Lower extremity ambulatory assistive devices (LEADs) are important augments that provide mobility and stability when weightbearing is restricted in the setting of injury, surgery, or balance disorders. In order to optimize patient safety and function when prescribing these devices, it is essential for the orthopaedic surgeon to have a firm understanding of their specific indications, proper fitting, energy demand, biomechanical advantages, and potential complications. Comprehension of normal gait cadence, identification of the functional deficit present and knowledge of available options will assist in safely prescribing the proper device. Over the last decade, newer alternatives to traditional LEADs (canes, crutches, walkers) have become available, including the rolling knee scooter and hands-free single crutch. These have been developed to improve mobility and independence; however, it is necessary to appreciate their limitations when prescribing them to patients. This review will provide an update on normal and pathologic gait biomechanics as well as the most common types of LEADs currently available to the orthopaedic surgeon, their indications, important considerations, proper fitting, associated energy expenditure, and complications.
BateniHMakiBE.Assistive devices for balance and mobility: benefits, demands, and adverse consequences. Arch Phys Med Rehabil. 2005;86(1):134-145.
3.
BauerDMFinchDCMcGoughKPBensonCJFinstuenKAllisonSC.A comparative analysis of several crutch length-estimation techniques. Phys Ther. 1991;71(4):294-300.
4.
BedigrewKMPatzkowskiJCWilkenJM, et al. Can an integrated orthotic and rehabilitation program decrease pain and improve function after lower extremity trauma?Clin Orthop Relat Res. 2014;472(10):3017-3025. doi:10.1007/s11999-014-3609-7
5.
BlairJAPatzkowskiJCBlanckRVOwensJGHsuJR; Skeletal Trauma Research Consortium (STReC). Return to duty after integrated orthotic and rehabilitation initiative. J Orthop Trauma. 2014;28(4):e70-e74. doi:10.1097/BOT.0000000000000006
6.
BurdettRGBorello-FranceDBlatchlyCPotterC.Gait comparison of subjects with hemiplegia walking unbraced, with ankle-foot orthosis, and with air-stirrup® brace. Phys Ther. 1988;68(8):1197-1203.
7.
CiufoDJAndersonMRBaumhauerJF.Impact of knee scooter flexion position on venous flow rate. Foot Ankle Int. 2019;40(1):80-84. doi:10.1177/1071100718794966
8.
DeanERossJ.Relationships among cane fitting, function, and falls. Phys Ther. 1993;73(8):494-500; discussion 501-504. doi:10.1093/ptj/73.8.494. Erratum in: Phys Ther 1993 Oct;73(10):712.
9.
DewarCGrindstaffTLFarmerB, et al. EMG activity with use of a hands-free single crutch vs a knee scooter. Foot Ankle Orthop. 2021;6(4):24730114211060054. doi:10.1177/24730114211060054
10.
DittmerDKTeasellR.Complications of immobilization and bed rest. Part 1: musculoskeletal and cardiovascular complications. Can Fam Physician. 1993;39:1428-1432, 1435-1437.
11.
DuaADesaiSSLeeCJHellerJA.National trends in deep vein thrombosis following total knee and total hip replacement in the United States. Ann Vasc Surg. 2017;38:310-314. doi:10.1016/j.avsg.2016.05.110
12.
FaruquiSRJaeblonT.Ambulatory assistive devices in orthopaedics: uses and modifications. J Am Acad Orthop Surg. 2010;18(1):41-50. doi:10.5435/00124635-201001000-00006
13.
FatoneSStineRGardS.Randomized cross-over study of AFO ankle components in adults with post-stroke hemiplegia. 13th ISPO World Congress, Leipzig, Germany. ISPO World Congress; 2010: 59.
14.
FoleyMPPraxBCrowellRBooneT.Effects of assistive devices on cardiorespiratory demands in older adults. Phys Ther. 1996;76(12):1313-1319. doi:10.1093/ptj/76.12.1313
15.
GellNMWallaceRBLaCroixAZMrozTMPatelKV.Mobility device use in older adults and incidence of falls and worry about falling: findings from the 2011-2012 National Health and Aging Trends Study. J Am Geriatr Soc. 2015;63(5):853-859. doi:10.1111/jgs.13393
16.
GoldbergBHsuJD, eds. Atlas of Orthoses and Assistive Devices. Mosby Incorporated; 1997.
17.
HaddenRMeekerJWeissJThompsonA.Patient-reported outcomes after Exosym bracing (Intrepid Dynamic Exoskeletal Orthosis (IDEO)) in the civilian population. Foot Ankle Orthop. 2019;4(4):2473011419S00194. doi:10.1177/2473011419S00194
18.
