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• Capsulitis is the painful inflammation of the joint capsule—the tough, leather‑like ligaments that surround and stabilize a joint.
• In the foot, it most commonly affects the second toe, often creating the sensation of walking on a marble or a bunched‑up sock.
• The condition develops when repetitive stress overloads the capsular ligaments beneath the metatarsal head, disrupting normal joint alignment.
• Diagnosis is based on clinical exam and imaging to assess the metatarsal parabola and rule out plantar plate tears.
• Early treatment with stiff‑soled shoes, taping, or orthotics can prevent progression to a plantar plate injury and reduce long‑term instability.
capsulitis
Author: Dr. Marc MitnickReviewed by: Medical Review Board
Capsulitis by definition is inflammation of a ligament. Anywhere in the body where two bones come together they form a joint; that is what allows movement within the skeletal system. (Your ankle bending up and down is movement of a joint.)
Surrounding the joint are the capsular ligaments, which act to keep the two bones lined up in approximation so that the joint can function in its optimal range. Ligaments are very tough tissue, almost leather like in texture.
The problem is that you have leather like structures trying to hold bone together (healthy bone has a tensile strength similar to low grade steel). If there is any stress placed on the joint from trauma, or abnormal biomechanical functioning you can be sure the “leather” is going to give out first before the “steel” does. This is what causes capsulitis.
Keep in mind that this problem can occur at any joint in the human body and even occurs in a number of places on the foot, but we are going to discuss the classic “foot capsulitis” as seen in the foot in the area of the metatarsal-phalangeal joint. As it turns out 1st metatarsal phalangeal capsulitis has its own name and is called turf toe.
Below is a skeletal model of the bottom of the forefoot. Note the red checkered area; that is the plantar ligament that is part of the capsular ligament which actually surrounds the whole joint. I have highlighted the plantar ligament because that is the part of the capsular ligament that is most affected in this condition.
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WHAT CAUSES CAPSULITIS
ACTIVITIES-such as stooping while gardening (similar to the rear foot on the male image below), constantly climbing ladders, doing work low to the ground like electrical or plumbing work. Sports activities such as running, where there is a constant excessive bending of the toes at the level of the metatarsal heads. Walking barefoot, quite often, may also create this problem.
SHOES-wearing very high heel shoes. This causes a constant bending at the level of the metatarsal heads which can allow them to over stretch.
Flimsy shoes like flip-flops or ballerina shoes, all cause excessive bending of the toes at the level of the blue arrows. The constant excessive bending of these toes will eventually cause the ligaments to overstretch, become inflamed, and then begin to hurt.
FOOT ARCHITECTURE-the way your foot is structured, can make some people more susceptible to this condition. Look at the x-ray in the pictures below. You will see the first metatarsal bone is much shorter than the second metatarsal bone. This excessive shortening creates more pressure on the second metatarsal bone at the level of the toes and this may very well end up in a capsulitis.
Keeping with my ongoing theme throughout this site; once you have a foot injury, walking on it just re-injures the injured area and thus increases the time it takes for the area to get better, if at all.
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DIAGNOSING CAPSULITIS
Typically a patient will present to the office complaining of pain in the forefoot, probably not relating any specific history of trauma, but the pain is just an ongoing nagging type pain. Many times the patient will have neuroma type symptoms. Click here for more information on Morton's neuroma. If you look at the site of Morton's neuroma and capsulitis you can easily see how they can be misinterpreted.
Sometimes, but not always, an x-ray may be taken to rule out a stress fracture or possible arthritis within the joint.
In most cases, pressing with your thumb at the level where the toe meets the metatarsal head (blue arrows), pain will be felt. Neuroma pain generally occurs between the metatarsal heads, while metatarsalgia will occur directly on pressure on the metatarsal head.
An experienced foot specialist should be able to differentiate between the two conditions. Many practitioners not totally familiar with foot pathology will come up with the wrong diagnosis.
