Fracture of the cuboid bone. Cuboid bone of the foot fracture photo Fracture of the calcaneus and cuboid bone

For pain in the cuboid bone of the foot, it is recommended to immediately go to the hospital. The cause of the pain syndrome can be hidden both in ordinary fatigue and in a serious fracture. The cuboid bone is located in front of the heel. According to its anatomical features, it has an irregular shape. Any overexertion of the feet leads to the appearance of severe pain.

Causes of pain syndrome

In most cases, the pain syndrome develops due to an injury. It is not so easy to damage this part of the foot, but the probability of damage still remains. The main function of the cuboid bone is the formation of arches on the sole. As a result, a groove is formed that provides full work to the tendons. Therefore, with any violations, the functionality of the muscles is sharply reduced.

The main causes of pain in the bone:

Mechanogenesis. Injuries of varying severity fall into this category. Usually these are fractures, as a result of which cuboid damage is noted. Forced movements accompanied by bone crushing are capable of provoking this process.
Excessive arching of the sole. This leads to dislocation of the cuboid bone. People involved in dancing and cycling are susceptible to this damage.
Stress fracture. More often fixed in beginner athletes. In this case, the person feels severe pain, swelling appears on the sole.
Peroneal tendinitis. This syndrome causes discomfort on the outside of the foot, indicating a fracture.

Only a specialist after carrying out diagnostic measures is able to identify the exact cause of the pain.

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Common Causes of Pain

The cuboid bone may suffer due to a stress fracture. Novice athletes, due to the lack of rich experience, at first harm their health. Excessive zeal can provoke the appearance of cracks in the foot. This happens as a result of monotonous and persistent repetitions of the same movements. Most often, this type of injury occurs during sports competitions. In this case, the victim feels a pulling pain, which intensifies over time.

In second place is the sprain. This is the most common cause of severe pain in the foot. In almost 85% of cases, it is the stretch that injures the cuboid bone. This happens as a result of inversion. Stretching can damage any ligament, even when twisting the leg.

Cuboid Syndrome. This cause is not fixed so often, however, damage in this area leads to prolonged pain. The process is observed with partial dislocation of the foot as a result of injury. In this case, the ankle can also be stretched. The pain is localized from the outer edge of the foot, its intensification is recorded in the morning and during physical activities. Without proper treatment, the symptom will not disappear on its own.

Tarsal Coalition. It is extremely rare, this condition is due to the fusion of bones with each other. The problem is congenital and manifests itself after 20 years. The pain syndrome occurs unexpectedly, while constant fatigue is felt. A person can be plagued by convulsions at any time of the day. Surgery can help relieve pain.

Bunyon. This is a foot deformity that causes the big toe to turn inward. This anomaly is accompanied by severe pain and inflammation. Sometimes a similar situation is fixed with the little finger.

Corn. Pain in the cuboid bone does not always indicate the presence of a serious pathology or injury. Sometimes a corn just fills up in this place.

In some cases, it develops under the skin, making it difficult to diagnose. A person is tormented by pain in the region of the cuboid foot, but in fact there is a corn.

Tendonitis and arthritis can lead to discomfort and additional symptoms. All these conditions are accompanied by a pronounced clinical picture.

Cuboid fractures are rare. This is due to the peculiarities of the anatomical position of the cuboid bone, in which it is protected from damage by the surrounding bones.

The main types of cuboid fractures are compression and avulsion fractures.

Fractures due to insufficient bone tissue are called stress fractures and constitute the third and least common group of injuries.

The most common variant of a cuboid fracture is an avulsion fracture in the region of its outer surface.

The separation occurs in the area of attachment of the calcaneocuboid ligament, and the bone fragment, in fact, is torn off along with it.

These fractures are best seen on radiographs or CT scans.

Often they are missed, mistaking the damage for a simple "sprain".

Patients describe the typical mechanism of injury as twisting of the foot, often with the foot tucked inward.

Clinically, with such fractures, pain will be localized along the outer edge of the foot.

Careful examination in such cases makes it possible to distinguish damage to the external ligaments of the ankle joint from an avulsion fracture of the cuboid bone.

The severity of subcutaneous hemorrhage and bruising with such fractures may be different.

Conservative treatment

The vast majority of avulsion fractures can be treated conservatively, as they are mostly non-displaced or minimally displaced.

