Imbalance: Why Do I Feel Unsteady?

How balance works

Your brain keeps you upright by combining three streams of information:

1. The inner ear (vestibular system): senses head movement and gravity
2. Vision: shows where you are relative to your surroundings
3. Proprioception: sensors in the feet, ankles, knees and spine tell the brain where your body is and how the ground feels

The cerebellum, at the back of the brain, coordinates these signals with muscle strength to keep you steady. When one input fails, the others compensate, which is why many people with nerve damage in their feet feel worst in the dark, when vision cannot help.

Imbalance vs dizziness vs vertigo

Many people have more than one at the same time.

Causes of imbalance

Inner ear causes

• BPPV: brief spinning when turning in bed or looking up, with lingering unsteadiness
• Vestibular neuritis and labyrinthitis: sudden severe vertigo and imbalance for days, often after a viral illness, improving over weeks
• Ménière's disease: episodes of vertigo with hearing loss, ringing and ear fullness
• Loss of inner ear function on both sides, for example after certain antibiotics (gentamicin), causing unsteadiness that is worse in the dark and a bouncing visual image when walking
• Vestibular migraine: episodes of dizziness and imbalance in people with migraine

Nerve and sensation problems

• Peripheral neuropathy: from diabetes, alcohol, vitamin B12 deficiency or chemotherapy. Numb or tingling feet make the ground hard to feel
• Spinal cord problems: compression in the neck or vitamin B12 deficiency affect the pathways carrying position sense

Brain conditions

• Stroke and TIA, especially affecting the cerebellum or brainstem
• Parkinson's disease: shuffling steps, stooped posture and falls
• Normal pressure hydrocephalus: a wide, "magnetic" gait, memory problems and bladder urgency
• Multiple sclerosis, cerebellar ataxias and brain tumors

Blood pressure and heart causes

• Orthostatic hypotension: a drop in blood pressure on standing, causing lightheaded unsteadiness, common in older adults, dehydration and with blood pressure medicines
• Heart rhythm problems and heart valve disease

Medicines and substances

Sedatives, sleeping pills, some antidepressants, anti-seizure medicines, opioids, antihistamines, blood pressure medicines and alcohol all impair balance. Taking 4 or more medicines is itself a risk factor for falls in older adults.

Musculoskeletal causes, including ankle swelling

Balance relies on strong legs and stable joints. Imbalance can come from:

• A swollen or recently sprained ankle: swelling and ligament injury damage the position sensors in the ankle, so the joint feels unstable and gives way. Repeated sprains can lead to chronic ankle instability
• Swelling of both ankles from fluid retention, which makes the feet feel heavy and reduces sensation
• Knee and hip arthritis, weak thigh muscles and foot pain
• Muscle loss with aging and inactivity

Vision problems

Cataracts, glaucoma, new glasses (especially bifocals and varifocals) and poor lighting make balance harder.

When to worry about loss of balance

Sudden imbalance is more concerning than gradual. Use BE FAST for stroke: Balance loss, Eyes (vision loss or double vision), Face drooping, Arm weakness, Speech difficulty, Time to call 911.

Also seek prompt care for imbalance with a severe headache, new hearing loss, falls, or numbness and weakness.

How doctors diagnose the cause

A doctor will ask how the imbalance feels, when it started, whether it is constant or comes in episodes, what triggers it, and about medicines, alcohol, falls and other symptoms. The examination often includes:

• blood pressure lying and standing
• eye movements and the head impulse test
• the Dix-Hallpike test for BPPV
• the Romberg test: standing with feet together and eyes closed
• walking, turning and heel-to-toe walking
• sensation, reflexes and strength in the legs
• ankle and knee stability

Tests may include hearing tests, vestibular function tests, blood tests (blood sugar, vitamin B12, thyroid), nerve conduction studies and MRI of the brain or spine.

Treatment for imbalance

• Treat the cause: repositioning maneuvers for BPPV, adjusting medicines, managing diabetes, B12 replacement, treating Parkinson's disease
• Vestibular rehabilitation: a physical therapist uses head, eye and balance exercises to retrain the brain. It is very effective for inner ear causes
• Strength and balance training: tai chi and structured programs reduce falls in older adults by about a quarter or more
• Ankle rehabilitation after sprains, with balance-board exercises and bracing
• Walking aids such as a cane or walker when needed

Preventing falls at home

• Remove loose rugs and clutter, and fix loose stair coverings
• Add grab bars in the bathroom and rails on both sides of stairs
• Use night lights between the bedroom and bathroom
• Wear supportive, low-heeled shoes with grip
• Stand up slowly, sitting on the edge of the bed for a moment first
• Have your vision checked yearly and review medicines with your doctor or pharmacist

Frequently asked questions

Why do I feel off balance all of a sudden?

Sudden imbalance can come from an inner ear problem such as vestibular neuritis or BPPV, a drop in blood pressure, a new medicine or alcohol. It can also be a stroke, especially with weakness, speech problems, vision changes or a severe headache. Call 911 if those are present.

Can a swollen ankle cause loss of balance?

Yes. Swelling and ligament damage after a sprain disturb the position sensors in the ankle, making it feel unstable and more likely to give way. Swollen feet from fluid retention also reduce sensation. Balance exercises during ankle rehabilitation help restore stability.

What is the difference between imbalance and vertigo?

Imbalance is feeling unsteady on your feet. Vertigo is a false sense of spinning or movement. Inner ear problems often cause both. Imbalance without vertigo more often comes from nerve damage, joint or muscle problems, medicines or brain conditions such as Parkinson's disease.

Can anxiety cause balance problems?

Yes. Anxiety can cause a feeling of unsteadiness, lightheadedness and a fear of falling, and persistent postural-perceptual dizziness (PPPD) often follows an inner ear episode. Other causes should be checked first, and vestibular therapy and treatment of anxiety both help.

What kind of doctor treats balance problems?

Start with your primary care doctor. Depending on the cause, you may be referred to an ear, nose and throat specialist, a neurologist, a cardiologist, or a vestibular physical therapist for balance retraining.