Conditions that may mimic capsulitis include:
| Condition | Primary Cause | Primary Pain Location | Key Differentiator |
|---|---|---|---|
| Capsulitis | Inflammation of the joint capsule/ligament. | Directly under the metatarsal head (often 2nd toe). | Pain is worse when bending toes up or walking barefoot. |
| Morton's Neuroma | Benign thickening/nerve irritation. | Between the metatarsal heads (usually 3rd and 4th). | Often causes tingling, numbness, or "walking on a marble" sensation. |
| Metatarsalgia | General term for ball-of-foot pressure. | Broad area across the ball of the foot. | Pain is typically dull and aching rather than sharp or localized. |
| Stress Fracture | Small crack in the metatarsal bone. | Top or bottom of the specific metatarsal bone. | Significant swelling on top of foot; pain persists even at rest. |
| Turf Toe | Sprain of the big toe joint capsule. | The 1st metatarsophalangeal (big toe) joint. | Affects big toe; usually from sudden hyperextension injury. |
| Plantar Plate Tear | A rupture or tear in the supporting ligament. | Directly under the toe joint. | May result in "daylight sign" where the affected toe drifts away. |
CAPSULITIS OF THE SECOND TOE
severe second toe pain
Of all the toes that can be affected, capsulitis of the second toe, resulting in pain appears to be the most prevalent, and there is a reason for this.
As noted in the x-ray above, for many people, the second metatarsal will bear a greater share of body weight then the other metatarsals.
This is due for one of two reasons. Either the second metatarsal is longer then the first metatarsal as depicted in the x-ray, or, the first metatarsal is hypermobile, meaning it has a tendency to move upwards during the gait cycle, which in turns puts more pressure on the second metatarsal.
Either of these situations may lead to severe second toe pain. The third, fourth and fifth metatarsals are not affected by this phenomenon.
Morton's neuroma may also lead to second toe pain as well.
It is also worth noting that these factors also make the second metatarsal more prone to stress fractures compared to the other metatarsals.
TREATMENT OF FOOT CAPSULITIS
The good news is some of the conservative treatments for neuroma will also help capsulitis, so even if your doctor is not quite accurate with the diagnosis, relief may still be obtained.
Sometimes a variation in the normal foot architecture (as described above) of the metatarsal bones may cause a capsulitis with none of the other precipitating factors present. Usually a prescription orthotic will help these individuals as well. In instances where an orthotic does not help, surgical remodeling of the metatarsal bone may be necessary. The goal of this surgery is to create a better metatarsal alignment between the affected metatarsal bone and the metatarsal bones adjacent to it.
Lastly, a condition known as a "plantar plate tear" is a worsening of this condition. In this instance the ligament has actually torn. This diagnosis can only be made with an MRI or injection of dye into the joint, and then checking for leakage out of the joint. So, in instances where you are undergoing conservative treatment with no real improvement, further testing would be indicated. In many instances this ends up with surgical intervention, although a six week course of immobilization may also be attempted.
Treatment in these instances may require not only repair of the torn ligament, but surgical correction of any bony abnormalities that may have precipitated the condition.
Again, a conservative regimen of immobilization of the joint for a period of 4-6 weeks should be tried first in an effort to allow the ligament to heal on its own. If that fails to solve the problem, then surgery would be the next step.
Frequently Asked Questions
What exactly is capsulitis?
Why does my second toe hurt the most?
What does capsulitis feel like?
- Walking on a marble or a "bunched-up sock."
- Sharp or nagging pain localized at the ball of the foot.
- Increased pain when walking barefoot or bending the toes upward.
How is it different from Morton's Neuroma?
Can I treat this without surgery?
- Stiff-soled shoes: Avoiding flimsy flip-flops or high heels.
- Orthotics: Using prescription orthotics with a metatarsal pad to offload pressure.
- Medication: Cortisone injections or oral anti-inflammatories to reduce swelling.
- Immobilization: Using a surgical shoe or CAM walker for a few weeks to let the ligament heal.
REFERENCES
Questions I Have Answered From Visitors
Capsulitis with orthotics & running shoes
I have a few questions for you regarding my recent foot pain (capsulitis) from starting a running routine. I’m a 42-year-old male engineer with a fairly sedentary lifestyle. I have been wearing RX custom orthotics for running and everyday shoes for several years. My left foot has an arch when seated, but it falls and becomes flat-footed when standing, while my right foot appears normal.
