Orthopedic Alterations in Lipedema

By August 17, 2023 July 7th, 2024 No Comments

Today I’m going to talk about a study by Dr. Isabel Forner-Cordero and her colleagues. Dr. Forner-Cordero is a clinician and researcher in Spain. The paper is titled Prevalence of Clinical Manifestations and Orthopedic Alterations in Patients With Lipedema: A Prospective Cohort Study. It was published in Lymphology in January 2022. 

This study’s main objective was to describe the clinical characteristics in patients with lipedema. Secondarily, the researchers wanted to assess and analyze orthopedic changes in this population. 

Study Design and Participant Recruitment

The study was a prospective non-interventional study of consecutive patients diagnosed with lipedema for orthopedic changes at a hospital in Spain between 2012 and 2019. A total of 138 participants were accepted into the study. 

To be included in the study, one had to be at least 18 years of age, have bilateral lower limb enlargement along with at least 3 other symptoms of lipedema, such as spontaneous or provoked pain or tenderness, easy bruising, family history of lipedema, and/or negative Stemmer sign. 

Those who were pregnant, had kidney, liver, or heart failure, and had blood clots, infections, and/or active cancer were excluded from the study. 

What data did they collect?

The data collected in this study included basic demographic information, such as age, height, and weight, in addition to data on the presentation of symptoms of lipedema and the presence of orthopedic alterations.  The lipedema symptoms assessed were the presence of disproportionate fat, pain, bruising, and other vascular changes.  The specific orthopedic conditions that were assessed included:  very high foot arch, flat feet, knee misalignment including valgus or varus knees, and knee osteoarthritis.  They also collected data on the type and stage of lipedema of each participant and the impact of lipedema on their daily life.

Who were the participants?

Participants had a median age of 47 years.  When using Body Mass Index (BMI) to assess participants, 23% were classified as normal weight and the remainder were considered overweight or obese.  The researchers also calculated the waist-to-height (WTH) ratio, considered by some scientists to be a more accurate reflection of health in participants with lipedema because it can show where fat is distributed in the body. By this calculation, 41% of the patients were considered slim or healthy. 

The most frequent type of lipedema was Type III (waist to ankles) with 98 out of 138 participants or 71% being this type. The majority of the participants were in stages 1 and 2 (100 out of 138 or 73%.)

I found it astounding that the average time from the onset of symptoms to getting a diagnosis was 25 years. Most of the participants (57%) reported that their symptoms started at puberty. 

A more advanced stage, higher BMI, greater WTH ratio, and increased severity of pain are all positively correlated with increased age. The pain was present in 92% of the participants. 86%  had a disproportion between the upper and lower body. Just over 90% were bruised frequently, and 90% had spider veins. 

As for orthopedic alterations, 30% of the participants had a high arch, and 15% had flat feet. Just 5 of the 138 participants, or less than 4%, had varus knee (bowlegged), while 39% had valgus knee (knock-kneed). Knee pain was present for 87 out of 138 participants (63%), with the average pain rated 6 out of 10. Almost 13%, or 8 out of 63 participants, had osteoarthritis, and it was more severe in older participants with a higher BMI and later stage of lipedema. 

What are the limitations of the study?

A selection bias could be identified as one limitation of the study, as most participants were type 3 and stage 1 or 2. This may be because these participants were easier to distinguish from simple obesity and or lymphedema that may have been induced by obesity. This means that the characteristics of the study participants may not accurately reflect what may actually be found in the Spanish population. 

Further, only 63 out of 138 participants underwent imaging of their knees, limiting the number of participants identified with osteoarthritis. Additionally, the imaging technique used (x-ray) cannot show cartilage damage, limiting the ability to diagnose osteoarthritis even further. 

What were the conclusions?

It was concluded that osteoarthritis was more severe in older participants and those with a higher BMI and later stage of lipedema. More advanced lipedema stage, higher BMI, greater WTH ratio, and increased severity of pain are all positively correlated with increased age. This may be evidence that lipedema is a progressive disease. 

There was also a much lower frequency of obesity, regardless of BMI or WTH ratio used, compared to other studies. For instance, other studies have reported that 76-88% of patients with lipedema were also obese, while this study found only 46% using BMI and 36% using the WTH ratio.  

The very long delay in diagnosis and treatment (average of 25 years) highlights the urgent need to raise awareness about lipedema among healthcare professionals. More than half of the participants reported an onset of the symptoms at puberty. Early diagnosis and referral to effective treatment would likely have better treatment outcomes. 

The pain was present in almost all the participants, with 38% reporting that it had significantly impacted work and social activities. Management of lipedema pain should be a focus of intervention efforts. 

The frequency of knee pain and orthopedic alterations demonstrates the significant impact that lipedema can have on a patient’s ability to exercise or even maintain mobility. The overall prevalence of osteoarthritis in the knee in the general population in Spain is ~15% while the incidence in those imaged in this study was 58% (37 out of 63), showing an increased incidence associated with lipedema. Additionally, an increased severity of osteoarthritis was associated with a more advanced stage of lipedema, suggesting that orthopedic examination should be an important part of an examination of a patient with lipedema.  

For more updates on the latest research regarding lipedema, check out Lipedema Simplified’s Flash Briefings. It’s our daily mini-podcast where we share tips, tools, and research pertaining to Lipedema.

~ Leslyn Keith, OTD, CLT-LANA
Board President, Director of Research | The Lipedema Project

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