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Nursing Field Notes / Musculoskeletal · Med-Surg Mobility

Crutch, Cane & Walker Training

Fitting, Gait Patterns, Stairs & Walker Safety

NG-064 Musculoskeletal ADHD-friendly visual edition

The device is only as safe as the technique. Crutches and canes both restore mobility while protecting a healing limb — but wrong fit or wrong gait turns an assistive device into an injury risk. This page goes deep on the mechanics: how to fit each device, the 4 crutch gait patterns, and exactly how weight moves on stairs.

📄 Simple Nursing original — opens in Drive →

🖐️ Weight on HANDSNever the armpits — axillary pressure = nerve damage.
🦯 Cane on the STRONG sideCane + weak leg move together, then the strong leg.
🪜 Up with the good, down with the badThe unaffected leg always leads going up; the crutches/cane + affected leg lead going down.
📏 2 finger-widths below axillaCrutch tip 6 in. out, 6 in. forward from the foot; elbow flexed ~15–30°.
🩼

FIT & TYPES

STEP 1 · MEASURE IT RIGHT

This builds on NG-167 (Ambulation) — that page covers the general body-mechanics/gait-belt overview. This page goes deep specifically on crutches, canes and walkers.

📏 Correct crutch fit — the numbers that get tested

✅ CORRECT FIT 2 finger-widths (1–2 in.) below axilla hands grip pad — weight goes HERE tips ~6 in. out & 6 in. forward of feet ❌ WRONG — TOO HIGH ⚡ pad jammed into armpit Compresses the brachial plexus → numbness, tingling, weak grip = "crutch palsy"

Weight bears on the hands/palms through the handgrips — the axillary pad is a balance point only, never a weight-bearing point.

🧠 "Pads for balance, palms for pounds." If a client is caught resting body weight on the crutch tops between steps, that's an immediate correction — nerve damage builds silently over minutes to hours of pressure.

🚨 The classic NCLEX trap: axillary nerve damage

  • Crutch top pressing into the axilla compresses the brachial plexus.
  • Presents as numbness/tingling in the hand, weak grip, and can progress to permanent nerve palsy ("crutch palsy") with prolonged pressure.
  • Never let the client "hang" on the crutches between steps.
🧠 Armpit ≠ anchor. Any test question describing tingling hands or a client leaning heavily under the arms on crutches is pointing straight at brachial plexus compression.

🦯 Cane types & hand placement

  • Standard (single-tip) cane — mild balance/weakness on one side.
  • Quad cane (4-point base) — more stability, e.g. hemiparesis.
  • Held in the hand on the client's strong/unaffected side.
  • Cane tip stays ~4–6 in. to the side of the foot; elbow flexed ~15–30° when the tip touches the floor.
🧠 "The cane babysits the bad leg from across the room." It's held opposite the weak leg so it can support that side's step.

📋 Weight-bearing status — know the abbreviations

Abbrev.Meaning
NWBNon-Weight-Bearing — no weight at all on the affected limb.
TDWB / TTWBToe-Touch/Down Weight-Bearing — toes may touch the floor for balance only, no true weight.
PWBPartial Weight-Bearing — a set fraction of body weight allowed (e.g. 30–50%), per provider order.
WBATWeight-Bearing As Tolerated — client self-limits based on pain.
FWBFull Weight-Bearing — no restriction.
🧠 The weight-bearing order determines which gait pattern is used — that's why Section 2 pairs each gait with its weight-bearing status.
🚶

GAIT PATTERNS

STEP 2 · MATCH THE GAIT TO THE ORDER

Four crutch gaits exist because clients have four different weight-bearing statuses — pick the gait, don't guess it.

👣 The 4 crutch gait patterns

4-POINT GAIT 1 2 3 4 R crutch → L foot → L crutch → R foot 3-POINT GAIT 1 1 1 2 Both crutches + BAD leg together, then GOOD leg 2-POINT GAIT 1 1 2 2 R crutch + L foot together, then L crutch + R foot SWING-TO / SWING-THROUGH 1 1 to/thru Both crutches forward, legs swing to or past them
GaitWeight-bearing status
4-pointPartial/full weight-bearing bilaterally; slowest, most stable — most closely resembles normal walking.
3-pointOne leg NWB or PWB, the other leg fully weight-bearing — the most common post-injury gait.
2-pointPartial weight-bearing bilaterally; faster version of 4-point.
Swing-to / swing-throughBilateral lower-extremity weakness or paralysis (e.g. paraplegia); swing-through is faster and covers more ground.
🧠 "3-point = 3 points of contact bearing weight." Two crutch tips + the unaffected (good) leg carry the body; the affected leg stays off the floor (or barely touches) and travels forward with the crutches. Say the pattern out loud while picturing footprints — the ADHD brain remembers rhythm better than a list.

🩹 3-point gait, step by step (most tested)

1
Advance both crutches forward together with the affected (bad) leg.
2
Shift weight onto the hands/crutches.
3
Swing the unaffected (good) leg through, past the crutches.
🧠 Bad leg travels with the crutches, good leg travels alone. That's the whole pattern.

⭐ Fitting & gait check — before the client walks away

  • Client demonstrates weight on hands, not axillae.
  • Elbows flex 15–30° at the handgrip.
  • Gait matches the ordered weight-bearing status.
  • Never use someone else's crutches — fit is individualized.
🧠 Re-teach on the spot if the client leans into the pads even once — bad habits under fatigue are how nerve injuries happen at home.
🪜

STAIRS & SAFETY

STEP 3 · UP GOOD, DOWN BAD

One rule drives both crutches and canes on stairs — lead with the strong side going up, lead with the support going down.

