt.

Tripod. (Thanks to Anne-Marie Lizarralde.)

I was lucky enough to have a temporary sojourn in the world of wounded bipeds, but I will do my best not to forget it. My fracture was a modest inconvenience, and there were definite advantages. My upper body has always been a frail and neglected territory, but getting around on sticks forced my arms and chest into reluctant shape. It was gratifying to discover that, after a few weeks of practice — like Tripod — I was able to comfortably tour my neighborhood on just three working limbs. Those muscles will soon return to their prior flimsy state, but other parts of the experience will not fade as quickly. In particular, I have gained a new appreciation for those who deal with disability with grace and confidence and for the inventors of adaptive technologies—the engineers who use their skills to help others. Emile Schlick, Anders R. Lofstrand Jr., and Thomas Fetterman are not names you often hear. None of them has a Wikipedia page. Yet they’ve improved the lives of many thousands of people, and I, for one, am grateful.

Stuart Vyse

Stuart Vyse is a psychologist and author of Believing in Magic: The Psychology of Superstition, which won the William James Book Award of the American Psychological Association. He is also author of Going Broke: Why American’s Can’t Hold on to Their Money. As an expert on irrational behavior, he is frequently quoted in the press and has made appearances on CNN International, the PBS NewsHour, and NPR’s Science Friday. He can be found on Twitter at @stuartvyse.