Giuseppe Setola, 38, who claims to be blind, suffered cuts and bruises after running for more than a mile through the sewer with his two bodyguards, who fired several shots at chasing police.
He had got into the sewer through an escape tunnel in his house.
Setola is among Italy's 10 Most Wanted and is said to be in charge of a vast criminal empire that controls drug running, prostitution, extortion and arms and is wanted for 17 murders.
Police named him as the prime suspect in the gunning down of six Africans four months ago in what was described as one of the largest and bloodiest "group massacres" in clan wars in recent years.
This week he fled through an escape tunnel into the sewer network from his hideout at a house in Trentola Ducenta near Naples after police raided the lair after a tip-off.
But he was tracked down to a private medical clinic at Mignano Montelungo, 50 miles to the north, where he had gone to be treated for his injuries under an assumed name.
Staff recognised him from his photofit and tipped off police, who stormed the premises and arrested him - just hours after detectives had seized more than £10m in mafia assets around Naples.
The area is the home of the local version of the mafia known as the Camorra. Setola was well known as a ruthless Godfather who struck fear into locals.
Naples anti-mafia prosecutor Franco Roberti said: "This is a great moment for the Italian state.
"We were certain Setola was in a situation of great difficulty. We promised all the citizens that he would be caught. We have kept that promise.
"I feel immense joy and a great sense of pride because the State has succeeded, the anti-mafia apparatus has worked."
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