Surgery

Surgical intervention in patients with avulsion fractures of the cuboid bone is rarely indicated.

The operation is indicated primarily for patients with clinically pronounced false joints after an avulsion fracture, in which adequate conservative treatment has already been carried out, including immobilization for 8-12 weeks and modification of the shoes used.

In such cases, it is usually sufficient to remove the unfused fragment of the cuboid bone.

Compression fractures are the second most common scaphoid fracture.

This variant of fractures occurs due to a relatively higher energy injury, most often in a fall on the foot.

These fractures are also often associated with Lisfranc injuries or other fractures/dislocations of the tarsometatarsal joints, which require special attention.

Patients usually report a history of high-energy trauma.

Shortly after such an injury, pronounced swelling of the foot most often develops. Patients with such a foot injury are usually examined very carefully, since cuboid fractures are often associated with fractures or dislocations in other parts of the foot.

All patients after a high-energy injury that led to a fracture of the cuboid bone undergo computed tomography, since combined injuries of the tarsal and metatarsal bones in such patients are also not uncommon.

Conservative treatment

Patients with isolated fractures of the cuboid bone without displacement or with minimal displacement are shown to be immobilized with a short plaster splint, which allows the possibility of loading the leg.

Upon termination of immobilization, the gypsum splint changes to an orthopedic boot and a dosed load on the foot is allowed.

The return to normal shoes is determined by the severity of pain and residual edema, the presence of radiological signs of adhesion.

Most often, patients begin to wear their usual shoes 8-12 weeks after the injury.

Surgery

The management of cuboid fractures with displaced fragments is still a matter of debate, as there is no consensus as to how significant the displacement must be in order for the fracture to be unequivocally amenable to surgical repair.

Most physicians agree that the cuboid is an important stabilizer of the lateral column (outer edge) of the foot, and changes in the length of the lateral column inevitably lead to foot deformity, flat feet, and pain.

The most common deformity due to a compression fracture of the cuboid is shortening of the lateral column, so any surgical intervention should be aimed at restoring this length of the lateral column.

There are various methods of surgical interventions. In our practice, we restore the length of the lateral column by internal fixation of the fracture with plates and screws and, if necessary, bone grafting using supporting autografts from the iliac crest.

The results of treatment in all patients were good, and we use this method of treatment for any fractures of the cuboid bone, accompanied by crushing of its articular surface.

In case of multi-comminuted fractures, the only way to restore the length of the lateral column of the foot can be bridge osteosynthesis with a plate. If the fracture is accompanied by severe soft tissue injury, external fixation may be the only possible treatment. Regardless of the fixation technique used, all attention should be focused on maintaining the length of the lateral column of the foot, without which it is impossible to restore the normal shape and function of the foot.

Fractures due to lack of bone tissue, or stress fractures of the cuboid bone, are usually characterized by the gradual development of pain in the region of the outer edge of the foot, aggravated by physical activity.

These fractures are rare and often go undiagnosed.

Diagnosis often requires advanced imaging techniques.

Stress fractures of the cuboid bone are common in athletes.

Conservative treatment

Conservative treatment in most cases allows to achieve consolidation of a stress fracture of the cuboid bone.

Initially, the patient may be immobilized for a period of 4-6 weeks.

In the absence of load, this period is sufficient for the healing of the fracture.

At the end of immobilization, the degree of load on the leg and the level of physical activity will be determined by the patient's symptoms.

Surgery

Surgical treatment for these fractures is rarely indicated. It can be indicated, for example, when the patient still has pain despite adequate conservative treatment.

Before making a final decision about surgical treatment, we prescribe a course of high-energy shock wave therapy to our patients.

Surgical treatment may include bone grafting of the fracture area and stabilization with a compression screw. If this is also ineffective, arthrodesis of the calcaneocuboid joint may be indicated.

The legs are the support of the body, and the feet are the support for the legs. Athletes often underestimate the importance of a healthy foot and ankle in achieving optimal athletic performance, not to mention overall well-being and health. The most unpleasant thing is that even minor injuries to the foot and ankle can have very bad long-term health consequences in the future. How foot injuries occur, what is foot dislocation and how to recognize, prevent and cure it - we will tell in this article.

