Impact of diabetes with and without neuropathy on plantar pressure, kinematics, kinetics, and muscle activity during gait: a systematic review and meta-analysis of observational studies

Diabetes mellitus (DM) and diabetic peripheral neuropathy (DPN) are linked to altered gait biomechanics, increasing functional limitations and foot ulcer risk. Although previous studies investigated biomechanical changes, findings are heterogeneous, methodologically limited considering the technological advances in the field, and outdated, with the last meta-analysis published in 2016. An updated synthesis is needed to identify consistent DM- and DPN-related gait patterns. PubMed, Embase, Scopus, Web of Science, Virtual Health Library and, CINAHL were searched for observational studies reporting gait biomechanics outcomes in adults with DM or DPN, compared with healthy individuals. Two independent reviewers assessed the risk of bias (modified Downs and Black checklist) and extracted data. Meta-analyses (random-effects models calculating mean differences [MD] with 95% confidence intervals) were performed when ≥ 3 studies met criteria. Heterogeneity was assessed through I 2 . Forty-three studies ( n = 4464) were included in the systematic review and 37 in the meta-analysis. Most studies showed good methodological quality, with scores ranging from 9 to 16 out of 18. Peak pressure was higher at the midfoot in DPN (MD = 58.49 kPa; CI 2.05 to 114.93); at the forefoot, both DM (MD = 70.26 kPa; CI 30.92 to 109.59) and DPN (MD = 125.98 kPa; CI 39.03 to 212.94) showed higher values. The DPN group exhibited higher rearfoot (MD = 5.46 kPa · s; CI 1.11 to 9.82) and hallux pressure–time integrals (MD = 2.99 kPa · s; CI 2.19 to 3.78). DPN exhibited shorter stride length (MD = − 0.10 m; CI − 0.15 to − 0.05), and delayed vastus lateralis activation (MD = 1.51%; CI 0.02 to 3.02). Joint kinematics revealed reduced knee range of motion (MD = − 4.45 deg; CI − 6.32 to − 2.59) and hip extension (MD = − 4.23 deg; CI − 5.30 to − 3.16) in DPN, and reduced hip range of motion in DM (MD = − 1.63 deg; CI − 1.92 to −1.33). Both groups showed reduced ankle plantarflexion (DM: MD = − 0.06 Nm/kg; CI − 0.10 to − 0.01; DPN: MD = − 0.05Nm/kg; CI − 0.06 to − 0.03) and hip flexion moments (DM: MD = − 0.14 Nm/kg; CI − 0.19 to − 0.08; DPN: MD = − 0.08 Nm/kg; CI − 0.13 to − 0.03). DPN also showed increased ankle power absorption (MD = 0.11 W/kg; CI 0.07 to 0.16). DM, particularly DPN, presents substantially impaired gait biomechanics, with a more cautious pattern suggesting a compensatory strategy to maintain stability. This is demonstrated by slower and longer steps, higher plantar loading, delayed muscle activation, and compensatory kinematic and kinetic strategies. Early gait assessment and targeted interventions may reduce ulcer risk and preserve functional mobility in adults with DM. PROSPERO CRD420251076593.