Lipoedema and Strength Training: Why Your Approach to Exercise Needs to Be Different

Lipoedema and strength training are topics I discuss with my lipoedema clients every time we start building an exercise routine. For those who have lipoedema (also known nowadays as Lipalgia syndrome), strength training is not an easy activity to take up, and there are a few reasons, starting with potential hypermobility and an inflammatory response post-exercise, but also a lack of joint stability.

Let’s then look into what approach I have to offer for lipoedema patients here at Melbourne Massage and Treatment, Myotherapy and Lymphoedema Clinic in Coburg.

Introduction: Strength training is important, but how you train matters

For someone who lives with lipoedema, delivering any forms of exercise, including walking, cycling, swimming, Pilates or gym-based workouts, may feel different and not always as easy given the pain response they may end up experiencing post-training.

That said, if you tried out several types of exercises, you may also have noticed that some exercises leave you feeling better, while others cause increased pain, heaviness, swelling or fatigue.

This does not necessarily mean that exercise is unsuitable for you.

Strength training can be a valuable part of lipoedema management. This is because strength training can help improve muscular strength, physical function, joint support and your ability to perform everyday activities.

That said, I believe there is an important distinction between simply following a strength-training programme and understanding how your body responds to individual movements when living with Lipoedema. Indeed, when I train someone who suffers from Lipoedema, we don’t want to take for granted that their mobility is optimal only because a lipoedema characteristic is hypermobility.

So, to start with, we would look into a mobility check and, where needed, a mobility exercise routine. That can be your ankle, thoracic spine, or even shoulder mobility.

From there, we would start working on improving stable joints, like your knee, by working on quads and hamstrings, for example.

This would allow us to:

• Establishing adequate mobility and movement control.
• Break down complex functional movements into simpler exercises.
• Finding an appropriate training volume and intensity based on individual recovery.

Let’s look at why these principles matter.

Start by assessing mobility, not by adding weights

My approach to an exercise program is based on a simple principle: Mobility before strengthening.

Too often I see clients who complain about their inability to do a squat, or to do overhead movement with weights, only to find out they lack mobility in their joints (ankle for squat, AC joint for overhead movement).

Therefore, before introducing resistance, I believe it is important to understand whether someone has sufficient mobility to perform a movement efficiently. Yes, because when you start loading the body with weights, you want to be efficient, not only strong.

So, mobility is the ability to move a joint through the range required for a particular activity while maintaining appropriate control.

Back to the squat example, first things first, I would want to understand whether you can comfortably move through the required ankle, and hip ranges.

• Can your ankle dorsiflex?
• Can your hip hinge?

Other things I also look at, when assessing than a squat are:

• Can you maintain an appropriate foot position while distributing your body weight?
• Does your knee track your foot direction?

These are basic questions, but they make a significant difference when deciding which exercises to introduce.

What if you are hypermobile?

Most often, people living with lipoedema also experience joint hypermobility.

Hypermobility describes joints that move beyond the usual range of motion. But not everyone would experience joint instability, discomfort, fatigue, or difficulties controlling their movements, and this creates an important consideration when prescribing strength training.

Someone who is hypermobile may not necessarily need to increase their joint range of motion. In fact, they may already have more range than they can comfortably control; therefore, they need more stability.

The stability concept brings us to the 2nd, but not less important, aspect of an analysis: pre-strength.

The stability then comes from the ability to develop sufficient muscular control to stabilise the joints throughout movement. Both mobile and stable joints.

Therefore, still using the squat example, imagine someone who may be able to extend their knees beyond a neutral position and struggle to maintain a controlled knee position. You would not want to load that joint heavily.

So what’s next? Well, we will need to develop more neural control of the muscle and joint. Make your nervous system work more on proprioception of that joint, so that you can stop the extension at the desired level.

So, for someone who lives with Lipoedema, therefore, most likely is hypermobile, the first steps to their strength training here at Melbourne Massage and Treatment are:

• Mobility check
• Stability check

Those two steps come with specific exercises and self-check tools, like the star excursions balance test (sticking to the Squat example here). We need to build your training on a step-by-step approach.

Break down functional movements into simpler exercises

Now, another big mistake I see in exercise programming is assuming that you should be able to perform a complex movement simply because you can understand the instructions.

Take a lunge, for example.

A lunge is a relatively simple exercise to demonstrate, but it requires several physical abilities to work together:

• Hip and ankle mobility.
• Knee control.
• Pelvic stability.
• Balance and coordination.
• Appropriate muscular strength.
• The ability to distribute body weight between both legs.

For someone with lipoedema, particularly when joint hypermobility is also present, coordinating all these elements simultaneously may be challenging.

So, before I keep correcting your lunge and assuming you should just be able to do it, I would prefer to break the movement down into simpler components.

