In short As speakers at a workshop that was part of the annual DGPL conference, specialist Dr. Julia Middelhoff and physical therapist Oliver Gültig discussed how important yet difficult the definitive diagnosis of lipedema is. A medical history of the pain and exclusion of other symptoms causing pain play an important role. The workshop report explains how much focus should be on compression therapy during subsequent treatment.
Compression stockings·Lymph and lipedema·Lymphbeschwerden
Recognizing lipedema patients and treating them quickly
Lipedema and compression therapy
From Bauerfeind Life on 23.01.2025

How is lipedema diagnosed, what treatment options are there, and what role do the new German Guidelines[1] play? Specialist Dr. Julia Middelhoff and physical therapist Oliver Gültig dealt with these and many other topics in Bauerfeind’s Lipedema Therapy Workshop, which took place on the occasion of the 66th annual conference of the German Society of Phlebology and Lymphology (DGPL) in Freiburg.
[1] German S2k Lipedema Guidelines: diagnosis, differential diagnosis, and treatment

Despite the recent rise in obesity, the number of lipedema patients has not increased in her practice – with this statement, Dr. Julia Middelhoff, Specialist in Abdominal Surgery, Phlebology, and Lymphology in Germany, opened the workshop. Nevertheless, a precise distinction has to be made between the two conditions so lipedema can be diagnosed, the specialist explained. The key criterion is the pain patients are in, which is also an aspect in the new Geman S2k Lipedema Guidelines that have applied since January 2024. Soreness, however, is a subjective parameter. For Dr. Julia Middelhoff, an exact medical history of the pain is therefore absolutely essential: when and in which areas of the legs does pain occur? An appropriate intensive patient discussion with an exact pain differentiation is thus indispensable for her. After all, there are no standardized pain examination methods for patients suffering from lipedema. In this context, other possible conditions or symptoms that cause pain must be identified. Lymphology expert Oliver Gültig highlighted that differentiating between lipedema and lipohypertrophy in particular is key. During Dr. Julia Middelhoff’s practical work, it often turns out that many painful symptoms have orthopedic reasons. A close look at patients’ foot positioning is therefore something she considers important. Furthermore, symptoms related to rheumatism must also be excluded as well as intervertebral disk damage, phlebological causes, and psychosomatic problems.

Diagnosis remains difficult and complex
Even though the appearance of patients should no longer be considered during categorization according to the new Guidelines, Dr. Julia Middelhoff believes that body weight, height as well as waist and hip circumference along with the BMI can still be key indicators that she includes in her diagnosis. Her tip when measuring seriously overweight patients: simply ask them to place their hands on their waist. They will then automatically go for the narrowest part of their body where you can do the measuring. She pointed out, however, that all recorded measurements are merely auxiliary parameters for which there are no exact decisive or standard values that would be 100 percent indicative of lipedema. This means that diagnosing lipedema remains difficult and complex. Paying close attention to the patient is therefore particularly important yet again.

Compression therapy: focus on flat knit
For the treatment concept of lipedema patients, comprehensive education is especially important, Dr. Julia Middelhoff emphasized. This includes, for example, not offering an unrealistic prognosis for weight loss and not playing with the hopes of patients. Focus should be much more on compression therapy, in combination with the proviso that it must be implemented consistently. In accordance with the new Guidelines, circular or flat knit products can generally be used for compression therapy. In Dr.Julia Middelhoff’s opinion, however, the circumference and the increase of fatty tissue determines the type of compression. She reported that 90 percent of her patients cannot actually be treated using circular knit products because of their body circumference, meaning that flat knit products are prescribed most often by her. The importance of manual lymphatic drainage has also changed in cases of pure lipedema in accordance with the new Guidelines. It is now only prescribed when pain reduction provided by compression therapy is no longer sufficient.

Patient communication: strengthening personal initiative, giving positive feedback
Patients can generally be treated very effectively, in combination with the required degree of personal initiative, according to Dr. Julia Middelhoff’s assessment. Taking patients on a journey, educating them, and getting them involved is therefore her motto. And when it comes to compression therapy, she recommended that, in cooperation with the medical supply retailer, patients should try just one type of compression product first and give clear feedback. It is also important to give positive feedback to patients. Referring them, for example, to self-help groups is beneficial where patients can develop more personal initiative and self-management together with others who are affected.
Lymphology expert Oliver Gültig also emphasized the importance of an exact diagnosis. From his perspective as a physical therapist, manual lymphatic drainage is rarely required during lipedema therapy. Compression therapy, on the other hand, is essential. Its success is significantly increased by a change of diet, long-term weight loss, and psychological support during treatment.

Source:
Bauerfeind Workshop “Recognizing lipedema patients & treating them quickly” on the occasion of the 66th annual conference of the German Society of Phlebology and Lymphology (DGPL) in Freiburg, Breisgau, October 3, 2024.
Pictures: Thomas Hauss, Bauerfeind AG, Adobe Stock