In a study at the High-Risk Diabetic Foot Clinic at the University of Texas27 at San Antonio, it was hypothesized that local skin temperatures on the affected limb would be higher in extremities with pathology (neuropathic ulcers, acute Charcot’s arthropathy) and the same in patients without pathology when compared to the corresponding site on the contralateral foot. Further, it was expected that temperatures return to normal once ulcer and fracture healing is complete. Lastly, it was questioned whether dermal thermometry could be potentially predictive of neuropathic ulceration. To that end, 143 consecutive patients with diabetes that presented for treatment to the High-Risk Diabetic Foot Clinic were enrolled. All were evaluated with thermometry. These patients were divided into 3 groups: 78 patients with asymptomatic loss of protective threshold, 44 with neuropathic foot ulcerations, and 21 patients with neuropathic (Charcot) fractures. Temperatures were evaluated with a portable handheld infrared skin temperature probe (Dermatemp 1001, Exergen Products, Watertown, MA, USA). Patients’ skin temperatures were measured at the time pathology was initially identified and at subsequent clinical follow-up visits for an average of 22.1 ± 6.4 months. Temperatures on the contralateral foot were measured as a control. In this population, there were significant differences in skin temperature in both the Charcot (8.30°F, p < 0.001) and ulcer groups (5.60°F, p < 0.001) compared with the region overlying the site of pathology on the contralateral side. No significant temperature difference was identified in the group with asymptomatic loss of protective threshold group and no acute pathology. Temperatures all normalized at the time of Charcot quiescence and ulcer healing. Eleven percent of patients in the ulcer group re-ulcerated a mean 12.2 ± 6.4 months after initial healing with a corresponding significant increase in skin temperature at the clinic visit immediately preceding reinjury (p < 0.001). These data suggest that monitoring of the corresponding contralateral foot site may provide objective, clinical information before other clinical signs of injury can be identified and that infrared dermal thermometry may be predictive of neuropathic ulceration.27 Subsequent studies have indicated that elevated skin temperatures are directly correlated with location of acute neuropathic osteoarthropathy (Charcot’s arthropathy) and that temperatures will equilibrate in a predictable manner as acute Charcot’s arthropathy resolves into a quiescent state.28,29 Furthermore, the difference in temperature on the wounded side compared with the corresponding contralateral site decreases as the surface area of the wound decreases.30 As a practical measure, the opposite extremity has been used in previous studies as a control because it is exposed to the same duration and control of diabetes and systemic complications as the affected limb and should represent a built-in comparison source. In this manner, the patient serves as his own control. Because the disease processes of neuropathic fractures and ulceration involves multiple factors that affect lower extremity perfusion and temperature regulation, it would be difficult to identify an absolute skin temperature level that could be considered normal or one that could be used as a universal reference. For instance, the baseline temperatures for a patient with Charcot’s fracture may be higher than diabetic patients without this complication or persons without diabetes.45-47 In a related study, temperatures assessed by manual palpation were identified as a relatively inaccurate means of quantifying skin temperature.47 To that end, eleven healthy physicians, eight male with a mean age of 28.6 ± 4.4 years, were enrolled for study. These subjects were instructed to palpate two of five steel cylinders of known temperature using the volar surface of their hands. The five cylinders, arranged randomly were carefully gradated to produce equal, 2, 4 and 6 degree Celsius temperature gradients. They were then asked whether the temperature difference between any two cylinders was equal, 2º, 4º or 6° Celsius. This process was repeated a total of ten times for each participant. Subjects correctly estimated the temperature gradient a mean 1.00 ± 0.89 times out of 10 random attempts. There was not a significant difference between temperature gradient and frequency of correct answers (p > 0.05). It was concluded that, while the laying on of hands in a clinical setting is a necessary and crucial component of the doctor-patient relationship, manual palpation, even in a controlled environment, is not a reliable or objective means to assess temperature.