Example: Building towards a lunge

Instead of starting with a complete lunge, I might progressively introduce the following exercises:

Step 1 – Establish joint control

Seated knee extensions: We start by learning to activate and strengthen the quad muscles while maintaining control throughout the movement.

Prone knee flexion: Hamstrings are the other muscle group responsible for your knee stability. Those muscles would work hard in that return phase of your lunge.

Supine supported hip movements: Introduce controlled hip flexion and extension, under resistance, without requiring you to balance your entire body weight, while moving your hip.

Side-lying glute med activation/strength: Your glute medius is a muscle that supports your pelvic stability while you stand on one leg. Making it work while you’re lying on your side helps you safely learn how to activate it before we step into single-leg standing exercises.

Step 2 – Split Squat

The difference between a split squat and a lunge is that the split squat is a lunge ending position, but you never return to a position with your feet beside each other, which is the lunge starting position. So in a split squat, your feet are one in front of the other, and you move your body up and down while you bend your knees.

This exercise can progress from:

• Double-hand support
• Single hand support
• No hand support, no weights
• No hand support, plus weights.

Further facilitation comes with controlled and small movement. There is no need to reach a full range of motion split squat, where your knee touches the floor.

Step 3 – Introduce individual components of the lunge

Stand on one leg.

To perform a lunge, even only for a fraction of a second, you will have to be comfortable standing on one leg.

Therefore, just standing straight on one leg is another step towards your lunge.

While you stand on one leg, we will aim for 30 to 60 seconds of standing, free of weight and with weights to follow. Other progressions can include adding other sensory stimulation, such as sounds, closing eyes, or shoulder taps.

Step 4 – Progress towards the complete movement

Now that we learned how to control and strengthen the individual group of muscles and joint needed to deliver a lunge, we can gradually introduce the movement range and reduce external support.

Eventually, a full lunge may become an appropriate exercise, but there is no reason to rush this progression.

The important point is that the exercise should match your current ability, not the other way around.

Lipoedema and strengthening it is also about finding the right exercise dose.

So, now that we have looked at how we can break down complex movement and build mobility and stability before strength, it is also time to introduce the concept of repetitions and sets.

In fact, exercises are a physiological stressor.

Therefore, when you train, your body responds to the mechanical and metabolic demands placed on it. This includes temporary changes in inflammatory signalling, muscle fatigue and tissue repair processes.

And these responses are normal parts of exercise adaptation, not something unique to Lipoedema.

However, people living with lipoedema may already experience chronic low-grade inflammation, tissue sensitivity, pain and a greater symptom burden.

Lipoedema is associated with inflammatory changes in adipose tissue, although the degree of inflammation and its clinical significance can vary considerably between individuals.

So, the same exercise programme may produce very different responses in two people. So we can’t use a set formula.

One person may tolerate three sets of an exercise without difficulty, while another may experience increased tenderness, heaviness or fatigue afterwards.

Neither response should be ignored, and the only way to find out what works for you is a trial-and-error approach.

Yes, starting with a small amount of reps per 2 sets, with a light weight (50% of your 1 rep max) and building from there.

If even this is too much, we can always regress by changing concentric load per eccentric load, stimulating mainly your muscle neural control, even before the actual contraction of the tissue.

Exercise is not a competition

When I start an exercise program with someone who suffers from Lipoedema, I often hear how they struggled to keep up with their gym partner.

My response to that is that there is no need for comparison. Not at all. Lipoedema is a condition that can put lots of stress and load on the body tissues, so it would make your exercise journey unique and not comparable to the one of someone who has no Lipoedema. And that’s absolutely fine.

So what I would suggest to focus on too is:

• Can you comfortably complete five repetitions?
• How do you feel immediately after the exercise?
• How do your legs feel later that day?
• Have you noticed increased pain, tenderness or heaviness the following morning?
• How long does it take you to return to your usual baseline?

These questions help establish whether the training stimulus is appropriate.

It is important to understand that feeling tired after exercise is not necessarily a problem. However, a substantial or prolonged increase in symptoms may indicate that the exercise dose needs to be adjusted.

So, what we are aiming for is a pain of 3-4/10 that can last about 24 hours. If the pain is more than that, or lasts longer than 24 hours, we may need to adjust the load.

Why recovery matters as much as the exercise itself

The recovery phase, post-strength exercises, is the time needed for the muscle and body tissues to actually respond to the inflammatory response caused by the exercises.

Therefore, keeping pushing the body over its limit without a proper resting phase is not sustainable and is not efficient either.

When looking at a lipedema presentation, we already know that the inflammatory markers are higher compared to the norms. So, not only do we need to be conservative about how much we push the body (especially in the early days of training), but we also need to monitor the response post-exercise, and if you end up in too much pain, or in pain for too long, that’s an indicator that something in your program needs to change.

