Crutches

by Kieran Healy on September 5, 2004

Seeing as Kevin is wondering whether M&Ms have gotten smaller since the last time he looked[1], my imponderable for the day is this: Why is it that in Europe (at least in my experience) patients with a sprained ankle or whatever are typically issued with forearm crutches whereas in the U.S. you get underarm crutches. It seems clear to me that the underarm kind is inferior in every important respect. So why does it survive in the U.S.?

Possible explanations:

  • Efficiency. Already ruled out. Underarm crutches are inferior.
  • Revealed Preferences. Underarm crutches must be more efficient because otherwise people wouldn’t be buying them.
  • Path Dependence. Some QWERTY-like event in the early 1900s locked American hospitals into the underarm regime.
  • Cultural. De Tocqueville notes somewhere that American individualism thrives in the presence of underarm supports for gammy legs, while the ancien regime’s tendency to lean at the elbow meant that its collapse was both inevitable and unforseen.
  • Marxist. The ruling crutches of any epoch are the crutches of the ruling class, etc.
  • Evolutionary Psychology. On the Pleistocene Savannah, Underarm crutches provided a selective advantage to their users due to their greater length, enabling Underarm-using groups to hold off predators at a slightly greater distance and obtain marginally higher-hanging fruit than their Forearm-using competitors.
  • Political Economy. A cartel of crutch producers in league with hospital crutch-wranglers and has cornered the market through aggressive undercutting of the competition and a complex system of kickbacks. Standard Crutch (New Jersey) pioneered this technique in the 19th century, bringing it to such a pitch of perfection that it was impossible to buy a forearm model without also getting three underarm models delivered to you.
  • Libertarian. Though technically inferior, underarm models are ultimately beneficial because they encourage a quicker return to standing on your own two feet.

Alternative explanations (perhaps even informative ones) are invited.

fn1. Perhaps they are simply further away than before?

{ 49 comments }

1

VJ 09.05.04 at 8:29 am

My bet is on the cultural-economic QWERTY path. Crutches of the underarm type have been around for a very long time, and there’s already an industry grown up around them to manufacture and supply them. It may also stem from the stigma of polio. People with forearm crutches ‘appear’ to be more significantly afflicted, and hence it assumes a more permanent cast, as in ‘Gee, she looks like she’ll have that for a very long time’. There are forearm crutches used in the US, they are typically used for much more serious and lasting injuries, where the user is likely to use the crutches everyday. This is where their efficiency pays off. The dividends of this may not be obvious to someone with a fleeting injury that might last only weeks. It’s my bet that the costs are somewhat greater for the forearm crutch too. Therefore, like QWERTY, it grew up from being ‘good enough’ for a couple of centuries, and has not changed much except for material composition.

2

John Quiggin 09.05.04 at 8:56 am

Categories like “sprained ankle” are culturally dependent, socially constructed realities. Crutches are merely crutches for these social constructions. il n’y pas de hors crutch

3

liberal japonicus 09.05.04 at 9:48 am

-because forearm crutches are for sissies?
-because I paid for a crutch damnit, so I want my money’s worth!
-because it requires some thought, and American hospitals don’t want to be liable for non-thinking American patients
-because with a ‘real’ crutch, you can grab it with both hands and beat an attacker over the head with it (assuming you can balance on one leg). With one of those forearm jobbies you’d probably thump yourself on the back of the head, thereby doing the attacker’s work for him

4

tew 09.05.04 at 9:51 am

Prices of forearm crutches on your linked-to page: $99, $125

Price of underarm crutches on your linked-to page: $45

Maybe underarm crutches are just cheaper to make?

5

FMguru 09.05.04 at 9:56 am

I think it’s a signalling mechanic.

Those giant, unwieldy underarm crutches are iconic – they’re what Americans envision when they hear the word “crutch”. Everyone who injures themselves gets issued a pair, so lurching around on them becomes a signal that you are recently injured and are likely to be fine in a few weeks.

Those efficient forearm crutches are used primarily by the long-term (or permanently) handicapped. Their presence signals that the user has a very serious and possibly permanent ailment or disfiguration, since they have gone to the trouble of procuring fancy, efficient crutches.

