Diabetic peripheral neuropathy (DPN) is usually discussed in terms of what it does to the skin: loss of protective sensation, unnoticed trauma, and ulceration. But the same nerve damage that makes a foot insensate also degrades the sensory information the body uses to stay upright. The result is a second, less-discussed complication — impaired balance, altered walking mechanics, and elevated fall risk, with consequences beyond fracture that include activity curtailment and loss of independence.
How Much Higher Is the Risk?
A 2024 systematic review and meta-analysis in BMC Geriatrics pooled data from 40,778 older adults and found that those with type 2 diabetes had a 63% higher hazard of falling than those without (HR 1.63, 95% CI 1.30–2.05), with a pooled odds ratio of 1.59 (95% CI 1.36–1.87). The single strongest factor identified was insulin use, associated with a 162% higher odds of falling (OR 2.62, 95% CI 1.87–3.65) — a signal that likely reflects both longer disease duration and the destabilising effect of hypoglycaemia (Freire et al., 2024).
A systematic review of 34 quality-assessed studies in the Journal of Diabetes Science and Technology concluded that diabetic neuropathy consistently degrades postural balance and gait kinematics while increasing fall risk (Khan and Andersen, 2022). A global burden review in Nature Reviews Neurology likewise identifies impaired gait, loss of balance, and consequent falls and fractures as core elements of DPN — a condition affecting up to half of people with diabetes (Savelieff et al., 2025).
The Mechanisms Behind the Instability
Reeves and colleagues, writing in Medicina, describe how sensory and motor deficits translate into measurable biomechanical change. Walking speed and step length decrease, step width increases, and joint ranges of motion narrow. Joint moments — the rotational forces generated around the ankle, knee, and hip — are reduced, which the authors characterise as a natural strategy to lower muscular demand in the face of reduced strength capacity.
Muscle weakness and atrophy are most pronounced in patients with DPN but are also present in diabetes without neuropathy, and they are not confined to the distal foot and ankle; proximal thigh musculature is affected as well. A key contributor to falls is the delayed neuromuscular response immediately after foot–ground contact in an insensate foot: the corrective reaction arrives too late to prevent loss of balance. Notably, pronounced balance impairment measured in gait laboratories was seen only in patients with DPN, not in non-neuropathic diabetes — and patients’ own perception of unsteadiness corresponded well with laboratory measures (Reeves et al., 2021).
Changes Appear Before Symptoms Do
A cross-sectional study of 176 participants published in Risk Management and Healthcare Policy compared gait and balance parameters across subclinical DPN, confirmed DPN, and healthy controls. Stride length and stride velocity were significantly reduced and stance and double-support phases significantly prolonged across all DPN subgroups. Centre-of-mass, ankle, and hip sway during eyes-open standing were significantly elevated in subclinical as well as confirmed DPN. The authors concluded that abnormal biomechanics are present early, arguing for balance assessment in people with more than five years of diabetes even without clinical neuropathic signs (Jiang et al., 2022).
What the Intervention Evidence Shows
The rehabilitation literature is encouraging but uneven. A systematic review in Clinical Interventions in Aging examined 16 studies of physical rehabilitation in people with DPN already at risk of falling. Participants in six studies improved sufficiently to move from moderate-to-high fall risk to low or no risk; seven showed no improvement and three were mixed. Interventions involving intentional weight shifting, manipulation of the base of support, and displacement of the centre of mass — including yoga and proprioceptive training — produced the most consistent results. The authors noted that most trials measured balance scores rather than prospective fall rates, which limits conclusions about fall prevention itself (Alissa et al., 2024).
A single-blind randomised controlled trial of 143 patients with type 2 diabetes and neuropathy, published in Diabetologia, tested two months of once-weekly home-based strength and balance training. Health-related quality of life did not change, but timed up-and-go, five-times sit-to-stand, ankle muscle strength, knee range of motion, and balance confidence all improved significantly and were sustained at six months, with no adverse events (Venkataraman et al., 2019). A separate 16-week randomised trial in Archives of Physical Medicine and Rehabilitation found that adding elastic-band resistance to balance training produced significantly greater gains in Berg Balance Scale scores and greater reductions in fear of falling than balance training alone, with the best results at 12 weeks (Armat et al., 2024).
The 2023 IWGDF prevention guideline reflects this evidence cautiously, suggesting that people at low-to-moderate risk be advised to undertake a preferably supervised foot–ankle exercise programme to reduce ulcer risk factors, and noting that a total increase in weight-bearing activity of roughly 1000 steps per day is likely safe with respect to ulceration risk (Bus et al., 2023).
Clinical Summary
Fall risk is a measurable, under-recognised consequence of diabetic peripheral neuropathy that begins before neuropathy is clinically obvious. Gait and postural changes are detectable in subclinical disease; insulin use and polypharmacy compound the risk; and offloading devices, while essential for ulcer healing, add their own instability. Structured strength and balance training reliably improves functional measures and balance confidence, though its effect on actual fall rates remains inadequately studied. Patients’ self-reported sense of unsteadiness correlates with objective laboratory findings, making it a reasonable question during routine neuropathy assessment.
References
- Freire LB, Brasil-Neto JP, da Silva ML, et al. Risk factors for falls in older adults with diabetes mellitus: systematic review and meta-analysis. BMC Geriatrics. 2024;24(1):201. doi:10.1186/s12877-024-04668-0
- Reeves ND, Orlando G, Brown SJ. Sensory-motor mechanisms increasing falls risk in diabetic peripheral neuropathy. Medicina (Kaunas). 2021;57(5):457. doi:10.3390/medicina57050457
- Khan KS, Andersen H. The impact of diabetic neuropathy on activities of daily living, postural balance and risk of falls — a systematic review. Journal of Diabetes Science and Technology. 2022;16(2):289–294. doi:10.1177/1932296821997921
- Alissa N, Shipper AG, Zilliox L, Westlake KP. A systematic review of the effect of physical rehabilitation on balance in people with diabetic peripheral neuropathy who are at risk of falling. Clinical Interventions in Aging. 2024;19:1325–1339. doi:10.2147/CIA.S459492
- Venkataraman K, Tai BC, Khoo EYH, et al. Short-term strength and balance training does not improve quality of life but improves functional status in individuals with diabetic peripheral neuropathy: a randomised controlled trial. Diabetologia. 2019;62(12):2200–2210. doi:10.1007/s00125-019-04979-7
- Armat MR, Mortazavi H, Akbari H, Baghizade S. The effect of resistance exercises using an elastic band on balance and fear of falling in older adults with diabetic peripheral neuropathy: a 16-week randomized controlled trial. Archives of Physical Medicine and Rehabilitation. 2024;105(4):733–741. doi:10.1016/j.apmr.2023.11.017
- Jiang X, Deng F, Rui S, et al. The evaluation of gait and balance for patients with early diabetic peripheral neuropathy: a cross-sectional study. Risk Management and Healthcare Policy. 2022;15:543–552. doi:10.2147/RMHP.S361698
- Bus SA, Sacco ICN, Monteiro-Soares M, et al. Guidelines on the prevention of foot ulcers in persons with diabetes (IWGDF 2023 update). Diabetes/Metabolism Research and Reviews. 2024;40(3):e3651. doi:10.1002/dmrr.3651
- Savelieff MG, Elafros MA, Viswanathan V, et al. The global and regional burden of diabetic peripheral neuropathy. Nature Reviews Neurology. 2025;21(1):17–31. doi:10.1038/s41582-024-01041-y
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