Relationship of the tissue stiffness measured using shear wave elastography with the pain threshold and quality of life of patients with lipedema: A cross-sectional study

Abstract

Objective

To assess the relationship between disease severity in lipedema and tissue stiffness measured using shear wave elastography (SWE) concerning pain threshold and quality of life as well as determine differences in subcutaneous tissue stiffness between patients with lipedema and healthy subjects.

Methods

71 participants were subjected to measurements using subcutaneous tissue elastic modulus with SWE imaging of lower limbs at three anatomical levels. The participants were divided into two groups: those diagnosed with lipedema (Group (1) (n = 35) and healthy subjects (Group (2) (n = 36). Patients with lipedema were categorized into three stages based on disease severity. Pain levels were assessed using the visual analog scale (VAS), pain pressure threshold through algometric measurement within lipedema stages, and quality of life using EQ-5D quality of life scale in all groups.

Results

No statistically significant differences in age, BMI, right and left three-zone elastic modulus averages were observed between the groups within BMI levels of 25–29.9 and ≥30 kg/m² (p > .05). Same BMI group, according to lipedema stage, the mean elastic modulus of the right pretibial region in stage 2 cases was significantly higher than in stage 1 cases within BMI levels of 25–29.9 kg/m² (p < .05). The all-region algometric measurements in Group 1 were significantly lower than those in Group 2, within BMI levels of 25–29.9 kg/m² and ≥30 kg/m². The average spontaneous VAS scores in Group 1 were significantly higher than those in Group 2 within the same BMI (p < .05). The VAS palpation scores in Group 1 exceeded those in Group 2 for BMI ≥30 kg/m² (p < .05). No significant difference in VAS palpation scores was observed for BMI 25–29.9 kg/m² (p > .05). The EQ-5D VAS scores of the control group were significantly lower than those of stage 1, 2, and 3 cases (p < .05).

Conclusions

In lipedema, pain characteristics may be more distinctive than the elastic properties of adipose tissue. Increased algometric measurements may reflect a specific objective sensation.

Keywords

Shear wave elastography lipedema pain pressure threshold

Get full access to this article

View all access options for this article.

References

Herbst

Kahn

Iker

, et al. Standard of care for lipedema in the United States. Phlebology 2022; 36(10): 779–796. https://pubmed.ncbi.nlm.nih.gov/34049453/

Poojari

Dev

Rabiee

. Lipedema: insights into morphology, pathophysiology, and challenges. Biomedicines 2022; 10(12): 3081. https://pubmed.ncbi.nlm.nih.gov/36551837/

Suga

Araki

Aoi

. Adipose tissue remodeling in lipedema: adipocyte death and concurrent regeneration. J Cutan Pathol 2009; 36(12): 1293–1298. https://pubmed.ncbi.nlm.nih.gov/19281484/

Felmerer

Stylianaki

Hägerling

. Adipose tissue hypertrophy, an aberrant biochemical profile and distinct gene expression in lipedema. J Surg Res 2020; 253: 294–303. https://pubmed.ncbi.nlm.nih.gov/32407981/

Faerber

Cornely

Daubert

. S2k guideline lipedema. J Dtsch Dermatol Ges 2024; 22: 1303–1315. https://pubmed.ncbi.nlm.nih.gov/39188170/

Priglinger

Wurzer

Steffenhagen

. The adipose tissue-derived stromal vascular fraction cells from lipedema patients: are they different? Cytotherapy 2017; 19(7): 849–860. https://pubmed.ncbi.nlm.nih.gov/28454682/

Prantl

Schreml

Gehmert

. Transcription profile in sporadic multiple symmetric lipomatosis reveals differential expression at the level of adipose tissue-derived stem cells. Plast Reconstr Surg 2016; 137(4): 1181–1190. https://pubmed.ncbi.nlm.nih.gov/27018673/

Bauer

von Lukowicz

Lossagk

. Adipose stem cells from lipedema and control adipose tissue respond differently to adipogenic stimulation in vitro. Plast Reconstr Surg 2019; 144(3): 623–632. https://pubmed.ncbi.nlm.nih.gov/31461015/

Al-Ghadban

Diaz

Singer

. Increase in leptin and PPAR-γ gene expression in lipedema adipocytes differentiated in vitro from adipose-derived stem cells. Cells 2020; 9(2): 430. https://pubmed.ncbi.nlm.nih.gov/32059474/

10.