The structure of the foot

The foot is a complex anatomical formation. It is based on the bone frame, represented by the talus, calcaneus, scaphoid, cuboid and sphenoid bones (tarsal complex), metatarsus and fingers.

bone base

The talus serves as a kind of "adapter" between the foot and lower leg, due to its shape providing mobility to the ankle joint. It lies directly on the heel bone.
The calcaneus is the largest of the foot bones. It is also an important bone landmark and the place of attachment of the tendons of the muscles and the aponeurosis of the foot. In functional terms, it performs a supporting function when walking. Anteriorly in contact with the cuboid bone.
The cuboid bone forms the lateral edge of the tarsal part of the foot; the 3rd and 4th metatarsal bones directly adjoin it. With its medial edge, the described bone is in contact with the navicular bone.
The navicular bone forms the medial portion of the tarsal foot. Lies anterior and medial to the calcaneus. In front, the navicular bone is in contact with the sphenoid bones - lateral, medial and middle. Together they form the bony support for the metatarsal bones.
The metatarsal bones are related in shape to the so-called tubular bones. On the one hand, they are motionlessly connected to the bones of the tarsus, on the other hand, they form movable joints with the toes of the foot.

There are five toes, four of them (from the second to the fifth) have three short phalanges, the first - only two. Looking ahead, let's say that the toes have an important function in the walking pattern: the final stage of pushing the foot off the ground is only possible due to the first and second toes.

Ligament apparatus

The listed bones are strengthened by a ligamentous apparatus, they form the following joints among themselves:

Subtalar - between the talus and calcaneus. It is easily injured when the ankle ligaments are sprained, with the formation of subluxation.
Talon-calcaneal-navicular - around the axis of this joint, it is possible to perform pronation and supination of the foot.
In addition, it is important to note the tarsal-metatarsal, intertarsal and interphalangeal joints of the foot.

The most significant for the formation of the correct arch of the lower leg are the muscles located on the plantar side of the lower leg. They are divided into three groups:

outdoor;
internal;
medium.

The first group serves the little finger, the second group - the thumb (responsible for flexion and adduction). The medial muscle group is responsible for flexing the second, third, and fourth toes.

Biomechanically, the foot is designed in such a way that, with the right muscle tone, its plantar surface forms several arches:

external longitudinal arch - passes through a mentally drawn line between the calcaneal tubercle and the distal head of the fifth phalangeal bone;
internal longitudinal arch - passes through a mentally drawn line between the calcaneal tubercle and the distal head of the first metatarsal bone;
transverse longitudinal arch - passes through a mentally drawn line between the distal heads of the first and fifth metatarsal bones.

In addition to muscles, a powerful plantar aponeurosis, mentioned a little above, takes part in the formation of such a structure.

Types of dislocations of the foot

Dislocations of the foot can be divided into three types:

Subtalar dislocations of the foot

With this type of foot injury, the talus remains in place, and the calcaneal, navicular and cuboid adjacent to it, as it were, diverge. In this case, there is a significant traumatization of the soft tissues of the joint, with damage to the blood vessels. The joint cavity and periarticular tissues are filled with an extensive hematoma. This leads to significant swelling, pain and, which is the most dangerous factor, to disruption of blood delivery to the limb. The latter circumstance can serve as a trigger for the development of foot gangrene.

Dislocation of the transverse tarsal joint

This type of foot injury occurs with a direct traumatic effect. The foot has a characteristic appearance - it is turned inward, the skin, on the back of the foot, is stretched. On palpation of the joint, the navicular bone displaced inwards is clearly felt. Edema is expressed as significantly as in the previous case.

Dislocation of the metatarsal joint

A fairly rare injury to the foot. Most often occurs with direct injury to the anterior edge of the foot. The most likely mechanism of injury is an elevated landing on the balls of the toes. In this case, the first or fifth phalangeal bones, or all five at once, can be displaced in isolation. Clinically, there is a step-like deformity of the foot, edema, inability to step on the foot. Significantly hampered voluntary movements of the toes.

Dislocations of the toes

The most common dislocation occurs in the metatarsophalangeal joint of the first toe. In this case, the finger moves inward or outward, with simultaneous flexion. The injury is accompanied by pain, significant pain when trying to push off the ground with an injured leg. Wearing shoes is difficult, often impossible.