If someone comes into my coffee shop, clumsily maneuvering on big underarm crutches, I assume that he just twisted his ankle or broke his leg skiing – probably overdid it while pursuing an active lifestyle. If someone comes into my coffee shop defty wielding aluminum forearm crutches, I assume that they’ve got some serious problem (paraplegic? birth defect?) which triggers a serious of cultural constructs (handicapped = diseased = bad person = deserves shunning, careful – it might be catching!).

I’m not sure why there’s such a divide between Europe and the US in this regard. Are people’s attitudes and public policy towards the homeless markedly different between the two? (serious question)

6

Jill 09.05.04 at 10:02 am

Goodness. My European sensibilities identify underarm crutches as “old-fashioned”, “technologically inferior” and “what poor people in old movies use”. I was astonished to see people in America using them. They seem so, well, low-tech and kind of, well, OLD.

Fancy that – you guys LIKE them! Peculiar.

7

Jack 09.05.04 at 11:15 am

Not crutches but hip joints.

according to one manufacturer of hip joints the UK uses old fashioned joints because they were pioneered in the UK. The originator struck a deal with a manufacturer which ensured a very good price in return for some degree of exclusivity, certainly including standard training for orthopaedic surgeons. Initially this did a lot for hip replacement in the UK but over time there has been substantial progress in hip joints and they leave the UK using a process that is less reliable and takes much longer to perform meaning more risk to the patient and fewer operations. A case of first is worst I suppose.

As for crutches, I imagine the price of forearm crutches would fall if they were used in the same quantities as underarm models. I wonder if there are multiple equilibria in the markets for crutches. I propose a geographical explanation. Just as with cars Americans drive clearly inferior but mauch larger models. Europe doesn’t have the wide open spaces that make gas guzzlers, SUVs and underarm crutches a viable option.

8

dsquared 09.05.04 at 12:19 pm

Regrettably, I think the answer may be that there is a limit to the amount of weight you can support on a forearm crutch, but you can use an underarm crutch for people who are a lot fatter.

9

David Tiley 09.05.04 at 12:30 pm

The underarm crutch is the saturday night special of prostheses. Poke! Whack! Trip!

I wonder if the forearm crutch is harder to learn and so problematical if you have a temporary injury?

In Australia, I think we go for underarms. It may also be that they have a larger range of adjustments when you borrow them from the hospital. Is there a nexus between forearm crutches and more modern casts for broken legs?

10

yabonn 09.05.04 at 12:34 pm

You girlie-men.

Real machos hop around.

11

Cathy 09.05.04 at 1:22 pm

We use them because that’s all they offer us. Based on experience!

12

Mike Huben 09.05.04 at 2:01 pm

Jared Diamond explained it in “Guns, Germs, and Steel”. Obviously, there were two independent inventions of crutches, one in the old world, and one in the new. Few tree species were appropriate for crutches on the two continents, and the European species were only suited for shorter forearm crutches. East/west diffusion of rival crutch technologies was limited by ocean barriers, which is why New Guineans are as smart as anybody and seldom sprain their ankles.

13

Bruce Baugh 09.05.04 at 3:16 pm

I’ve had to use crutches for extended periods several times in my life and have friends with permanent disabilities that require them, so I’ve got an actual answer.

Part of it is that, yes, forearm crutches are more expensive here. Part of it is that they’re also associated in many minds here with serious and generally permanent disabilities – for people with multiple dystrophy, say. One of the archetypal charitable fundraising images for the MD telethon, March of Dimes, and the like is of the kid with heavy corrective lenses, spinal or major limb deformation, and forearm crunches, gimping along.

It’s worth noting that the forearm crunch is generally superior, at least in my experience, but not in hugely clear-cut fashion. In particular it’s not an improvement if you’re coping with shoulder, upper chest, or upper arm damage; it can hurt like hell to brace yourself for the next step, depending on what’s messed up there. And since one of the classic pools of crutch users is the football player who may well have been injured by a bad tackle, there’s some reinforcement for underarm crutch use there.

So the forearm crutch goes under-used, for a combination of medical and cultural reasons.

