## 4 Discussion
The authors highlighted that qualitative thermogram interpretation demonstrated high sensitivity for anomaly recognition but low specificity in diagnostic terms. Furthermore, it is challenging to differentiate temperature alterations resulting from bone or soft tissue injuries and to ascertain the extent of these lesions [27]. This is due to the fact that regions exhibiting elevated temperatures indicate an enhanced vascular response to injury, although this is not always confined to the precise location of the lesion. In comparison to bone injuries, soft tissue injuries frequently manifest as even more elevated temperatures on thermograms. This may be attributed to the discrepancy in depth between bones and the more superficially located and more readily injured soft tissues. Therefore, thermography can be a valuable addition to the diagnostic process, particularly in understanding the pathophysiology of foot stress. However, it is essential to complement this with detailed clinical examinations and other complementary tests, as there are currently no consistent criteria to help establish a foot diagnosis based on thermograms alone. It is of particular significance that [PERSON] et al. [31] demonstrated a moderate correlation between increased plantar temperature and vertical foot pressure. The authorsproposed a potential correlation between foot load, foot pressure and plantar temperature fluctuations in relation to shear forces. [PERSON] et al. [36] employed the use of a thermal infrared camera and a bespoke shear force plate to investigate the potential correlation between plantar tensions and elevated foot sole temperature following exercise. Following a 10 min period of walking, pressure, stress and shear data were recorded, and thermograms were performed before and after the exercise. This resulted in the identification of a moderate linear relationship between shear forces and maximum post-exercise plantar temperature (r = 0.78, \(p\) = 0.0002). It is hypothesised that the elevation in plantar temperature resulting from physical exertion is more closely associated with shear forces than triaxle plantar stresses. However, it should be noted that thermal cameras are not a reliable method for predicting shear stress forces. However, the results from [PERSON] et al. [37] indicated an inverse relationship between foot version and thermal symmetry immediately after running, with the medial ROIs exhibiting higher temperatures than the lateral ROIs (\(p\) < 0.05), which differed from the findings of [PERSON] et al. [36]. Similarly, [PERSON] et al. [38] examined the impact of footwear instability on foot sole temperature after walking for 10 min at 1.44 m/s with each shoe type (with two hours of rest between each test). The authors identified a significant difference in the results for the midfoot area (\(p\) = 0.004, ES = 1.2). One potential explanation for this result is that the portion of the foot experiencing reduced contact time during the stance phase may be subjected to increased friction with the footwear. This would result in a greater temperature increase [37], which would also remain more constant in unstable shoes due to the alteration in plantar distribution that they create [38]. The study by [PERSON] et al. [29] examined diabetic patients who either engaged in weight-bearing activities at a moderate intensity (athletes) or did not perform such activities (non-athletes). Significant differences were identified in pressure, temperature and the plantar surface skin temperature gradient between the two cohorts. This was particularly evident among athletes, where the temperature gradient was higher in the first metatarsal head of these participants than in those who did not engage in exercise (athletes: mean value = 1.66 \(\pm\) 1.31/non-athletes: mean value = 1.20 \(\pm\) f 1.20/\(p\)-value = 0.02). The authors identified a single significant linear relationship between plantar pressure and weight-bearing activity in athletes, specifically in the second and third metatarsal heads of the right foot.