In August 2014, I transitioned to running outside on asphalt with new running shoes (NB1260). After 2-3 weeks, I developed pain in my right foot under the second metatarsal. My podiatrist diagnosed me with capsulitis at the second metatarsal joint. He gave me a cortisone shot and told me to rest for one week. I rested for two, but the pain resurfaced during a light run. I am scheduled to get new orthotics with a metatarsal "cut out."
Questions:
- Q1: What do you recommend regarding a metatarsal "pad" or "cut out" for my new orthotics?
- Q2: Although I have a flat foot, am I a pronator?
- Q3: If I wear RX orthotics, do I still need to wear supportive/motion control running shoes or can I wear normal running shoes with more cushioning?
Response:
Hi Rob, In regards to your questions I have a few points to mention. Capsulitis is a fairly easy diagnosis for a podiatrist, and in most cases does not require an x-ray or MRI. However, since you had a cortisone shot and rested for two weeks, but the pain returned, I would not be too quick to have new orthotics made just yet.
You should be certain that capsulitis is what you have before you actually go out and have new orthotics made. One other possibility is that you may actually have a stress fracture, which can occur that far up in the metatarsal bone. I suggest having an x-ray, and if that appears normal, ask your podiatrist to tape a metatarsal pad on to your foot and try running. If that alleviates the pain, then proceed with the orthotics.
On the subject of using a cut-out pad to treat capsulitis: I have never heard of using that type of padding for this condition. In capsulitis, there is an over-stretching of the capsular ligament. A metatarsal pad placed just behind the bone elevates it, reducing the stretch. Conversely, a cut-out pad allows the metatarsal head to drop further, which stretches the ligament more and can actually exacerbate the problem. A cut-out is generally only helpful for metatarsalgia (pain directly under the bone).
Regarding your other questions: If you have a flexible flat foot that flattens out when you stand, that is pronation. As far as running shoes go, any decent running shoe is fine once you are in orthotics. A custom orthotic takes over control of your foot mechanics much better than a store-bought motion-control shoe ever could, as it is based on your specific foot structure.
Foot-Pain-Explained.com
Capsulitis I think
First, thanks for putting together this website. Its the most informative site I have found dealing with foot problems.
Last June I started having pain and swelling at the base of the second toe. After a couple of months I got to a podiatrist who said I have capsulitis. I have had three cortisone shots. I last saw the podiatrist 6 weeks after the third shot (January). The shots helped and we both thought the problem would completely heal in 6 to 9 weeks.
Its March 22 and I still have the swelling and discomfort when I walk more than a short distance. I'm 61 years old and I really miss walking for exercise. I get along fairly well at work, I just can't walk very far without swelling and sorness. Is it time for me to go back to the podiatrist? Is this the kind of problem that may stay with me for a long time yet? How long does something like capsulitis take to heal? I would like to avoid surgery, but is surgery a likely option?
Response:
Hi Joe, Thanks for the kind words regarding this site....I try.
Anyway, capsulitis sometimes requires more than just cortisone shots, because many times they may be nothing more than temporary and you certainly cannot keep going back for shots. In most cases the problem with pain on the bottom of the foot is that you keep re-aggravating the problem by overstretching the capsular ligament and thus once again the pain.
What I normally do at this point is add an orthotic with a metatarsal pad (see my section on capsulitis) in an effort to upwardly raise the metatarsal which will keep the ligament from over-stretching. This and some short term anti-inflammatory medication should do the trick.
As far as surgery goes I would seek to avoid that because the goal of surgery is to break the metatarsal bone and elevate it. The problem here is that the end result can be mixed, anywhere from no improvement, to a non-union (fracture does not heal) to the formation of a painful callus on the adjacent metatarsal bones. This type of surgery was popular years ago and the reason it is not done as often anymore is because it has too high a failure rate. But, have your doctor discuss all your options and then come to some agreement on your next move.
Foot-Pain-Explained.com
Capsulitis?