Actually, things like the Standard Oil joke explanation are depressingly common in medical supply. That stuff is weird, and only when it gets really blatant (as in the recent bill forbidding the government to negotiate better rates on drugs) does the public ever notice it. But a recurring comment from literate friends of mine whose conditions require frequent care is that they just can’t read authors like Kafka anymore, because it’s too damn true.

14

eszter 09.05.04 at 3:31 pm

Could it be that you’re not comparing the right things? That is, my impression (completely anecdotal) is that in the US, people are given these anderarm crutches for injuries that get you perhaps a cane at best in Europe. Whereas if you have the type of injury that would give you a forearm crutch in Europe, you’re put in a wheelchair in the US. This is probably a bit exaggerated, but I think there may be something to it. (You’d need to be comparing treatment of same/very similar injuries, and I suspect you don’t have info to know if that’s what you’re doing.) The question I always used to have along these lines was: Why was this person given a crutch at all (underarm) when they could likely walk around just find with a cane? And in that case, I just figured underarm crutches are more visible (cultural sign: I’ve been injured, I need special treatment) and more expensive, justifying higher costs. (A propos people’s comments that the underarm crutch is cheaper; since when does the American health care system care that it’s charging a patient a fortune for something as long as it can justify it in some way?)

15

eszter 09.05.04 at 3:36 pm

I realize there is a bit of a flaw in my argument in that if the system doesn’t mind going for the more expensive treatment then that would mean they might as well give people the forearm crutch. I find the cultural argument somewhat convincing (stigma attached to forearm crutch vs underarm crutch), but still think that the cane/crutch question is relevant.

16

dsquared 09.05.04 at 3:47 pm

A Straussian would presumably hint that America is full of forearm crutches, and if you only knew what a true “forearm crutch” was you’d know it.

17

janet 09.05.04 at 3:57 pm

Because.

This probably isn’t related, but in medical practice, a lot of things just vary regionally. For example, if you’re having open surgery to fix an abdominal aortic anuerysm, you’re more likely to have a retroperitoneal incision if you’re in California and a vertical incision if you’re in the Midwest (or mayber it’s the other way around).

18

KCinDC 09.05.04 at 4:19 pm

since when does the American health care system care that it’s charging a patient a fortune for something as long as it can justify it in some way?

The system wouldn’t care if it were charging a patient, but it’s normally charging an insurance company. Insurance companies are committed to limiting cost, even if it’s not what’s best for the patient, and insurance companies call the shots for the health care of most Americans.

19

eszter 09.05.04 at 4:29 pm

kcindc – I realize that (but it’s fair for you to point it out since I didn’t comment on this in my note), nonetheless, costs seem extreme compared to what you pay for similar services elsewhere. So how do you explain that? Why aren’t insurance companies putting more pressure on hospitals not to charge $5/aspirin? (And are we conveniently forgetting about those who don’t have insurance to cover these crazy costs?)

20

Romo Domo 09.05.04 at 4:41 pm

As an aside for whats its worth not that I’d want to bother anyone but given how effortlessly sociological theorizing both fits the subject matter and underscores the folly…of both, it seems that theory might actually require a crutch involving more than the usual broom handle up the ….

21

dsquared 09.05.04 at 4:46 pm

For example, if you’re having open surgery to fix an abdominal aortic anuerysm, you’re more likely to have a retroperitoneal incision if you’re in California and a vertical incision if you’re in the Midwest (or mayber it’s the other way around).

I think it’s the other way round if you’re in the Southern Hemisphere?

22

Rumor Monger 09.05.04 at 5:12 pm

Because Bush is gay.

Kitty Kelly Bush Book Rumors

23

Filter 09.05.04 at 5:14 pm

It’s just because forearm crutches are used in Europe: they look French.

24

yabonn 09.05.04 at 5:30 pm

they look French.

And they’re called “cannes anglaises” in france.

The euro-plot thickens.

25

LMS 09.05.04 at 6:21 pm

While forearm crutches more aesthetically pleasing (like, that’s a big requirement–?), are less unwieldly and probably easier to use, they have other consraints. I could use my hands while being propped up via underarms; not sure I could do the same using forearm crutches. And with both knees out of commission, I needed all the propping I could get.

