**4. Neurological assessment of diabetic foot**

The clinical assessment of diabetic foot ulcer is currently subjective and limited, hampering effective diagnosis, treatment and prevention. Population-based studies report that the annual incidence of foot ulcers in diabetics is estimated to have DFU throughout their lives [17–19]. Once onset, despite treatment, foot ulcers may take weeks or months to heal, or may not heal at all. In addition, DFU is repeated frequently. Approximately 40% of patients will relapse within 1 year and 60% of patients will relapse within 3 years. The DFU not only reduces an individual's quality of life, but also has significant economic and social implications in the form of increased hospitalization rates, cost of care, and reduced patient mobility [20].

Most guidelines recommend 10 g of monofilament to assess neuropathy in diabetic patients. This test can be combined with another test to screen for neuropathy. Biothesiometer or graduated tuning fork (Rydel Seiffer) to determine the vibration perception threshold [21, 22]. The Modified Neuropathy Disorder Score (NDS) tests (**Table 1**) different sensory modalities of the foot and ankle - (i) vibration perception (using a 128 Hz sound fork), (ii) temperature perception (warm/cold), (iii). Pain (sharp/dull) and (iv) ankle jerk reflex- score range is 0 to 10, 0 for intact sensation and 10 for complete numbness with DPN. The Vibration Perception Threshold (VPT) is a semi-quantitative measure of sensory perception, usually placed at the tip of the toe and measured with a neuro or biothesiometer. VPT displays 0–50 volt readings, where 50 volt indicates complete numbness of DPN. Severe DPNs are usually stratified by VPTs with a modified NDS score of 6 or higher (or) of 25 volts or higher [22–25].

Inadequate foot protection due to nerve injury (neuropathy) does not result in compensatory mechanisms for painful stimuli such as dragging/gait changes to redistribute foot pressure. Continued inflammation results in enzymatic autolysis with tissue destruction and ulcers. The main goal of DFU clinical practice is to prevent the formation of ulcers through early detection and intervention. This reflects the challenges and medical costs associated with effective treatment after the onset of an ulcer. Regular foot evaluation and training are recommended for people with diabetes. This process is usually stratified by the risk of developing an ulcer. Current risk assessments are clinical and subjective, assessing the presence of callus as a surrogate marker for neuropathy, foot malformations, and high sole load, and for medium-risk or high-risk individual therapeutic footwear is recommended [26, 27].

Clinical evaluation tools require special training of clinical examiners to make accurate assessments based on patient outcomes. This assessment helps to efficiently