Signs and symptoms of a dislocation

The main symptoms of a dislocated foot are:

Pain, which occurs abruptly, immediately after the impact of a traumatic factor on the foot. At the same time, after the cessation of exposure, the pain persists. Strengthening it occurs when you try to lean on the damaged limb.
Edema. The area of the damaged joint increases in volume, the skin is stretched. There is a feeling of fullness of the joint from the inside. This circumstance is associated with concomitant trauma of soft tissue formations, in particular, blood vessels.
Loss of function. It is impossible to make an arbitrary movement in the damaged joint, an attempt to do this brings significant pain.
Forced position of the foot- part of the foot or the whole foot has an unnatural position.

Be careful and attentive! It is impossible to distinguish a dislocation of the foot from a sprain and fracture of the foot visually without an x-ray machine.

First aid for dislocation

First aid for dislocation of the foot is the following algorithm of actions:

The victim must be laid on a comfortable flat surface.
Next, you should give the injured limb an elevated position (the foot should be above the knee and hip joints), placing a pillow, jacket or any suitable tool under it.
To reduce post-traumatic edema, you need to cool the injury site. For this, ice or any product frozen in the freezer (for example, a pack of dumplings) is suitable.
In case of damage to the skin, it is necessary to apply an aseptic bandage to the wound.
After all the actions described above, it is necessary to deliver the victim as soon as possible to a medical facility where there is a traumatologist and an X-ray machine.

Dislocation treatment

Treatment of a dislocation consists in the procedure of repositioning the leg and giving it a natural position. The reduction can be closed - without surgical intervention, and open, that is - through an operative incision.

It is impossible to give any specific advice on how and how to treat dislocation of the foot at home, since there is no way to do without the help of an experienced traumatologist. Once the dislocation has been corrected, he can give you some advice on what to do if your foot is dislocated so that you can get back on your feet as quickly as possible.

After the reduction procedures, a fixing bandage is applied, for a period of four weeks to two months. Do not be surprised that when fixing the lower leg, the splint will be applied to the lower third of the thigh - with fixation of the knee joint. This is a necessary condition, since the process of walking with a fixed ankle is very dangerous for the knee joint.

Recovery after a dislocation

After immobilization is removed, the process of rehabilitation begins - the gradual inclusion of the muscles of the immobilized limb in the work. You should start with active movements, but without relying on the injured limb.

To restore bone density at the site of injury, you need to walk a small distance every day, gradually increasing it.

For a more active restoration of limb mobility, we offer several effective exercises. To perform them, you will need a cuff with a fixation ring and a strap for fastening in the area of the Achilles tendon. We put the cuff on the projection area of the metatarsal bones. We fix the strap through the Achilles tendon slightly above the level of the heel. We lie down on the mat, put the legs on the gymnastic bench. Three options follow:

In addition to the exercises described for developing the foot after an injury at home, you can use other methods and improvised means: roll a ball with your foot, perform backbends with a towel, and so on.

Fracture of the cuboid bone of the foot is very rare. This bone is located in the outer part of the foot, but usually breaks in combination with others, or after a direct serious injury, for example, from a heavy object falling from above. The main share of bone fractures is due to a fall from a height and an unsuccessful landing on the feet. Among all injuries of all bones of the skeleton, it accounts for only 0.14%.

The cuboid bone is located between the bones of the metatarsus and calcaneus.

Usually, a fracture occurs without splinters, but in rare cases, comminuted ones also occur. This type is most often accompanied by concomitant fractures of the surrounding bones. In this case, the treatment is much harder and longer.

How to recognize?

The first symptoms of this fracture:

violations of the foot (it hurts to move, turn, sometimes a person can lean, but only on the heel);
strong pain;
tumor;
bleeding.

In the future, more obvious signs appear that indicate precisely this injury:

pain in a certain place on palpation;
leg deformity;
stepped performances;
increased pain when trying to move (foot abduction, rotation, etc.)

If the fracture is accompanied by subluxation, dislocation, displacement, a stepped deformity appears on the back side.

An accurate diagnosis can only be made after an x-ray and examination by a specialist.

How to treat?

In case of injury, you must immediately fix the knee and ankle joints. Use all means at hand for this (sticks, ropes ...) It is important that the fragments do not move, and the recovery is faster.

If the bone breaks without splinters, the treatment is fairly simple. The patient is put in a plaster cast in the form of a boot, completely fixing the foot. A metal arch support is embedded on the sole. The bandage starts from the fingertips to the second third of the lower leg. You need to wear a cast for two to three months.