26

enronal 09.05.04 at 6:40 pm

The most obvious explanation is a faulty premise. The forearm crutches aren’t superior. Underarm crutches require less strength and allow the trunk of the body to lend support because the top of the crutch is squeezed between the upper arm and trunk. Their lower cost is another factor. European markets are less competitive and the forearm crutch makers have stifled competition.

27

Brian 09.05.04 at 7:26 pm

I’ve never tried forearm crutches. I suppose I should. I don’t buy the notion that they are superor, though.

I’m an amputee, so I spend at least part of every day on crutches. As someone as already noted above, it’s possible to jam underarm crutches into your armpit and free up both hands. The first thing I do when I get out of bed in the morning is crutch over to the kitchen and make myself some coffee. With crutches fixed in my armpits, I am a stable tripod, and making coffee is no problem. I don’t see how I could do this with forearm crutches.

I also think getting up and down stairs would be harder with forearm crutches, though that may only be because I’ve never seen it done.

28

Gary 09.05.04 at 8:26 pm

Why do most Americans prefer Chevies to BMWs?

Why do most Americans prefer Windows to Macintosh?

Why do most Americans prefer Wonder Bread to a whole-grain rustic loaf?

29

Gary 09.05.04 at 8:28 pm

Why do most Americans prefer football to soccer?

30

Zackary Sholem Berger 09.05.04 at 8:55 pm

There’s a small but respectable literature on crutch design – as previous commenters have pointed out, it’s really not a question of axillary vs. forearm, but a matter of which crutch is better for what purposes. Here’s a good summary article:

http://www.oandp.org/jpo/library/1993_01_020.asp

31

PanJack 09.05.04 at 9:02 pm

Speak softly and carry a big crutch?

32

PanJack 09.05.04 at 9:03 pm

Speak softly and carry a big crutch?

33

Thomas Mayer 09.05.04 at 10:12 pm

Postmodernist explanation: To state that more underarm crutches are used in Europe is to state a so-called “fact”. But, in fact, there are not facts, so there are no underarm crutches, and since underarm crutches are easier to use for womem and other oppressed people, their absence shows how oppessive our society is.

34

Barbara O'Brien 09.06.04 at 1:00 am

A crutch for a sprained ankle? What species of weenie needs a crutch for a sprained ankle?

35

eudoxis 09.06.04 at 1:14 am

It seems clear to me that the underarm kind is inferior in every important respect.

Why? Is this based on personal observation or a recent study?

Axillary crutches bear a higher percentage of user weight and are more stable. They require less training and result in fewer instability injuries. Acute injuries require that the injured leg bears no weight at all. For long-term use, all sorts of ambulatory devices are available, taylored to individual strength and preference. Usually, chronic disabilities are varied in the limitation of limb use, that is, some weight bearing is often possible. The forearm cruthes are preferred in those situations.

Great explanations, though.

36

RSN 09.06.04 at 1:32 am

“It seems clear to me that the underarm kind is inferior in every important respect.”

You’ve obviously never been on crutches before. That, or you’re just another anti-American bigot.

37

Avedon 09.06.04 at 1:39 am

When I busted my ankle in America, my brother had a handy set of underarm crutches available. When I got back to the UK, I learned that they won’t give them to you here because they are afraid you’ll lean your full weight on them all the time and cut off the circulation to your arms.

My verdict: It’s much easier to balance with underarm crutches. So much so that I gave up on the sticks and rented a walker for the rest of the time I needed the assist.

None of these were any use to me on stairs, of course, which is a real pain given the design of your average London house.

38

travc 09.06.04 at 2:41 am

Why can’t I resist commenting on this…. anyway

A good portion of the disparity is probably due to the fact that the American medical system likes using a “one-size fits all” approach. (Lots of reasons for this.)

Underarm crutches are overkill for most injuries, but also work on more serious injuries where an forearm crutch wouldn’t.

Along those lines, I’ve noticed crutches getting rare in general in the US. Wheelchairs are the default now. Again, just a one-size fits all overkill. Terribly inefficient, but it works.

As for price… Medical products have a very very weak correlation between price of production and sale price. If hospitals wanted to start issuing forearm crutches in the US, the price would come down pretty instantly. Right now, forearm crutches are expensive here because the people who buy them know that they are better (at least for them) and are being charged for having a clue.

