PMC5755236_01
Swelling over right Achilles tendon.
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On examination, there was a large cystic swelling, but no inflammatory skin changes or discharge to suggest an infection (Fig. 1). 
MRI scan. T2 PD fat sat sequence sagittal image of right ankle showing high-signal collection within the Achilles tendon.
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Continuity of the Achilles was demonstrated (Fig. 2). 
Intraoperative image of large cystic swelling over Achilles tendon.
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He underwent surgery to explore the tendon where an irregular, cystic, fibrofatty lesion was identified within the tendon (Figs 3-5).
Intraoperative image showing internal cystic granuloma within Achilles.
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He underwent surgery to explore the tendon where an irregular, cystic, fibrofatty lesion was identified within the tendon (Figs 3-5).
Excised LARS ligament specimen.
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He underwent surgery to explore the tendon where an irregular, cystic, fibrofatty lesion was identified within the tendon (Figs 3-5).
Low power histology slide showing foreign body giant cell reaction to suture material.
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This was successfully resected and sent for histology which showed a florid granulomatous and histiocytic response to the suture material, in keeping with a suture granuloma (Figs 6 and 7).
40x histology slide showing foreign body giant cell reaction to suture material.
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This was successfully resected and sent for histology which showed a florid granulomatous and histiocytic response to the suture material, in keeping with a suture granuloma (Figs 6 and 7).
40x histology slide showing abscess extension into muscle.
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There was histological evidence of the abscess extending into the muscle (Fig. 8). 
Intraoperative image of FHL transferin situ.
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We then reconstructed his Achilles tendon using an Flexor Halluces Longus (FHL) transfer (Fig. 9).