Neuromas and Capsulitis - Jeffrie C. Leibovitz, DPM

The Neuroma You Have May Not Be a Neuroma!

So maybe you believe you have a neuroma in your foot. Maybe you’ve been to your primary care physician, and they’ve said it’s a neuroma.

That’s all well and good, but we don’t want you to be surprised if you come to us and it turns out—in our best Arnold Schwarzenegger from Kindergarten Cop voice—that “it’s not a neuroma!” Odds are very likely that you have a capsulitis instead.

But maybe we should back things up a bit.

What is a neuroma, anyway?

A neuroma is a non-cancerous growth of tissue around a nerve, usually between third and fourth toes. This growth is often in response to trauma or consistent stress against the nerve. The growth of tissue may be an attempt to protect the nerve from further impacts, but it just gets more compressed or pinched within the tissue.

Symptoms of a neuroma include burning or electrical type of pain in the forefoot (especially when weight is placed upon it) and swelling.

That sounds like me! Why would it not be a neuroma?

Because for about every 25 patients who come to us believing or being told they have a neuroma, one of them actually does.

And we are not blaming primary care physicians for anything here. Primary care physicians make best judgments regarding the evidence received for the whole body. That requires some knowledge in just about every part and function of the body, but our body is much too complex to know it all. That’s why specialists exist to make deeper and more accurate diagnoses.

Many PCPs have been schooled to think “neuroma” when forefoot pain is a symptom, but the culprit is more often capsulitis.

Neuroma May Not Be a Neuroma

So what is capsulitis?

Capsulitis is an inflammation of the ligaments around the joint at the base of a toe. These ligaments form a “capsule” or balloon around the ends of the bone, holding them together.

This condition can technically happen at the base of any toe, but the second toe tends to be the most common. That’s because the second toe can get into plenty of situations where it takes on extra force and strain, inflaming its capsule.

All the toes should bear weight relatively evenly. But if something takes the toes out of alignment, it can be a lot like a table having a long leg of a table; all the weight will come to bear on that one toe, and you can’t exactly shove a napkins under the other toes to make things better (more on this later).

Certain long-term conditions can increase one’s risk of capsulitis. These include:

  • Most types of bunions, which affect the alignment of the first toe and essentially shifts its weight-bearing duties to the second toe.
  • Having a metatarsal that is longer or shorter than “standard” length. Having a second toe that is longer than your big toe (also known as Morton’s toe) is a common example.
  • Having a contracted toe, like a hammertoe.
  • Having Hallux Limitus, leading to a big toe that doesn’t easily bend. To compensate, the foot will roll out so the hallux does not have to bend as much, forcing more weight onto other toes.

Many of the structural abnormalities above can be genetically inherited, so ask your family how many of them have pain in their second toes. If it’s a few or more, you might have been an unfortunate winner in the family lottery.

Capsulitis also tends to be seen later in life. With great experience comes great foot pain. Also, the condition tends to become aggravated by anything that places even more pressure on the area, such as running or wearing high-heeled shoes.

Forefoot Pain

How can I tell the difference between capsulitis and a neuroma?

Both a neuroma and capsulitis cause pain in the forefoot, but they often take different forms.

Neuroma pain tends to be felt more between the toes, and can be accompanied by a tingling sensation that extends up into the toes themselves.

Capsulitis pain, on the other hand, tends to be isolated beneath the metatarsal bone. If you push on the bottom of the toe and it hurts as it flexes upward, that is more likely capsulitis than a neuroma.

Of course, the best way to be sure of what you have is to come see us, because it’s important to receive professional attention in either case!

What can we do about capsulitis?

Perhaps the biggest problem with capsulitis is that you can’t really just sit it out and wait for the problem to resolve itself. Ice and massage may help you feel better at the end of a long day, but it will do nothing in the long run.

This is not an injury specific to sports as much as it is a structural condition. With every step, you will be placing strain on that joint once again.

That said, it is very problematic to just let the problem go unaddressed. As the capsule of the joint further weakens with time, it can lead to further misalignment and tissue failure. Like riding a horse and pulling on only one rein, the toe will keep moving in one direction with little to counter it. The joint capsule along the bottom of the toe may eventually tear from the strain against it.

A warning for all you tough guys out there: continued excessive pressure on a metatarsal can lead to a stress fracture. When this develops, you are on a 4-6 week vacation from weight bearing and activity.

Protection and management are the keys to capsulitis care. We may recommend an accommodative insert—sort of like a baby orthotic—that can provide protective support to the toes and help restore balance among them. Many patients report improvement in comfort within a day of using them.

We also recommend a change to footwear that is more accommodating to up and down movement in the toes. And if you have additional problems that are contributing to an imbalance in your toes—such as a bunion or hammertoe—that will very likely need to be addressed as well.

Get Help for Your Capsulitis (or Possible Neuroma)

Regardless of the cause, forefoot pain is not something to let slide. Our Indianapolis office is suited to finding the best route of treatment for your condition, no matter what it is.

Give us a call at (317) 545-0505 to schedule an appointment, or fill out our online contact form to have a member of our staff reach out during business hours.