Capsulitis is an inflammatory condition that can occur at virtually any joint in the human body. In the foot, capsulitis commonly found beneath the forefoot. Inflammation of the joint capsule of the forefoot is caused by excessive mechanical load being applied to the forefoot. The most common site that capsulitis occurs is beneath the second metatarsal head as shown in the picture on this page. In this picture, the plantar (bottom) aspect of each of the metatarsal heads is marked and numbered. The red area adjacent to the second metatarsal head is the most common area where we see capsulitis occurring in the forefoot.

Treatment of capsulitis

The primary goal in treating forefoot capsulitis is to find ways to off load the forefoot. Off loading is a simple technique that can be accomplished in many different ways. Felt metatarsal pads and forefoot gel cushions are by far the most popular ways to off load the forefoot. Proper placement of metatarsal pads can be a little tricky at first. We often use Pedag Comfort and Pedag Holiday inserts as a reference for patients trying to place metatarsal pads in shoes. The advantage of the Pedag products is that these particular inserts have the met pad positioned in the correct location in relationship to the metatarsal heads. Simply place the insert in the shoe and the metatarsal pad is properly placed. Once you know how a metatarsal pad should feel, you can use individual felt or foam metatarsal pads much more easily.

Shoes design can also be used to off load the forefoot and relieve symptoms of capsulitis. One example of a shoe that can aid in the treatment of capsulitis would be a clog. The rocker sole on a clog has been used for years to off load the forefoot.

Prescription orthotics are another method used to off load the forefoot. Special modifications can be built into orthotics to accommodate areas of capsulitis.

Should the methods mentioned for off loading fail to relieve the pain, an injection of cortisone can do wonders to treat capsulitis. It's important to realize that forefoot capsulitis is a mechanical problem caused by focal loading on one metatarsal head. Logic says that off loading is necessary to decrease load applied to the metatarsal head. Cortisone addresses forefoot capsulitis in a little bit different manner. I often compare a shot of cortisone to throwing a wet blanket over the fire without actually knowing why the fire's there. But the bottom line is that cortisone often helps. In many instances, a shot of cortisone can make a problem of capsulitis disappear indefinitely.

And lastly, surgical procedures may help in recalcitrant cases of forefoot capsulitis. In particular, a metatarsal osteotomy is used to elevate the metatarsal and reduce the symptoms of capsulitis. An osteotomy is a surgical fracture in the metatarsal.

The following images show the steps used to complete a Jacoby osteotomy of the second metatarsal. Variations to this procedure may include the type of osteotomy or methods of fixation. Image 1 shows the location of the metatarsal head and planned incision. Image 2 shows the dissection of the extensor tendons and capsule of the second metatarsal phalangeal joint. Images 3 and 4 show isolation of the second metatarsal in preparation for the osteotomy. Image 5 and 6 show the V shaped osteotomy completed and ready for fixation. And image 7 shows final closure of the surgical wound.

This procedure is completed in a hospital or surgery center using a general anesthetic or local with sedation. The procedure takes about 30 minutes to complete. Patients may be partial to full weight bearing following this surgery. Most patient will require some form of walking cast to protect the osteotomy. Fixation is removed at three weeks. Most patients are back to 100% of full activities by 12 weeks post-op.

Metatarsal - there are five metatarsal bones in each foot. Each metatarsal bone runs from the arch to the ball of the foot. When load is applied to the forefoot, each metatarsal head carries a portion of that load.
Itis - the suffix applied to any inflammatory condition.
Capsule - the soft tissue layer that surrounds any joint. The inner lining of the capsule is called synovium and produced synovial fluid, the fluid that lubricates the joint.
MPJ (metatarsal phalangeal joint) - the joint between the metatarsal and the toe bone.

Capsulitis occurs most commonly at the 2nd metatarsal phalangeal joint of the forefoot. The capsule is the envelop that surrounds the joint.  The inner lining of the capsule is called synovium.  The synovium produced synovial fluid, the fluid that lubricates the joint.  The second metatarsal phalangeal joint consists of the head of the metatarsal, which is covered in cartilage, and the base of the proximal phalanx, or bone of the toe. Numerous tendons traverse the joint and pull like the reins of a horse to guide the motion of the toe. Blood vessels and nerves also pass the joint as they travel to the end of the toe.

The development of capsulitis is very dependant upon the relative length of each metatarsal bone. The longer the metatarsal bone, the greater the tendency for capsulitis to occur. In the picture to your left, the horizontal yellow lines define the relative length of the first, second and third metatarsal bones of the left foot. This picture shows how much longer the second metatarsal bone is. Why is this important? Let's use a silly example to describe why; take two bamboo poles, one five foot long and another ten feet long. Hook them under your arms and hold them out in front of you , parallel to the ground. Now slowly lower the poles. The longer of the two poles, the ten foot pole is going to hit the ground first, followed by the shorter five foot pole. This is essentially how the long metatarsal bones of the forefoot carry our body weight. With each and every step, this load is repeated. Ideally, we'd like to see that load applied to the foot is applied in such a way that it is equally distributed. Equal, even distribution of load helps to prevent focal loading on any one bone or soft tissue structure. But often we'll see that the bone behind the second toe, called the second metatarsal, is long, just like the ten foot bamboo pole. Repetitive loading of the second metatarsal results in inflammation of the tissue structures beneath the metatarsal head (ball of the foot) and capsulitis begins.

Over time, the metatarsal that is sustaining increased load will have one of two outcomes. In abrupt cases of loading, the metatarsal may sustain a stress fracture. A stress fracture is the method by which the metatarsal accommodates the load by changing the structure of the bone. But more common than a stress fracture is an increase in the size and girth of the metatarsal. The image above shows red markings that define the girth of the second and third metatarsals. In this x-ray view, the second and third metatarsals should be approximately the same girth. You can see in the image how the second metatarsal is not only longer (yellow lines) but also larger, (red lines). This particular image shows how a metatarsal, when subjected to increased load will increase in size to accommodate that load.

Arthritis

Capsulitis

Forefoot stress fractures

Freiberg's infraction

Gout

Metatarsalgia

Morton's neuroma

Sesamoiditis

Sesamoid fracture

• Mortons Neuroma

• Freibergs Infraction

• Metatarsalgia

• Bursitis

• Stress Fractures

This article was written by Jeffrey A. Oster, DPM and last updated 10/23/09.