In this report, a case of bilateral achilles swelling in a 67-year-old female patient, is reviewed. The diagnosis was established using both clinical & imaging modalities. Various treatment options were discussed, and the diagnosis was confirmed by histology. The role of MRI is also explored in this report.
The patient presented to the senior author's foot & ankle clinic with bilateral swellings in the achilles area, which had developed over the last two years. The swellings had progressively increased in size, caused discomfort to the patient whilst walking. Patient did not complain of any other swellings, and there was no family history of similar swellings or of hypercholestrolaemia. On examination, the patient was found tobe thin-built and had arcus senilis in both eyes, no xanthelesma were found. No significant cardiac signs and symptoms were elicitable. An examination of the achilles areas revealed the presence of a fusiform-shaped swelling measuring 15 x 3 x 3.5 cm on the left side and a swelling of similar shape measuring 12 x 6 x 3 cm on the right side. A blood examination showed type 2A hypercholesterolaemia. Plain X-rays clearly show the extent of the soft-tissue swelling around the achilles area (Fig. 1a). MRI scans were obtained which included T1 and T2 sequences of sagittal and axial sections, stir sequences and a post-contrast T1 sequence (Figs. 2a-d). These scan findings showed that the masses had infiltrated the tendons,and commenced at the musculo-tendinous junction. Both the masses were of a similar appearance and of almost a low signal on all sequences. A small amount of high signal was seen on the lateral aspect of the left achilles area. They were well-defined and were seen to displace the surrounding soft-tissues. No other abnormalties were seen in the calf, ankle or bone marrow. The lesions definitely did not appear benign.
Bilateral achilles tendon xanthomas are rarely mentioned in literature; till 1973, only 173 cases were reported, of which only 15 patients had had surgical excision, and 6 of them had had surgical reconstruction. It has important ramifications in internal medicine and dermatology. Although not found in our patient, other xanthomas of the tendons and skin and/or cardiovascular disease are closely associated. The patients do have either type 2 or type 3 hyperlipoproteinaemia. Most of them regress after treatment with hypolipedaemic drugs; some of them have to be resected. There are only about half a dozen cases in the literature with excision and tendon reconstruction. Our patient had to undergo exploration, resection and reconstruction in view of the size of the swellings and the symptoms caused. They were explored sequentially within a gap of three months, the left side first. The patient returned to full activity after six weeks of immobilisation on each side. The patient was started on hypolipedaemic drugs. Histological studies revealed that the swellings were tendon xanthomas (Figs. 3a and b). An early diagnosis is imperative as it may avoid the surgery in early stages and also in view of cardiovascular complications. In patients presenting with swelling in the achilles area, the possibility of tendon xanthomas should be considered as it may avoid more sinister complications if an early treatment with hypolipedaemic drugs is instituted. The MRI scans revealed a low signal through all sequences. MRI, although it can define the masses accurately with specific anatomical information,is of low value in specifying the underlying pathology. The MRI and the US technique provide equal information on the anatomy of the achilles tendon. As an abnormally high signal intensity in the xanthoma was found in very few patients, the value of a specific pathological diagnosis is limited.
Bilteral achilles tendon xanthomas.
1. X-ray: Bilateral Achilles tendon areas show localized tissue thickening, with no obvious bone destruction or fracture signs at the bone margins. The calcaneus and surrounding bony structures appear generally normal.
2. MRI: Bilateral Achilles tendons predominantly present with lower signal intensity across all sequences, displaying evidently thickened tendon contours. Heterogeneous signals can be seen within the tendon tissue, generally appearing low or slightly low in intensity, with clear margins and an acceptable demarcation from surrounding soft tissue. No obvious bone invasion or bone marrow edema is observed.
Based on bilateral Achilles tendon swelling, imaging findings indicating abnormal tendon thickening, and consideration of the patient’s age and medical history, the following diagnoses and differential diagnoses may be considered:
1. Tendon Xanthoma: Commonly associated with dyslipidemia (such as Type II or Type III hyperlipoproteinemia), characterized by abnormal lipid deposition and thickening within the Achilles tendon. MRI typically shows low or slightly low signal, often presenting bilaterally.
2. Chronic Inflammation or Degeneration of the Achilles Tendon (Achilles Tendinopathy): Common in middle-aged individuals or athletes, can manifest as tendon thickening and signal abnormalities, typically accompanied by a history of chronic overuse and inflammation.
3. Rare Soft Tissue Tumors: For instance, aponeurotic fibroma or synovial sarcoma, which may cause localized swelling. However, MRI findings with these conditions tend to be more complex and can include infiltration of surrounding tissues or bone involvement. If the clinical progression is benign without invasive features, the probability of such tumors is relatively low.
Taking into account the patient’s bilateral symmetrical Achilles tendon swelling, probable dyslipidemia (suggested by clinical indications or laboratory tests), and MRI findings, further confirmed by intraoperative and pathological examinations, the most likely final diagnosis is “Bilateral Achilles Tendon Xanthoma.” Tendon xanthoma is closely related to dyslipidemia, and early detection and intervention contribute to preventing disease progression and potential cardiovascular complications.
1. Medication:
- Initiate appropriate treatment for hyperlipidemia, considering statins or other lipid-lowering agents to improve lipid levels and to help reduce further enlargement of the tendon xanthomas.
- Regularly monitor lipid profiles and liver function based on the patient’s condition, adjusting medication dosages promptly.
2. Surgical Intervention:
- If the xanthomas are significantly large, symptomatic, or impair daily activities, surgical excision of the lesion or Achilles tendon reconstruction may be considered.
- Postoperative care includes immobilization and rehabilitation training to ensure maximum restoration of foot and ankle function.
3. Rehabilitation and Exercise Prescription:
- Early Stage (0–6 weeks, preoperative or early postoperative): Emphasize protection and immobilization. Under the guidance of a physician or physical therapist, perform gentle passive ankle joint exercises and minor muscle contraction training, avoiding excessive stress on the Achilles tendon.
- Intermediate Stage (6–12 weeks): After removing external fixation or braces, progressively transition to low-load exercises under professional supervision. These may include small-range isometric ankle resistance exercises, ankle pump exercises, and gradually increasing heel-raise exercises. Recommended frequency is 3–4 times weekly, 15–30 minutes per session, at an intensity below the threshold of significant pain.
- Late Stage (beyond 3 months): Once scar tissue and tendon structures have adequately healed, increase loads appropriately—such as short-step walking, low-impact stationary cycling, or swimming. Training frequency can be gradually increased to 4–5 times a week, approximately 30 minutes each time. As function improves, higher-intensity resistance training or light jogging may be considered under professional supervision.
- Throughout the rehabilitation process, closely monitor ankle stability, pain, and swelling. If notable discomfort or worsening pain occurs, seek reevaluation and adjustment of the rehabilitation plan.
Disclaimer:
This report is based on current data and imaging findings for reference in clinical decision-making and is not a substitute for an in-person medical consultation or the opinion and diagnosis of a professional physician. Specific treatment plans should be formulated based on a comprehensive evaluation of the patient’s complete medical history, clinical manifestations, laboratory results, and specialist consultations.
Bilteral achilles tendon xanthomas.