🪜 Stairs with crutches — the tested sequence

⬆️ GOING UP 1. GOOD leg up 2. shift weight 3. crutches + BAD leg "Up with the GOOD leg" ⬇️ GOING DOWN 1. crutches + BAD leg 2. shift weight 3. GOOD leg down "Down with the BAD leg"

Up with the good leg, down with the bad leg — the crutches always travel with the affected leg.

🧠 "Good goes up to heaven, bad goes down to the basement." Whichever direction, the crutches stay glued to the affected leg's step.

🚨 Top-missed NCLEX pattern: cane on stairs

Going up: lead with the strong leg, cane follows, weak leg last. Going down: cane descends first, weak leg next, strong leg last.

🧠 Same "good up / bad-side-support down" logic as crutches — the device (cane or crutches) always moves with the weaker side.

✅ Everyday cane gait

1
Cane + weak leg advance together.
2
Strong leg steps through, past the cane.
🧠 "The cane babysits the bad leg." They move on the same beat.

🔗 Cross-reference: Ambulation basics (NG-167)

NG-167 covers the general assistive-device overview, gait belts, and body mechanics/fall-risk assessment that apply to every mobility aid. This page (NG-064) is the deep dive specifically on crutch and cane fitting and gait mechanics — read both together.

➡️ See NG-167 — Ambulation for gait-belt technique, walker use, and the broader fall-prevention checklist before any first ambulation.
🚶

WALKERS

STEP 4 · THE MOST-USED AID, THE LEAST-TAUGHT ONE

A walker gives more support than a cane and needs less skill than crutches, which is why it is the aid most of your clients will actually go home with. The questions are about fit, sequence and the two things that cause falls.

🚶 The sequence — walker, weak, well

✅ WALKER → WEAK → WELL 1 Advance the walker about one step length — not further 2 Step in with the WEAK leg the injured, painful or surgical side 3 Bring the STRONG leg through it carries the load, so it moves last

All four legs of a standard walker are on the floor before any step is taken. Never "walk" a standard walker by shuffling two legs forward at a time — that is the single commonest error, and it is what tips a client over sideways.

The walker stays about one step length ahead. Pushed out too far, the client leans forward to reach it, the center of gravity goes outside the base of support, and the walker becomes the thing that causes the fall.

🧠 "Walker, weak, well." Same logic as crutches and canes — the aid and the bad leg travel together, the good leg does the work last.

📏 Fitting a walker

  • Client stands inside the walker, arms relaxed at the sides.
  • Handgrips sit level with the greater trochanter — the hip bone — or the crease of the wrist.
  • Elbows flex about 15 to 30 degrees when gripping. Same angle as crutches.
Too high and the shoulders shrug and tire; too low and the client stoops, which is both unsafe and exhausting.

🛞 Which walker for which client

TypeWho it suits
Standard
(no wheels)		Most stable. Must be lifted every step, so it needs upper-body strength. Used for non-weight-bearing and partial weight-bearing.
Two-wheeled
(front wheels)		For a client who cannot lift a standard walker. Rear legs have glides or tennis balls so it slides, not catches.
Four-wheeled
(rollator, seat, brakes)		For endurance problems rather than weight-bearing limits. Not for someone who needs to lean on it for weight — it rolls away.

🚨 The two things that cause walker falls

The errorWhat to teach instead
Pulling up on the walker to stand. It is not anchored — it tips toward the client. Push up from the chair armrests, get steady, then reach for the walker one hand at a time.
Backing into a chair blind and sitting down while still holding the walker. Back up until the legs touch the seat, reach back for one armrest, then the other, then lower. Lock a rollator's brakes first.
🚨 A walker is never used on stairs. If the question puts a walker on a staircase, the answer is about a different plan — a stair rail, a transfer, or a different aid entirely.

✅ Home safety before discharge

  • Remove throw rugs and trailing cords — the classic exam answer.
  • Rubber tips intact on every leg; replace them when worn smooth.
  • Non-skid shoes that fit. No backless slippers.
  • Clear a turning path; turn in a wide arc with small steps, never a pivot.
  • Lighting on the routes to the bathroom and kitchen.

🆚 Cane vs walker vs crutches — one line each

AidThe deciding fact
CaneMild one-sided weakness. Held on the strong side, advances with the weak leg.
WalkerGreater instability or bilateral weakness. Advance it, then weak, then strong.
CrutchesWeight kept off one limb entirely. Weight rides on the hands, never the axillae.
🧠 "Strong holds the cane, weak leans on the walker."
⚡

QUICK RECALL

SAY IT OUT LOUD
🖐️ Hands, not armpitsWeight on the handgrips — axillary pressure risks nerve palsy.
🩹 3-point gaitBoth crutches + bad leg together, then good leg.
🦯 Cane = strong sideCane + weak leg together, then strong leg.
🪜 Up good, down badUnaffected leg leads up; device + affected leg lead down.
🎯 Cover & check — 4 rapid-fire questions
Q1: Where should crutch weight be borne, and what happens if it isn't?
On the hands/palms through the handgrips. Resting weight on the axillary pads compresses the brachial plexus — numbness, tingling, weak grip, potentially permanent "crutch palsy."
Q2: A client is non-weight-bearing on the left leg. Which crutch gait, and what's the sequence?
3-point gait — both crutches and the affected (left) leg advance together, then the unaffected (right) leg swings through past the crutches.
Q3: A client with a cane is going up a flight of stairs. What's the correct order?
Strong leg leads up first, the cane follows, and the weak leg comes last — "up with the good leg."
Q4: Which crutch gait most closely resembles normal walking, and who is it appropriate for?
4-point gait — for clients who can bear at least partial weight on both legs; it is the slowest but most stable pattern.