Kruppa

Georgiou

Biermann

. Lipedema-pathogenesis, diagnosis, and treatment options. Dtsch Arztebl Int 2020; 117(22-23): 396–403. https://pubmed.ncbi.nlm.nih.gov/32762835/

11.

Amann-Vesti

Franzeck

Bollinger

. Microlymphatic aneurysms in patients with lipedema. Lymphology 2001; 34(4): 170–175. https://pubmed.ncbi.nlm.nih.gov/11783595/

12.

Weissleder

Brauer

Schuchhardt

. [Value of functional lymphoscintigraphy and indirect lymphangiography in lipedema syndrome]. Z Lymphol 1995; 19(12): 38–41. https://pubmed.ncbi.nlm.nih.gov/8659203/

13.

Dinnendahl

Tschimmel

Löw

. Non-obese lipedema patients show a distinctly altered quantitative sensory testing profile with high diagnostic potential. Pain Rep 2024; 9(3): e1155. https://pubmed.ncbi.nlm.nih.gov/38617100/

14.

Brenner

. Wie kommt der Schmerz ins Lipödem? Lymph Forsch 2017; 21(1): 40–47.

15.

Chakraborty

Crescenzi

Usman

. Indications of peripheral pain, dermal hypersensitivity, and neurogenic inflammation in patients with lipedema. Int J Mol Sci 2022; 23(18): 10313. https://pubmed.ncbi.nlm.nih.gov/36142221/

16.

Buso

Depairon

Tomson

, et al.

Lipedema: a call to action!

Obesity 2019; 27(10): 1567–1576. https://pubmed.ncbi.nlm.nih.gov/31544340/

17.

Shavit

Wollina

Alavi

. Lipoedema is not lymphoedema: a review of current literature. Int Wound J 2018; 15(6): 921–928. https://pubmed.ncbi.nlm.nih.gov/29956468/

18.

Aksoy

Karadag

Wollina

. Cause and management of lipedema-associated pain. Dermatol Ther 2021; 34: 34. https://pubmed.ncbi.nlm.nih.gov/33001552/

19.

Blaszkiewicz

Willows

Dubois

. Neuropathy and neural plasticity in the subcutaneous white adipose depot. PLoS One 2019; 14(9): 0221766. https://pubmed.ncbi.nlm.nih.gov/31509546/

20.

Younger

Kapphahn

Brennan

. Association of leptin with body pain in women. J Womens Health 2016; 25(7): 752–760. https://pubmed.ncbi.nlm.nih.gov/27028709/

21.

Saxton

Withers

Heagerty

. Emerging roles of sympathetic nerves and inflammation in perivascular adipose tissue. Cardiovasc Drugs Ther 2019; 33(2): 245–259. https://pubmed.ncbi.nlm.nih.gov/30747398/

22.

Bettariga

Fumagalli

Aloisi

. Characterization of pain in lipedema: reliability and validity of pain pressure thresholds and hand-held sphygmomanometer assessments in people with lipedema. Lymphatic Res Biol 2025; 23(2): 95–100. https://pubmed.ncbi.nlm.nih.gov/39718932/

23.

Iker

Mayfield

Gould

. Characterizing lower extremity lymphedema and lipedema with cutaneous ultrasonography and an objective computer-assisted measurement of dermal echogenicity. Lymphatic Res Biol 2019; 17(5): 525–530. https://pubmed.ncbi.nlm.nih.gov/30615553/

24.

Monnin-Delhom

Gallix

Achard

. High resolution unenhanced computed tomography in patients with swollen legs. Lymphology 2002; 35(3): 121–128. https://pubmed.ncbi.nlm.nih.gov/12363222/

25.

Vaughan

. CT of swollen legs. Clin Radiol 1990; 41(1): 24–30. https://pubmed.ncbi.nlm.nih.gov/2297962/

26.

Dimakakos

Stefanopoulos

Antoniades

. MRI and ultrasonographic findings in the investigation of lymphedema and lipedema. Int Surg 1997; 82(4): 411–416. https://pubmed.ncbi.nlm.nih.gov/9412843/

27.