HallJClarkeAKHarrisonR.Guidelines for prescription of walking frames. Physiotherapy. 1990;76(2):118-120.
19.
HintonCACullenKE.Energy expenditure during ambulation with ortho crutches and axillary crutches. Phys Ther. 1982;62(6):813-819. doi:10.1093/ptj/62.6.813
20.
HolderCGHaskvitzEMWeltmanA.The effects of assistive devices on the oxygen cost, cardiovascular stress, and perception of nonweight-bearing ambulation. J Orthop Sports Phys Ther. 1993;18(4):537-542.
21.
HoytBWNelsonSYFayJGWadeSMBrooksDIPotterBK.IDEO energy-storing orthosis: effects on lower extremity function and preservation. Injury. 2021;52(11):3505-3510. doi:10.1016/j.injury.2021.07.023
22.
HustedHOtteKSKristensenBBØrsnesTWongCKehletH.Low risk of thromboembolic complications after fast-track hip and knee arthroplasty. Acta Orthop. 2010;81(5):599-605. doi:10.3109/17453674.2010.525196
23.
IkedaAJFergasonJRWilkenJM.Clinical outcomes with the intrepid dynamic exoskeletal orthosis: a retrospective analysis. Mil Med. 2019;184(11-12):601-605. doi:10.1093/milmed/usz004
24.
JonesASilvaPGSilvaAC, et al. Impact of cane use on pain, function, general health and energy expenditure during gait in patients with knee osteoarthritis: a randomised controlled trial. Ann Rheum Dis. 2012;71(2):172-179. doi:10.1136/ard.2010.140178
25.
KocherBKChalupaRLLopezDMKirkKL.Comparative study of assisted ambulation and perceived exertion with the wheeled knee walker and axillary crutches in healthy subjects. Foot Ankle Int. 2016;37(11):1232-1237.
26.
KumarRRoeMCScreminOU.Methods for estimating the proper length of a cane. Arch Phys Med Rehabil. 1995;76(12):1173-1175. doi:10.1016/s0003-9993(95)80129-4
27.
LamR.Practice tips: choosing the correct walking aid for patients. Can Fam Physician. 2007;53(12):2115-2116.
28.
LauferY.Effects of one-point and four-point canes on balance and weight distribution in patients with hemiparesis. Clin Rehabil. 2002;16(2):141-148. doi:10.1191/0269215502cr481oa
29.
LiuHHEavesJWangWWomackJBullockP.Assessment of canes used by older adults in senior living communities. Arch Gerontol Geriatr. 2011;52(3):299-303. doi:10.1016/j.archger.2010.04.003
30.
MahoneyJESagerMAJalaluddinM.Use of an ambulation assistive device predicts functional decline associated with hospitalization. J Gerontol A Biol Sci Med Sci. 1999;54(2):M83-M88. doi:10.1093/gerona/54.2.m83
31.
MakiBEHollidayPJTopperAK.A prospective study of postural balance and risk of falling in an ambulatory and independent elderly population. J Gerontol. 1994;49(2):M72-M84. doi:10.1093/geronj/49.2.m72
32.
MartinKDUnangstAMHuhJChisholmJ.Patient preference and physical demand for hands-free single crutch vs standard axillary crutches in foot and ankle patients. Foot Ankle Int. 2019;40(10):1203-1208. doi:10.1177/1071100719862743
33.
McBeathAABahrkeMBalkeB.Efficiency of assisted ambulation determined by oxygen consumption measurement. J Bone Joint Surg Am. 1974;56(5):994-1000.
34.
MullisRDentRM.Crutch length: effect on energy cost and activity intensity in non-weight-bearing ambulation. Arch Phys Med Rehabil. 2000;81(5):569-572. doi:10.1016/s0003-9993(00)90036-4
35.
O’SullivanSB.Perceived exertion. A review. Phys Ther. 1984;64(3):343-346.
36.
OrishimoKShapiraAKremenicIMcHughMNicholasS.Comparison of hip and low back loads between normal gait, axillary crutch ambulation and walking with a hands-free crutch in a healthy population. Int J Sports Phys Ther. 2021;16(6):1454-1458. doi:10.26603/001c.29517.
37.
OwensJGBlairJAPatzkowskiJCBlanckRVHsuJR.Skeletal trauma research C: return to running and sports participation after limb salvage. J Trauma. 2011;71(Suppl 1):S120-S124.