The correct modeling of the foot is important.

Recovery takes longer. At first, the patient is generally forbidden to walk, over time, you can gradually load the injured leg.

After the plaster is removed, the person must undergo physiotherapy and mechanotherapy.

They include exposure to interference currents. This is an excellent tool for relieving edema and hematoma, in addition, it relieves pain, and normalizes trophic processes in tissues. As a bactericidal agent, ultraviolet irradiation is used. If the foot hurts very much, bromine electrophoresis is used. The ankle joint is developed with special exercises.

UHF therapy is used to improve blood flow, stimulate immunity and tissue regeneration. Massage therapy works well.

Full recovery takes three months.

For the next year, the patient must wear orthopedic shoes with flat soles only.

Effects

In a healthy person, complications rarely occur. And yet, it is worth remembering that the foot is a very complex mechanism in which every bone and muscle is interconnected. Therefore, the slightest violation can lead to pathogenesis.

The motor function is disturbed - it is difficult for a person to take the foot away, supination and pronation are limited. Also, lameness can last for a long time. Sometimes patients (mostly in adulthood) may lose their ability to work and the ability to move normally.

Pain may persist for some time after a cuboid fracture. If they do not go away, the remaining fragments must be surgically removed.

If the fracture does not heal for a long time, this indicates a violation of the body. Lack of calcium, vitamins, tissue nutrition processes, etc. Therefore, it is important to eat right during treatment. Eliminate all bad habits and choose healthy foods. Your diet should include spinach, dairy, meat, seafood, bananas, etc. try to eat less salt so that there are no serious edema.

It is also possible with improper or insufficient treatment.

In most cases, a fracture of the cuboid bone heals quite quickly and completely.

Fracture of the bones of the foot is one of the most common injuries of this part of the lower limb, consisting of 26 large and small bones. Damage requires a long and complex treatment due to the fact that the foot is constantly involved in the motor function of the lower extremities.

The term of recovery depends on the type and severity of the injury, the correct and necessary amount of medical care provided at all stages of treatment, the age of the victim, the general condition of the body and other factors.

A fracture of the bones of the foot occurs due to a mechanical effect on the foot or a sharp movement of the foot from its wrong position. A heavy falling object can also break the integrity of the bone tissue. Most often, the injury occurs due to a fall on the leg from a great height.

There is a pathological type of fracture, when a slight mechanical impact is sufficient to cause damage. This is due to the weakness of bone tissue caused by osteoporosis, osteochondrosis, the presence of oncological neoplasms, pathologies of an autoimmune nature.

In accordance with the reasons that led to injury, one of the bones is damaged, which is associated with a certain location and distribution of the load. Foot fractures according to the impact factor are divided into the following:

Injury can occur due to excessive physical exertion, with intense sports. In such cases, a so-called stress fracture occurs. As a result of constant pressure, the bone tissue cracks. Basically, such injury occurs with the talus and metatarsal bone.

How is it manifested?

Fractures of the bones of the foot vary in symptomatic presentation, depending on the type of damaged bone. The main symptoms of a broken foot are:

Strong pain;
Bruise;
Swelling at the site of injury;
Difficulty in movement;
Deformation.

Fractures of the bones of the foot are always accompanied by severe swelling and hematoma under the skin in the injured area. The intensity of the pain syndrome is different - from mild to unbearable. Signs of a foot fracture due to bone damage:

Heel	increase in size; edema; vault seal; painful sensations; restriction of mobility.
Phalanx	intense pain symptom; excessive mobility; pain when trying to stand on a full foot.
Scaphoid, cuboid, sphenoid bone	the ability to walk, resting on the heel; swelling of the back of the foot; pain when trying to turn the foot
Ramming	swelling in the ankle; constraint in movements; pain when touching the heel

Often, when injured, mild pain occurs, and the victim does not immediately understand that a fracture has occurred, confusing the injury with a bruise. In such cases, an accurate diagnosis can only be made through a medical examination and x-rays.

First aid

After the injury, the victim must be taken to the trauma department, where a trauma specialist can determine whether a bruise or fracture has actually occurred. Prior to the arrival of doctors, first aid is required.