Thank you for your very interesting and informative site! I'm a 60-year-old woman, not overweight, experiencing what feels like a bubble on the bottom of my foot, just behind my middle toe. I don't see any discoloration or swelling. It is not painful, but causes increasing discomfort if I walk barefoot or in shoes other than my sturdy walking shoes.
The walking shoes correct my pronation, and I wear them 98% of my waking hours. They reduce my condition to a mild, constant annoyance, as if I had a plastic, fluid-filled bubble in my shoe. I first noticed it six months ago, and attributed it to sleeping with my sheets tucked in tightly, so that my toes were always pressed down or my feet turned awkwardly to the side.
Leaving my covers loose gave me immediate relief, but the condition seems to have worsened a bit, with the "bubble" feeling larger and sometimes as if it is also behind my second toe. Am I correct in thinking this might be capsulitis? I wish I lived near your office, but since I am far away, I would appreciate knowing if you believe there's any chance that this condition will improve with time and my sensible shoes. If staying off the foot completely for a time would help, how long would such a recovery time typically be?
Response:
Hi, Thanks for your kind words. You state that this condition started six months ago which would tell me that it is probably not going away on its own. The "bubble" feeling that you get is probably due to inflammation on the bottom of the foot and it could possibly be inflammation from capsulitis, but there is also the possibility that you have a soft tissue growth underneath the skin such as a cyst.
Theoretically, staying off your foot should improve the problem, if it is a capsulitis, but it is impossible to give you a time frame, plus that is not the most efficient way to treat the problem. Why not make an appointment with a podiatrist and find out exactly what is causing your discomfort and have some treatment geared towards alleviating the problem in a timely manner.
Foot-Pain-Explained.com
String tied around toes
Visitor's question
About six or seven years ago I started to get the feeling as if a string were tied around the 2nd and 3rd toes of the left foot. It is not particularly painful, just irritating. It is not turning color, does not feel numb but it does feel somewhat different than the other toes although I would be hard pressed to describe the feeling.
I spent a lot of time on my feet at work and drove a manual shift car for many years (clutch), so I thought that may have had something to do with it. After a year or two of it not going away I saw a podiatrist and he said something about a ligament that holds the toes together laterally, and gave me an insert to put in my shoe (went under the ball of the foot). After wearing it for six months with no improvement I returned to see him and he gave me a slightly different insert which again did not seem to help.
Recently I noticed the same feeling in the same area of the RIGHT foot. I read about capsulitis and neuroma but they do not seem to be the same thing. I see a lot of hits on the internet of people with “string tied around toes” syndrome but no diagnosis or solutions. Any ideas?
Doctor's answer
Hi Ernie,
I have been a podiatrist for a very long period of time and cannot recall ever having someone describe their toes as if there were a string tied around them, but that’s just me. Based on your description it sounds like this sensation is occurring at the base of each toe. I say that because the podiatrist you saw gave you two different inserts, one at least was supposed to raise the ball of your foot. I therefore assume the insert had a metatarsal pad built into it which would be used for capsulitis or possibly a neuroma.
Since the podiatrist mentioned a ligament he probably had a working diagnosis of capsulitis as that is an inflammation of the ligament that actually holds the toe bone to the metatarsal bone behind it. There really is not a ligament that holds each toe together with the adjacent toe.
If both capsular ligaments are inflamed, that could give you the sensation you describe, assuming the “string” feeling is occurring at the base of your toes. Assuming your circulation is fine going into your toes, the two most probable causes of your sensation would be either capsulitis or neuroma. Both conditions cause inflammation at the base of the toes and can create unusual sensations. Many people also describe it as feeling like their sock is rolled up under their foot.
Certainly driving a clutch could set this off on your left foot. I had a clutch on my last car and developed capsulitis myself — once I got rid of the car, the capsulitis went away.
Usually an insert with a properly placed metatarsal pad can be helpful. You did not mention if these inserts were custom made or simply off‑the‑shelf. At this point you might want to consider a cortisone injection or a round of anti‑inflammatory medication (if you can tolerate it) for two to three weeks to reduce inflammation.
