Vol. 19 • Issue 24 • Page 24
In practicing physical therapy, therapists encounter a great variety of clinical pathologies involving the musculoskeletal system. Some of these are well known, such as back, shoulder and knee pathologies. However, there are other conditions within the scope of PT practice, such as lymphedema, that are typically not well known. Fortunately, physical therapists are becoming better versed with conditions affecting the lymphatic system. While numerous articles have appeared in the PT literature concerning lymphedema in recent years, very few articles have addressed the related condition of lipedema.
Lipedema was first described in 1940 by Allen and Hines, who were physicians at the Mayo Clinic.1 They described lipedema as a clinical syndrome affecting only women in whom symmetrical swelling of the legs and feet had been present for many years. Additional symptoms they noted were complaints of aching distress in the legs.
Lipedema was also described to be often associated with a gradual increase in body weight as well as to have a genetic predisposition. The exact incidence of lipedema is unknown. A recent epidemiological study in Germany by Michael and Ethel Földi has determined that 11 percent of the female population has lipedema, or what non-professionals often term "cellulite."2 Even though lipedema was first described in the United States almost 70 years ago, a large number of therapists and physicians are still unaware of the disease here in the U.S.3 In contrast, a significant number of textbooks and research articles on lipedema have been published in German.4 Lipedema may be confused with lymphedema, though Allen and Hines in their seminal article clearly presented the differential diagnosis between lipedema and lymphedema.1
One of the major differentiating characteristics between lymphedema and lipedema is the nature of how they present. Primary lymphedema typically occurs in women, usually in puberty with unilateral or bilateral swelling of the legs. In cases where both lower extremities are involved, lymphedema often occurs in one extremity before the other becomes involved, resulting in an asymmetrical presentation.
With primary lymphedema, the swelling usually begins distally in the toes and then progresses proximally up into the thighs. In contrast, lipedema typically starts in the buttocks and thighs and progresses distally only to the ankles.
Additional characteristics for differential diagnosis include a positive Stemmer skin fold sign (a thickened skin fold at the base of the second toe so that the tissue cannot be lifted away from the bone). A positive Stemmer sign is found in lymphedema but is absent in lipedema. Some other key points are outlined in the table.
It should also be mentioned that combination forms such as lipo-lymphedema are not uncommon. Lipo-lymphedema is a condition in which individuals with lipedema later develop lymphedema in addition to the underlying and ongoing lipedema.2,5-8 Lipedema is characterized by a progressive, symmetrical accumulation of fat in the subcutaneous tissue, which typically begins at menarche, during pregnancy or at menopause. The exact cause of this fat accumulation is presently unknown. This abnormal fat is deposited at the hips and then over time, the fat deposition progresses down to the ankles. Orthostatic edema also commonly develops in the ankles and shins, especially on warm days. 2,5-8 Not only is lipedema often confused with lymphedema, lipedema is also commonly confused with obesity. While obesity often accompanies lipedema, they are separate entities. Women who actually have lipedema and are "overweight" can mistakenly believe that they should go on a diet or exercise more to lose weight.
It must be stressed that women with only lipedema will not be able to lose weight by dieting or exercising. Thus, women with lipedema often are emotionally distressed, because no matter what diet or exercise program they try, they are unable to lose weight. In fact the opposite occurs, since lipedema is progressive, and women with lipedema may gain weight over time.2
Lipedema, like lymphedema, can be treated by the lymphedema therapist with manual lymph drainage (MLD) and complete decongestive therapy (CDT). Typically, much more time is needed to achieve the desired results of decreased limb girth when treating the patient with lipedema as compared to the patient with lymphedema. Also, the therapist needs to be extremely careful when applying bandages during compression, since the patients are typically very sensitive to touch and bruise easily.
An added benefit of MLD and CDT in patients with lipedema is that over time, the hypersensitivity to pressure is minimized or goes away. It is critical that patients with lipedema wear the bandages and/or compression garments as much as possible to maximize treatment success.2,5-8 Until very recently, surgery was of limited success at best and potentially harmful to the patient. Liposuction under general anesthesia was performed "dry," meaning without subcutaneous infiltration. In addition, large sharp cannulas were used during liposuction to remove the fat, which caused considerable tissue damage. One of the complications of this type of surgery was damage to the lymphatic system that could result in increased swelling. Thus, lymphatic system experts such as Földi have recommended that liposuction not be used to treat lipedema.2 Recently Schmeller and Meier-Vollrath have described a new type of surgical procedure called tumescent liposuction that holds potential for successfully treating patients with lipedema.8-9 Tumescent means "to abnormally distend especially by fluids." Tumescent liposuction is performed using local anesthesia and is a "wet" technique that uses a mixture of lidocaine and prilocaine to infiltrate and "swell up" the subcutaneous tissue. The surgeon also uses a blunt microcannula during this procedure.
These surgical refinements make it easier for the surgeon to safely remove the abnormal fat deposits, thus resulting in less tissue damage. Schmeller and Meier-Vollrath point out that even when using the newer tumescent liposuction method, conservative treatment such as MLD and CDT are still needed after surgery, though not as frequently as before surgery.8-9 There is much that the properly trained therapist can do to treat patients with lipedema, and to also educate such patients on the nature of their edema. While lipedema historically has often been overlooked or misdiagnosed, advances in both surgical techniques and increased awareness of the conservative treatment techniques mean that more patients who have lipedema can now get proper treatment.
1. Allen, E., & Hines, E. (1940). Lipedema of the legs: A syndrome characterized by fat legs and orthostatic edema. Proceedings of the Staff Meetings. Mayo Clinic, 15, 184-187.
2. Földi, E., & Földi, M. (2006). Lipedema. In: Földi, E., & Földi, M., Strößenreuther, R., Kubik, S. (eds.) Földi's Textbook of Lymphology for Physicians and Lymphedema Therapists. 2nd edition, Munich, Germany: Elsevier, Urban & Fisher.
3. Fonder, M., Loveless, J., & Lazurus, G. (2007). Lipedema, a frequently unrecognized problem. Journal of the American Academy of Dermatology, 57, S1-S3.
4. Schmeller, W., & Meier-Vollrath, I. (2007). Lipödem-aktuelles zu einem weitgehend unbekannter Krankheitsbild. Aktuelle Dermatologie, 33, 1-10.
5. Tiwari, A., Cheng, K-S., Button, M., Myint, F., & Hamilton, G. (2003). Differential diagnosis, investigation, and current treatment of lower-limb lymphedema. Archives of Surgery, 138, 152-161.
6. Warren, A., Janz, B., Borud, L., & Slavin, S. (2007). Evaluation and management of the fat leg syndrome. Plastic Reconstructive Surgery, 119, 9e-15e.
7. Zuther, J. (2005). Lymphedema Management--The Comprehensive Guide for Practitioners. New York, NY: Thieme.
8. Schmeller, W., & Meier-Vollrath, I. (2008). Lipedema. In: Weissleder, H., & Schuchhardt, C. (eds.) Lymphedema Diagnosis and Therapy. 4th edition. Essen, Germany: Viavital.
9. Schmeller, W., & Meier-Vollrath, I. (2006). Tumescent liposuction: A new and successful therapy for lipedema. Journal of Cutaneous Medical Surgery, 10, 7-10.
Harold Merriman is assistant professor and general medicine coordinator for the DPT program in the Department of Health & Sport Science at the University of Dayton, Dayton, OH.