Doing massage, kneading the affected area to reduce pain is prohibited. The person providing assistance should touch the leg as little as possible so as not to dislodge the broken bone.

A splint should be placed to relieve pain and prevent a displaced fracture of the foot. In the case when a special medical device is not at hand, sticks, pieces of reinforcement, boards are used, they must be placed on both sides of the foot, bandaged to the injured limb with bandages, gauze, a rag, etc.

If the injury is of an open type (it is easy to find out by the presence of an open wound surface, bleeding), the wound must be treated with antiseptics, hydrogen peroxide, Chlorhexidine, and the edges of the wound should be lubricated with iodine. A bandage is applied to stop the bleeding.

When applying a splint, the material at hand used to fix the foot must be wrapped with a rag or bandage so that the open wound does not come into contact with a dirty object.

How to treat?

Medical assistance to the victim begins with anesthesia. For this, painkillers are prescribed, and if they are not effective enough, a blockade is placed - the introduction of an anesthetic directly into the site of injury.

In case of a foot fracture, treatment is selected on an individual basis and requires an integrated approach: If the injury is of a closed type, and there is no displacement, long-term fixation of the foot is necessary by applying a plaster cast. The terms of wearing a cast vary from 1 to 3 months, depending on the severity of the clinical case.
If a closed fracture is accompanied by displacement, it is necessary to carry out a reposition - folding the bones in the right order. Reposition is carried out in two ways - open and closed, depending on the severity. After folding the bones in the desired primary position, a plaster cast is applied. If there was a lot of debris, medical staples and screws are used to fix them. After removing the cast, the motor function of the foot should be restored. It is necessary to develop an injured foot carefully and gradually.
Injury to the navicular bone in most cases is accompanied by a fracture of adjacent bones. Quite often the fracture of a bone leads to simultaneous dislocation. As a rule, this is accompanied by intense pain sensations - a blockade is placed to relieve symptoms. If there is no dislocation and displacement, it is necessary to wear a cast for up to 5 weeks.
In case of dislocation with a fracture, the Elizarov apparatus is installed to reposition the bones. In severe clinical cases, assistance to the victim is provided by an open operation - a bone fragment is fixed with a silk thread suture. The limb immobilization period is up to 12 weeks.
A fracture of the sphenoid bone without displacement is treated by applying a plaster cast, the period of wearing a plaster cast is from 1 to 1.5 months. Rehabilitation after a fracture can last more than 1 year.
A fracture of the cuboid bone involves the imposition of gypsum for up to 2 months, in case of displacement, a closed reposition is performed.
When the fingers are injured, it is very painful for a person to step on his foot, a cyanotic swelling appears at the site of the injury. Treatment - a plaster bandage, for a period of 4-6 weeks.

While in a cast, you must follow a diet. The basis of the diet should be sour-milk and dairy products enriched with calcium, which helps to strengthen bones and accelerate their fusion.

Before you remove the plaster, you must undergo an examination by a doctor. It is possible to find out whether the bones have completely grown together only on an x-ray. After removing the plaster cast, a set of exercises is prescribed to restore the motor function of the foot.

Rehabilitation

Swelling after removing the plaster cast will persist for a long time. To stop this symptom, you can use drugs with a local spectrum of action - gels, ointments, creams. A massage is performed to dissolve the accumulated fluid.

Physiotherapy and special exercises are effective and mandatory means of rehabilitation, which can significantly reduce the period of complete recovery after an injury. Without exercise therapy and physiotherapy, the muscles of the foot can atrophy, which will lead to loss of motor function. Massage should be carried out only by a specialist. If you do the massage yourself, the effect of it can be just the opposite, you can only damage the fused bones and soft tissues, increasing swelling.

Before you begin to develop the foot with physiotherapy exercises and massage, the patient is prescribed to wear arch supports immediately after the removal of the cast, usually for a year.

During the first 4-6 months after the injury, it is recommended to replace the usual orthopedic shoes. The complex of physiotherapeutic procedures is selected individually, aimed at reducing swelling, pain and accelerating the process of bone tissue fusion.

A person with a broken foot is unable to walk on both legs. Timely and correctly rendered first aid to the victim will help prevent the development of serious complications. Competent treatment often includes wearing a plaster cast, following a specially selected diet, and conducting complex rehabilitation (physiotherapy, massage, exercise therapy) at the final stage of treatment.