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.
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
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
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
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.
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
Over time, the metatarsal that is sustaining increased load will
have one of two outcomes. In abrupt cases of loading, the metatarsal may
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.
|The symptoms of forefoot capsulitis are particularly noticeable when patients are barefoot on hard surfaces such as hardwood floors or bathroom floors. Pain increases with the time spend on hard surfaces. The pain of forefoot capsulitis is relieved with rest.
Forefoot stress fractures
Products Recommended for Capsulitis:
This article was written by Jeffrey A. Oster, DPM and last updated 2/5/13.
No additional information is available for this topic.
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