Crutch Walking: the method, the errors, and the exam

What the skill is for

Crutch walking lets a patient with a lower limb injury, post-surgical restriction, or partial weight-bearing order move independently without loading the affected leg. It is taught after fractures, sprains, joint replacements, and some soft tissue injuries where the prescriber has specified a weight-bearing status: non-weight-bearing, partial weight-bearing, or weight-bearing as tolerated.

Correct crutch use protects the injured limb and protects the patient from a second injury: falls, skin breakdown at pressure points, and nerve damage from improper technique. The most consequential error, resting weight in the axillae rather than through the hands, can compress the radial nerve against the humerus and cause 'crutch palsy,' a preventable nerve injury with wrist drop and weakness that can take weeks to resolve.

The method, step by step

Fit crutches first: with the patient standing, the crutch tip sits about two inches lateral to the foot and the top of the crutch sits two to three finger-widths below the axilla, with hand grips adjusted so the elbows have a slight bend, roughly 15 to 30 degrees, when gripping. Weight should transfer entirely through the hands on the grips, with the axillary pads acting only as a light stabiliser against the side of the chest, never a weight-bearing surface.

Gait pattern depends on the weight-bearing order. The three-point gait, used for non-weight-bearing or partial weight-bearing status, moves both crutches and the affected leg forward together, then the unaffected leg follows through. The two-point gait, used with greater weight-bearing ability, moves one crutch with the opposite leg simultaneously, alternating sides.

For stairs, the sequence is fixed and worth memorising exactly: going up, the unaffected leg goes first, followed by the crutches and affected leg together. Going down, the crutches and affected leg go first, followed by the unaffected leg. The mnemonic 'up with the good, down with the bad' captures it, and it is the single most tested detail in this skill.

Where it goes wrong

The most common error is resting body weight on the axillary pads instead of the hands, either from poor initial teaching or fatigue during a long walk. Watch for a patient who leans into the crutches rather than pushing through the palms; this is the moment to re-teach, not just remind.

Poor fit is the second common source of error: crutches set too tall force weight into the axillae regardless of technique, and crutches set too short cause the patient to stoop and lose balance. Patients also commonly reverse the stair sequence under pressure or fatigue, stepping with the affected leg first going up, which loads the injured limb exactly when it needs the most support. Rubber tips worn smooth or wet, slippery floor surfaces, and loose clothing or footwear are frequent environmental contributors to falls that are easy to overlook during a skills check.

Practising it deliberately

Teach the skill on a flat, clear surface first, with the patient in supportive, closed-toe shoes, before introducing any incline or stairs. Have the patient demonstrate the gait pattern back to you rather than simply asking if they understand, since crutch walking is a motor skill that verbal confirmation does not verify.

Check hand position at the grips directly, looking for white-knuckle pressure through the palms rather than shoulders hunched up toward the ears, which signals axillary loading. Practise the stair sequence on a supervised staircase with a rail available, and rehearse it in both directions before considering the patient safe for unsupervised stairs. Reassess technique whenever fatigue, pain medication, or a change in weight-bearing order is introduced, since any of these can quietly degrade a previously correct technique.

Applying it on the exam

NCLEX items on crutch walking usually present a scenario and ask you to identify correct versus incorrect technique, or to sequence a stair-climbing action. The safe habit is to translate the stem into the underlying rule immediately: is this a question about where weight bears, or about direction on stairs? Match it to hands-not-axillae or up-with-the-good-down-with-the-bad before evaluating the answer options.

Expect distractor answers that describe a plausible-sounding but reversed stair sequence, or that describe the patient resting comfortably on the axillary pads as if this were acceptable. Both should be recognised immediately as incorrect. Questions may also test crutch fit, phrased around finger-widths of clearance under the axilla or elbow flexion angle, so hold those specific figures rather than a general sense of 'properly fitted.'

A worked example

A patient recovering from an ankle fracture, non-weight-bearing on the left, is being discharged with crutches and needs to navigate three steps to reach the front door. The nurse should teach: right leg (unaffected) up first, then crutches and left leg (affected) together to join it on the same step, repeated for each step going up.

Coming back down the same steps, the sequence reverses: crutches and left leg (affected) down first to the lower step, then the right leg (unaffected) follows to join them. Throughout, the nurse should observe that the patient's weight transfers through the palms on the hand grips, not through the shoulders into the axillary pads, and that the patient pauses to establish balance on each step rather than moving continuously. This worked example is close to how a stairs question is typically structured on the exam.