How balance works
- Inner ear: senses head movement and position.
- Vision: tells you where you are in space.
- Proprioception: nerves in the feet and joints sense the ground and body position.
- Muscles and joints: make corrections.
- Brain: combines all of this information.
Inner ear causes
Damage to the balance organs on both sides, for example from certain antibiotics or ageing, causes unsteadiness, especially in the dark or on uneven ground, and blurred vision when walking. After vestibular neuritis, incomplete recovery can leave a feeling of imbalance without spinning. Ménière’s disease and BPPV usually cause episodes of spinning, but some people describe unsteadiness between attacks.
See vertigo and crystals in ear.
Nerves in the feet
Peripheral neuropathy, often from diabetes or vitamin B12 deficiency, reduces sensation in the feet, so the brain receives less information about the ground. People feel unsteady, especially in the dark or on uneven surfaces.
See tingling in feet and burning feet.
Muscle weakness and joints
Weakness in the hips, legs and core, often from inactivity or ageing, makes balance corrections harder. Arthritis in the hips, knees and ankles, foot pain and poor footwear also contribute.
Vision
Cataracts, new varifocal glasses, eye conditions and poor lighting reduce visual information for balance. Unsteadiness that worsens with new glasses often improves as you adjust.
Medicines and alcohol
- Sleeping tablets and sedatives.
- Some antidepressants and anti-epileptic medicines.
- Blood pressure medicines causing drops on standing.
- Taking many medicines together.
- Alcohol.
A medication review with a doctor or pharmacist can help.
Low blood pressure on standing
A drop in blood pressure when standing up can cause unsteadiness, sometimes without true dizziness, particularly in older adults, people with diabetes or those on blood pressure medicines. Standing up slowly and staying hydrated help.
Anxiety and persistent postural-perceptual dizziness
Anxiety can cause a feeling of unsteadiness or of walking on a moving surface. Persistent postural-perceptual dizziness (PPPD) is a common condition in which unsteadiness lasts for months, often after a vestibular problem, and worsens when standing, moving or in busy visual environments such as supermarkets. It responds to vestibular rehabilitation, cognitive behavioural therapy and sometimes medication.
See anxiety symptoms.
Neurological causes
Less commonly, imbalance is caused by Parkinson’s disease, cerebellar conditions, multiple sclerosis, normal pressure hydrocephalus, previous strokes or spinal cord problems. These usually come with other signs, such as tremor, slowness, clumsiness, speech changes or bladder problems.
How it is assessed
- History and examination of ears, eyes, nerves, muscles and walking.
- Blood pressure lying and standing.
- Hearing tests and vestibular function tests.
- Blood tests for B12, glucose and thyroid.
- MRI if a neurological cause is suspected.
Balance and vestibular exercises
- Standing with feet together, then heel-to-toe, holding a support.
- Standing on one leg.
- Walking heel-to-toe along a hallway.
- Turning the head while walking.
- Standing on a cushion with eyes open, then closed, with support.
- Sit-to-stands and strength exercises.
See vertigo exercises. A physiotherapist can tailor a vestibular rehabilitation programme.
Reducing the risk of falls
- Use good lighting, including at night.
- Remove trip hazards and use handrails.
- Wear well-fitting shoes with good grip.
- Use a walking aid if recommended.
- Have regular eye checks.
Imbalance in older adults
In older adults, unsteadiness often has several small causes at once, such as mild neuropathy, reduced vision, weaker legs and several medicines. Addressing each of them, with strength and balance training, an eye test, a medication review and safer footwear, can make a big difference and reduce the risk of falls.
When to seek urgent help
- Sudden imbalance with weakness or numbness on one side.
- Slurred speech, facial droop or double vision.
- Sudden severe headache.
- Inability to walk or stand.
- Imbalance after a head injury.
- Repeated falls.
Key points to remember
- Balance depends on the inner ear, eyes, feet nerves, muscles and brain.
- Neuropathy, inner ear problems, weakness, medicines and anxiety are common causes.
- Balance and vestibular exercises help many people.
- Sudden imbalance with neurological symptoms is an emergency.
Questions about feeling off balance
These answers are general information and do not replace an examination or individual medical advice.
Why do I feel off balance but not dizzy?
Inner ear problems, neuropathy, muscle weakness, vision, medicines or anxiety can cause unsteadiness.
Can anxiety make you feel off balance?
Yes, anxiety and PPPD commonly cause unsteadiness.
Can an inner ear problem cause imbalance without vertigo?
Yes, especially damage to both inner ears.
What is disequilibrium?
A feeling of unsteadiness or imbalance without spinning.
Can low B12 cause balance problems?
Yes, it can damage nerves and affect balance.
Do balance exercises really help?
Yes, vestibular rehabilitation and balance training are effective.
When is feeling off balance an emergency?
With sudden weakness, speech problems, facial droop or severe headache.
Can dehydration make you feel unsteady?
Yes, it can lower blood pressure and cause unsteadiness.
Why do I feel off balance in supermarkets?
Busy visual environments can worsen unsteadiness, especially in PPPD.
Sources
This guide is for general information and does not replace medical advice. How a problem is diagnosed and treated depends on your examination and medical history. If you think you have an emergency, contact your local emergency services.