A lesser possibility is a growth in the area — such as a ganglion cyst or bursitis — which could also create this sensation. The fact that you are now experiencing the same problem on the right foot makes a growth less likely, but if treatment fails on the left foot, an MRI might be indicated.
Since you are now having symptoms on both feet, the next thing I would look at is the shoes you wear, as footwear is often the common denominator in bilateral forefoot issues. Very flexible shoes like flip‑flops, boat shoes, or any shoe with excessive forefoot bend can aggravate capsulitis or neuroma. A more rigid shoe — such as a well‑made dress shoe or a good athletic walking shoe — would likely be more helpful.
Activities such as ladder climbing, stooping, gardening, carpentry work, or climbing stairs barefoot can also set off capsulitis.
My suggestion would be to first evaluate your shoes and activities and make any changes you can. Then return to your podiatrist and inquire about oral anti‑inflammatory medication or a cortisone injection.
Marc Mitnick DPM
If you happen to live in the New York - New Jersey area and would like to visit our office
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DISCLAIMER: The purpose of this site is purely informational in nature. It is not intended to diagnose, treat or cure any medical condition. This information is not a substitute for advice from a medical professional. Please consult your healthcare provider for accurate diagnosis and treatment. The information presented here may be subject to errors and omissions.
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LH
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First, thanks for putting together this website. Its the most informative site I have found dealing with foot problems. Last June I started having pain and swelling at …….
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Unknown location
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Like others have stated...This site is amazing and I am so thankful that it was created.
....Keep up what your doing. Your a life saver.
Michelle
Colorado
Thanks again for the information provided on your site. It's easy for non-medical folk to understand your writing, and helps provide better communication between patient and doctor.
annielou
Colorado
Wonderful advice
by: Anonymous
This is the best site for foot problem info.
Thank you for this information. This description fits my pain and inflammation behind my 2nd toe perfectly.
by: Max
location unknown
Again, I really appreciate that you responded to my inquiry, and that your mention of Parkinson's helped me to find my way to a diagnosis of this difficult to diagnose disease. Most patients see on average 16 doctors before they are diagnosed. I hope that you can help other people that ask for your expertise in the future.
Barb D.
Canada
I just wanted to say that I am very greatful for this website!! I have had a fusion in my rt foot and am finally getting a little bit better......
Bonnie
location unknown
Again, Thank you from the bottom of my heart for taking the time to answer my question....your an angel!
Nancie
Wisconsin
Thank you for your response. You have provided some great insight (to my question)....
Julie
location unknown
Thank-you so very much for responding so quickly and in such detail to my question!! I will give my surgeon a call today!! This website is terrific!!!! Thank-you again!
Renae
North Carolina
Many Thanks Dr Marc!
Thank you for your response. It sounds like a good plan to me. He did not cut the wart out first ...
KG
location unknown
Thanks again doc for having this website and we STILL need qualified Podiatrists in beautiful sunny Tampa Bay (Bradenton) Florida.
Bessie Mae
Florida
Dear Dr. Mitnick, Thank you so very much for taking your time to answer my question. You have greatly relieved my anxiety related to the continual tingly I feel in my feet. I will share your response with my podiatrist next week. God bless you for having this question and answer page on your website! Most gratefully,
Lynne T.
location unknown
Your webpage is excellent, I commend you on sharing your knowledge to the public.
Robert
New Jersey
Thank you. you were more detailed than what others have told me they finally called from the last xrays and my son is now in a cast for 2 weeks he did have a fracture that was not noticeable.
a mom
location unknown
I have read your website and I have to admit that I am amazed at all the information that is on here. I have learned more than the three years I have been going to several doctors that I have seen!!
Melody
Lenoir, NC
Thank you so much Doc for a quick and thorough response!
Rustam
Bellevue, WA
I cannot thank you enough for your response, opinion, and suggestions! I want you to know how much it means to me, and I'm sure everyone else who has ever asked you a question! I feel like you're a lifesaver and have empowered me to take a stronger role and stand up for myself and my feet!
Jodi
location unknown
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