Duewell

Hagspiel

Zuber

. Swollen lower extremity: role of MR imaging. Radiology 1992; 184(1): 227–231. https://pubmed.ncbi.nlm.nih.gov/1609085/

28.

Çamlıdağ İ

ÖS

Özden

. Two-dimensional shear wave elastography of the perirenal fat: can sticky fat be predicted? J Clin Ultrasound 2019; 47(4): 201–205. https://pubmed.ncbi.nlm.nih.gov/30560576/

29.

Wang

Fan

, et al. Determination of the elasticity of breast tissue during the menstrual cycle using real-time shear wave elastography. Ultrasound Med Biol 2015; 41(12): 3140–3147. https://pubmed.ncbi.nlm.nih.gov/26403697/

30.

Lin

Ding

Mao

. Non-invasive assessment of liver fibrosis in a rat model: shear wave elasticity imaging versus real-time elastography. Ultrasound Med Biol 2013; 39(7): 1215–1222. https://pubmed.ncbi.nlm.nih.gov/23602805/

31.

Ishibashi

Yamagata

Sasaki

. Real-time tissue elastography for the diagnosis of lymph node metastasis in oral squamous cell carcinoma. Ultrasound Med Biol 2012; 38(3): 389–395. https://pubmed.ncbi.nlm.nih.gov/22266228/

32.

Zarrad

Duflos

Marin

. Skin layer thickness and shear wave elastography changes induced by intensive decongestive treatment of lower limb lymphedema. Lymphatic Res Biol 2022; 20(1): 17–25. https://pubmed.ncbi.nlm.nih.gov/34939855/

33.

Lee

Cho

. Can tissue stiffness measured using shear-wave elastography represent lymphedema in breast cancer? Lymphatic Res Biol 2022; 20(6): 607–611. https://pubmed.ncbi.nlm.nih.gov/35394367/

34.

Polat

Ozturk

Polat

. Efficacy of ultrasound and shear wave elastography for the diagnosis of breast cancer-related lymphedema. J Ultrasound Med 2020; 39(4): 795–803. https://pubmed.ncbi.nlm.nih.gov/31705687/

35.

Akita

Yoshida

Omura

. Noninvasive, objective evaluation of lower extremity lymphedema severity using shear wave elastography: a preliminary study. J Plast Reconstr Aesthetic Surg 2021; 74(12): 3377–3385. https://pubmed.ncbi.nlm.nih.gov/34215544/

36.

Naouri

Samimi

Atlan

. High-resolution cutaneous ultrasonography to differentiate lipoedema from lymphoedema. Br J Dermatol 2010; 163(2): 296–301. https://pubmed.ncbi.nlm.nih.gov/20408836/

37.

Delgado

Lambert

Boutris

. Validation of digital visual analog scale pain scoring with a traditional paper-based visual analog scale in adults. J Am Acad Orthop Surg Glob Res Rev 2018; 2(3): e088. https://pubmed.ncbi.nlm.nih.gov/30211382/

38.

Lau

Blazevich

Newton

. Assessment of muscle pain induced by elbow-flexor eccentric exercise. J Athl Train 2015; 50(11): 1140–1148. https://pubmed.ncbi.nlm.nih.gov/26523661/

39.

Dresser

MacIntyre

Chisholm

. Is bone tenderness, as measured by manual algometry, associated with vitamin D deficiency? J Can Chiropr Assoc 2014; 58(3): 320–327. https://pubmed.ncbi.nlm.nih.gov/25202161/

40.

Wolfs

Dirksen

Kessels

. Performance of the EQ-5D and the EQ-5D+C in elderly patients with cognitive impairments. Health Qual Life Outcome 2007; 5(33): 33. https://pubmed.ncbi.nlm.nih.gov/17570832/

41.

EuroQol Group . EQ-5D available versions website. https://www.euroqol.org/web/users/language_a.php (Accessed May 5, 2025).

42.

Kaya

Solmaz

Bolol

. Validity and reliability of EuroQol in measurement of health related quality of life in patients with laryngectomy. Ü.F.N. Hem. Derg 2007; 58(53): 30–39.

43.

Kaya

Babadağ

. Romatoid artritli bireylerde sağlığa ilişkin yaşam kalitesi. İstanbul Üniversitesi FNHYO Hemşrelik Dergisi 2004; 13(53): 51–71.