38.
PatzkowskiJCBlanckRVOwensJG, et al. Comparative effect of orthosis design on functional performance. J Bone Joint Surg Am. 2012;94(6):507-515. doi:10.2106/JBJS.K.00254
39.
PotterBKSheuRGStinnerD, et al. Multisite evaluation of a custom energy-storing carbon fiber orthosis for patients with residual disability after lower-limb trauma. J Bone Joint Surg Am. 2018;100(20):1781-1789. doi:10.2106/JBJS.18.00213
40.
PriebeJRKramR.Why is walker-assisted gait metabolically expensive?Gait Posture. 2011;34(2):265-269. doi:10.1016/j.gaitpost.2011.05.011
41.
RahmanRShannonBFickeJ.Knee scooter-related injuries: a survey of foot and ankle orthopedic surgeons. Foot Ankle Orthop. 2020;5(1);1-9. doi:10.1177/24730114209
42.
RambaniRShahidMSGoyalS.The use of a hands-free crutch in patients with musculoskeletal injuries: randomized control trial. Int J Rehabil Res. 2007;30(4):357-359. doi:10.1097/MRR.0b013e3282f1fecf
43.
RebCWHauptETVander GriendRABerletGC.Pedal musculovenous pump activation effectively counteracts negative impact of knee flexion on human popliteal venous flow. Foot Ankle Spec. 2023;16(2):97-103.
44.
ReismanMBurdettRGSimonSRNorkinC.Elbow moments and forces at the hands during swing-through axillary crutch gait. Phys Ther. 1985;65(5):601-605.
45.
RovicJSChildressDS.Pendular model of paraplegic swing-through crutch ambulation. J Rehabil Res Dev. 1988;25(4):1-16.
46.
RubensteinLZ.Falls in older people: epidemiology, risk factors and strategies for prevention. Age Ageing. 2006;35(Suppl 2):ii37-ii41. doi:10.1093/ageing/afl084
47.
SehgalMJacobsJBiggsWS.Mobility assistive device use in older adults. Am Fam Physician. 2021;103(12):737-744.
48.
ShoupTEFletcherLSMerrillBR.Biomechanics of crutch locomotion. J Biomech. 1974;7(1):11-19.
49.
StevensJAThomasKTehLGreenspanAI.Unintentional fall injuries associated with walkers and canes in older adults treated in U.S. emergency departments. J Am Geriatr Soc. 2009;57(8):1464-1469. doi:10.1111/j.1532-5415.2009.02365.x
50.
ThysHWillemsPASaelsP.Energy cost, mechanical work and muscular efficiency in swing-through gait with elbow crutches. J Biomech. 1996;29(11):1473-1482. doi:10.1016/0021-9290(96)84543-x
51.
Van HookFWDemonbreunDWeissBD.Ambulatory devices for chronic gait disorders in the elderly. Am Fam Physician. 2003;67(8):1717-1724.
52.
van RielKMHartholtKAPannemanMJPatkaPvan BeeckEFvan der CammenTJ.Four-wheeled walker related injuries in older adults in the Netherlands. Inj Prev. 2014;20(1):11-15. doi:10.1136/injuryprev-2012-040593
53.
WorkmanMIEttehadiHSaragasNPFerraoPN.Knee scooter related injuries and satisfaction in patients following foot and ankle surgery. Foot Ankle Surg. 2022;28(7):887-890. doi:10.1016/j.fas.2021.12.003
54.
WrightDLKempTL.The dual-task methodology and assessing the attentional demands of ambulation with walking devices. Phys Ther. 1992;72(4):306-312; discussion 313-315. doi:10.1093/ptj/72.4.306
55.
YeohJRutaDMurphyGA, et al. Post-operative use of the knee walker after foot and ankle surgery, a retrospective study. Foot Ankle Orthop. 2017;2(3):2473011417S0004. doi:10.1177/2473011417S000419
56.
YoudasJWKotajarviBJPadgettDJKaufmanKR.Partial weight-bearing gait using conventional assistive devices. Arch Phys Med Rehabil. 2005;86(3):394-398. doi:10.1016/j.apmr.2004.03.026
Supplementary Material
Please find the following supplemental material available below.
For Open Access articles published under a Creative Commons License, all supplemental material carries the same license as the article it is associated with.
For non-Open Access articles published, all supplemental material carries a non-exclusive license, and permission requests for re-use of supplemental material or any part of supplemental material shall be sent directly to the copyright owner as specified in the copyright notice associated with the article.