39

laura 09.06.04 at 3:01 am

The people I’ve seen with forearm crutches here in the US have been, as several people have noted, more likely to be encrutched for the long time if not permanently; they have also tended to be able to put at least some weight on their legs, as opposed to many of the people I see on underarm crutches (and as opposed to the person I recently WAS on underarm crutches) who are not putting any weight at all on the foot or leg in question. Is there a difference there? How easy is it to keep all your weight off one leg with forearm crutches?

(And while we’re discussing crutches, can I just say ow? I hate those things, although even a couple months after getting off them, I have more muscle definition in my arms than I ever did. But I’m not overweight and I’m in reasonably good shape — what do out-of-shape and/or fat people do when they have to be on crutches? I just don’t see how it’s possible.)

40

laura 09.06.04 at 3:02 am

The people I’ve seen with forearm crutches here in the US have been, as several people have noted, more likely to be encrutched for the long time if not permanently; they have also tended to be able to put at least some weight on their legs, as opposed to many of the people I see on underarm crutches (and as opposed to the person I recently WAS on underarm crutches) who are not putting any weight at all on the foot or leg in question. Is there a difference there? How easy is it to keep all your weight off one leg with forearm crutches?

(And while we’re discussing crutches, can I just say ow? I hate those things, although even a couple months after getting off them, I have more muscle definition in my arms than I ever did. But I’m not overweight and I’m in reasonably good shape — what do out-of-shape and/or fat people do when they have to be on crutches? I just don’t see how it’s possible.)

41

michael s. 09.06.04 at 8:29 am

I broke my ankle last year and was on underarm crutches for six weeks and it beefed my arms and shoulders up quite a bit.
Perhaps americans like to beef up more?

42

Richard 09.06.04 at 10:18 am

> How easy is it to keep all your weight off one leg with forearm crutches?

Easy. Although forearm crutches are less stable than underarms, and it’s very straightforward to go arse over tit if you hit a greasy patch of ground.

43

bad Jim 09.06.04 at 10:51 am

Can anyone who remembers the 19th century think of canes as anything but a weapon? Consider Charles Sumner being clobbered over the head and left for dead.

I’ve used a cane myself once or twice. Back problems. Haven’t hit anyone. Yet.

44

JamesW 09.06.04 at 12:05 pm

Brian: going up and down stairs is easier with forearm crutches assuming you have a hand-rail or banister, since you hold the unused rail-side crutch in the other hand. Without a rail, don’t even think of it.
When I broke my leg skiing (in France), managing stairs with the canne anglaise was the cricial examination for being let out.

45

Francis Xavier Holden 09.06.04 at 2:35 pm

Have you ever tried to cut down a branch off a tree and try to make a forearm crutch?

Americans have a history of carrying big sharp cutting knife things and makeing their own crutches from the nearest tree. It’s just a matter of finding a forked branch and a few cuts here and there and away you go on your genuine pioneer armpit crutch.

No tolerance for designer girlie-man forearms crutches.

46

yabonn 09.06.04 at 2:45 pm

Actually, i just like to say crutch.

Crutch, crutch, crutch, crutch, crutch.

47

Catarina the Swede 09.06.04 at 8:42 pm

I must agree with Jill. Underarm crutches got a feel in my mind of WWII movies. I’ve never seen underarm crutches being used IRL in Europe.
I myself have spent much of my youth on forearm crutches (due to several soccer injuries on foot and knee) and never experienced any problems with them. I even own my own pair because after a while I stopped bothering going to see a doc for another sprained ancle. I just brought out my crutches for a few weeks and stayed off my foot.

48

epistemology 09.06.04 at 11:05 pm

1. They are cheaper.
2. They allow a greater proportion of your weight to be passed through the crutch.
3. They allow weight bearing with your hands free by leaning on your armpits (not advised due to axillary nerve injuries).
4. I think that, because the early adopters of forearm crutches in the US were obviously impaired by Muscular Dystrophy or the like, while most axillary crutch users were clearly temporarily disabled by a broken leg, say, forearm crutches were stigamtized in some people’s minds as being for disabled people.
5. They are cheaper.

49

drew 09.07.04 at 2:51 am

eszter – in america any non-old person who uses a cane is a pimp.

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