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92 Lymphoedema and ChroniC SweLLing
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FIGURE 2.7 Posterior view of the patient in Figure2.6.
FIGURE 2.8 Type III late stage 2 with chronic oedema of lower legs and
feet, anterior view. Note the more pronounced ankle ‘cu’ and irregular
texture of the skin.
FIGURE 2.9 Same patient as gure 2.8, lateral view. The ‘hood’ of excess
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tissue over the knees becomes more pronounced as lipoedema progresses.
FIGURE 2.10 Same patient as gures 2.8 and 2.9, posterior view.
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why lipoedema patients often report frequent and unexplained bruising. Hypermobility, where joints can extend beyond their normal
range of motion, is also common among lipoedema patients and it is
again thought that this is linked to weakened connective tissue.
Hypermobility is discussed further in Chapter4.
Diagnosing Lipoedema
There are currently no diagnostic tests for lipoedema and the condition is therefore diagnosed based on the patient’s history and clinical
examination. This is typically done by specialist servicesasit can be
dicult to diagnose due to the similarities with obesity and lymphoedema. Lipoedema can be very unpredictable and patients do not
allpresent with the same features. If lipoedema is suspected then
referral to a specialist service should be arranged to conrm the diagnosis and ensure appropriate management. There are no dedicated
lipoedema services in the United Kingdom and not all lymphoedema
services will see lipoedema patients. Depending on the service, referrals may need to come from a doctor, so it is essential this is discussed
with the patient’s GP. Patients could also be signposted to groups
such as Lipoedema UK.
A clear diagnosis should describe the location and progression of
the condition, although it may be dicult to distinguish the true
extent if there is lymphoedema or obesity present as well. Classication systems exist for both lipoedema location and severity. Tables2.23
and 2.24 are collated in the Best Practice Statement (Wounds
UK2017) based on the work of multiple studies.
TABLE 2.23
Type Area aected
Type I Pelvis, buttocks and hips
Type II Buttocks to knees
Type III Buttocks to ankles
Type IV Arms
Type V Lower legs
Classication oflipoedema based onanatomy.
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TABLE 2.24
Stage Description
Stage 1 Smooth appearance to the skin
Stage 2 Skin has an irregular dimpled texture like orange peel
Stage 3 Skin texture becomes more irregular than in Stage 2.
Stage 4 Lipoedema with lymphoedema
Classication oflipoedema according todisease progression.
Small nodules or grainy texture felt beneath the skin
Nodules beneath the skin can become st sized
Fat deposits grow ever larger, particularly around the knees
and thighs, signicantly distorting limb shape
Sometimes referred to as lipo-
lymphoedema
Impact ofLipoedema
As explained earlier in the chapter, lipoedema fat does not reduce in
the same way as normal body fat in response to dieting. This means
that weight is lost mainly from areas unaected by lipoedema, generally from the waist up, and patients sometimes describe themselves as
‘pear- shaped’ because of their disproportionate body shape. The
pathophysiology behind this is not understood, but patients often
report a long history of unsuccessful dieting before becoming aware of
their lipoedema. Research has shown that weight loss in the aected
areas through dietary means is not impossible, but cannot be expected
to the same extent as for nondieting with little or no improvement is understandably very upsetting
for patients and can have a profound eect on their mental health.
Due to the distorted limb shape, lipoedema patients also often report
diculty buying clothes and shoes, and many describe embarrassment and feeling that they need to hide their legs. This can lead to
isolation and restricted social interaction, further feeding into the signicant psychological impact that lipoedema can have.
lipoedema fat. This common pattern of
Treatment andManagement ofLipoedema
Current treatment for lipoedema is limited, but its management
should always be holistic. Despite diculty losing weight being a key
feature, it is important that patients are supported to maintain their
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current weight as much as possible. This is because lipoedema deposition is exacerbated by further weight gain. There is increasing
evidence that a ketogenic or anti- inammatory diet can improve
lipoedema symptoms (Jin etal.2022). Such diets may not be appropriate for all patients, so referral to a dietitian for expert advice is sensible.
A focus on preserving and promoting mobility is also important
as this often deteriorates as lipoedema progresses. Movement can be
limited by pain caused by the inamed fatty tissue, and if there are
other factors such as venous disease or arthritis this will further exacerbate pain. Activity avoidance because of pain also contributes to
the cycle of deteriorating mobility.
Genu valgum (knock knees) is common, as is degenerative knee
pain, and this can lock a patient into a vicious cycle of deteriorating
mobility and weight gain. It is felt that this structural weakness is
partly due to the weakening of connective tissues in the joints.
Another factor is the sheer size and weight of the excess limb bulk,
which pulls joints out of alignment and aects gait, thus further
restricting mobility. Lipoedema patients often develop a swaying gait,
rocking from side to side as they walk, and this is caused in part simply by an involuntary attempt to avoid chang of the thighs (Stutz
and am Wald2011). Support from therapy teams to optimise mobility
is important, particularly if patients are felt to be at high risk of falls.
Referral to podiatry, for biomechanical assessment and gait analysis,
is also highly recommended, as supportive footwear and orthotics
can better align the joints, leading to improved calf muscle pump
function, optimised mobility and reduced pain.
As with most lower limb conditions, a core treatment for
lipoedema is compression. For lymphoedema the aim of compression is to encourage the movement of uid through the lymphatics to
reduce swelling. Sadly, with lipoedema no amount of compression
will reduce the aected fatty tissue and so the focus is to provide comfort and support, and thus a reduction of pain, to the aected limbs.
The lymphatics will still be inuenced, however, and so a wellcompression garment will help to reduce or prevent any secondary
swelling that may occur.
Due to the shape distortion of lipoedema, custom- made at- knit
garments are often required, although o- the- shelf circular- knit
garments can be appropriate in the early stages. Softer fabrics may
be better tolerated because of the hypersensitivity some patients
tting
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experience, but these are not always appropriate in terms of required
support. If lipoedema extends above the knees into the hips or buttocks, then full- length garments such as leggings or tights should be
considered. This may not be practical for some patients though, so a
combination of below- knee stockings with Capri pants may be more
appropriate. As with all compression, garments must be suited to
what is therapeutic for the patient but also to what they can physically manage and are prepared to wear.
Non- cosmetic liposuction (NCL) can be performed to signicantly reduce limb bulk and impressive results are possible. The procedure is not suitable in all cases and is not currently available on the
NHS. There has been recent campaigning by patient groups, most
notably Lipoedema UK, to obtain National Institute for Health and
Care Excellence (NICE) approval for NCL for lipoedema. NICE
acknowledged the debilitating impact on patients’ lives that
lipoedema can have, but concluded that the condition remains
under- recognised and requires more research (NICE2022).
SUMMARY
Lipoedema is poorly recognised and poorly understood creating distress for people who have this long term condition. Eective specialist assessment and management can dramatically improve a person’s
mobility and their quality of life.
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