44.

Amato

ACM

Saucedo

Santos

KDS

. Ultrasound criteria for lipedema diagnosis. Phlebology 2021; 36(8): 651–658. https://pubmed.ncbi.nlm.nih.gov/33853452/

45.

Weir

Jan

. BMI classification percentile and cut off points. StatPearls [internet]. Treasure Island (FL): StatPearls Publishing, 2025. Available from. https://www.ncbi.nlm.nih.gov/books/NBK541070/

46.

Paolacci

Precone

Acquaviva

. Genetics of lipedema: new perspectives on genetic research and molecular diagnoses. Eur Rev Med Pharmacol Sci 2019; 23(13): 5581–5594. https://pubmed.ncbi.nlm.nih.gov/31298310/

47.

Ishaq

Bandara

Morgan

, et al. Key signaling networks are dysregulated in patients with the adipose tissue disorder, lipedema. Int J Obes 2022; 46(3): 502–514. https://pubmed.ncbi.nlm.nih.gov/34764426/

48.

Ryden

Andersson

Bergstrom

, et al. Adipose tissue and metabolic alterations: regional differences in fat cell size and number matter, but differently: a cross-sectional study. J Clin Endocrinol Metab 2014; 99(10): 1870–1876. https://pubmed.ncbi.nlm.nih.gov/24937536/

49.

Nankam

PAN

Cornely

Klöting

, et al.

Is subcutaneous adipose tissue expansion in people living with lipedema healthier and reflected by circulating parameters?

Front Endocrinol 2022; 13: 1000094. https://pubmed.ncbi.nlm.nih.gov/36387874/

50.

Schwahn-Schreiber

Marshall

. Pr€avalenz des Lipodems bei berufst € €atigen Frauen in Deutschland. Phlebologie 2011; 40(03): 127–134.

51.

Hoffstedt

Arner

Wahrenberg

, et al. Regional impact of adipose tissue morphology on the metabolic profile in morbid obesity. Diabetologia 2010; 53(12): 2496–2503. https://pubmed.ncbi.nlm.nih.gov/20830466/

52.

Sun

Kusminski

Scherer

. Adipose tissue remodeling and obesity. J Clin Investig 2011; 121(6): 2094–2101. https://pubmed.ncbi.nlm.nih.gov/21633177/

53.

Kim

Lun

Wang

, et al. Loss of white adipose hyperplastic potential is associated with enhanced susceptibility to insulin resistance. Cell Metab 2014; 20(6): 1049–1058. https://pubmed.ncbi.nlm.nih.gov/25456741/

54.

Taljanovic

Gimber

Becker

, et al. Shear-wave elastography: basic physics and musculoskeletal applications. Radiographics 2017; 37(3): 855–870. https://pubmed.ncbi.nlm.nih.gov/28493799/

55.

Naganuma

Ishida

. Factors other than fibrosis that increase measured shear wave velocity. World J Gastroenterol 2022; 28(46): 6512–6521. https://pubmed.ncbi.nlm.nih.gov/36569278/

56.

Wolf

Deuel

Hollmen

, et al. A distinct cytokine profile and stromal vascular fraction metabolic status without significant changes in the lipid composition characterizes lipedema. Int J Mol Sci 2021; 22(7): 3313. https://pubmed.ncbi.nlm.nih.gov/33805070/

57.

Finocchietti

Mørch

Arendt-Nielsen

, et al. Effects of adipose thickness and muscle hardness on pressure pain sensitivity. Clin J Pain 2011; 27(5): 414–424. https://pubmed.ncbi.nlm.nih.gov/21415721/

58.

Gerhardt

Hartmann

Tesarz

, et al. Subgroups of musculoskeletal pain patients and their psychobiological patterns - the LOGIN study protocol. BMC Muscoskelet Disord 2012; 13(3): 136. https://pubmed.ncbi.nlm.nih.gov/22862787/

59.

Romeijn

JRM

de Rooij

MJM

Janssen

, et al. Exploration of patient characteristics and quality of life in patients with lipoedema using a survey. Dermatol Ther 2018; 8(2): 303–311. https://pubmed.ncbi.nlm.nih.gov/29748843/