Here is what can be adjusted:

• Fewer repetitions;
• Fewer sets;
• Lower resistance;
• Longer recovery periods;
• More supported exercises;
• Gradual increases in training volume.

This way, as your tolerance improves, the training stimulus can be progressively increased.

The goal is to find the maximum amount of exercise that can be performed consistently without repeatedly exceeding your recovery capacity.

This is very different from trying to push through every exercise session regardless of how the body responds.

Does exercise increase inflammation in lipoedema?

This may be the most important part of this blog and the Lipoedema and Strength Training topic.

As mentioned above, exercise can temporarily increase inflammatory signalling, particularly following unfamiliar or demanding exercise.

That said, this doesn’t mean that exercise makes chronic inflammation worse, because, luckily, the body knows how to adapt to stimuli.

Indeed, regular, appropriately prescribed physical activity can have beneficial effects on metabolic health and inflammatory regulation. So yes, initially it may feel counterproductive doing exercises when being in a state of chronic inflammation, but here is what science has to say:

The 2024 consensus statement published by the Italian Society of Motor and Sports Sciences and the Italian Society of Phlebology identifies physical exercise as an important component of conservative lipoedema management. It discusses potential benefits including:

• improved muscle function;
• lymphatic circulation;
• modulation of inflammation.

The challenge, then, is finding the appropriate balance.

If the training stimulus is too demanding, the resulting fatigue and symptom aggravation may make it difficult to maintain a consistent exercise routine.

If the stimulus is appropriate, it can provide an opportunity for the body to adapt and gradually improve its physical capacity.

And this brings us to the same usual principle on which Myotherapy and Melbourne Massage and Treatment is based:

Your goal is to be in line with your capacity, your needs, and what your body can do at the present moment. That’s the starting point. Then, from there, we can gradually build a program that, step by step, would take you further and further with your capacity.

Progression should be based on control and recovery, not just strength

Now that we understand what the best approach to Lipoedema and Strength training is, we need to dive a bit more into the concept of tissue adaptation.

Past the initial phase of training, when things start feeling easier, we still need to be on the lookout for what an increase in load may mean, because strength is only one part of functional movement.

Indeed, things to consider include:

• Can you maintain joint control throughout the exercise?
• Can you perform the movement without unnecessary compensation?
• Can you control the lowering phase of the movement?
• Can you maintain balance and coordination?
• Can you repeat the exercise without experiencing excessive symptom aggravation?
• Can you recover adequately before the next session?

A classic example to summarise the above is someone able to perform a weighted squat, increase the load, but then start experiencing worse quality of movement, lack of stability in the knees or pain during the exercise in a non-targeted area.

In this situation, I would continue working on stability and movement control rather than automatically increasing the load.

Mobility → Stability → Strength

If you have looked around my website, on the blog page or even on the Fitness Class page, you may already come across the concept of mobility, stability, and Strength. This is the progression I prefer to use when introducing exercise, with or without working with someone who has Lipoedema.

Mobility: Establish the movement range required for the activity.

Stability: Develop the ability to control that movement and maintain appropriate joint positions.

Strength: Introduce progressive resistance once the movement can be performed with sufficient control.

This does not mean every exercise must follow a rigid three-stage process. Mobility, stability and strength can overlap.

However, it provides a useful framework for understanding why someone may need to spend more time developing movement control before progressing to heavier resistance. And also gives you the opportunity to build efficiency in your movements under load. Because of a lack of mobility or stability, as in the usual example of the squat, it means you will lack the ability to perform a fine movement that may allow you to move more load.

Strength training should support everyday activities

If you’re at this stage, you may still ask yourself why we all should look into strength training; well, here is why: We should all look into exercises under load to improve our ability to participate in everyday activities.

Then, for someone living with lipoedema, this may include:

• Getting up from a chair more comfortably;
• Walking for longer periods;
• Climbing stairs;
• Getting in and out of a car;
• Carrying shopping bags;
• Maintaining balance;
• Improving confidence when moving;
• Participating in recreational activities

These goals may require different exercise selections depending on the person’s symptoms, mobility, strength and current physical capacity.

For one person, improving a sit-to-stand movement may be the most valuable starting point.

For another, developing sufficient strength and control to climb stairs may be the priority.

This is why I do not believe there is one universal strength-training programme for lipoedema.

The programme needs to reflect your needs and your goal, starting from where you are at now with your body and clinical history.

How I approach strength training at my Coburg clinic

At Melbourne Massage and Treatment Myotherapy and Lymphoedema Clinic in Coburg, I believe exercise should be approached as an individual process rather than a standard workout.

My approach starts with an initial assessment to understand the person’s movement abilities, physical limitations, symptoms and goals.

From there, I can identify which movements need to be developed and which exercises are appropriate as a starting point.

I use a combination of:

• Mobility exercises;
• Joint stability and motor-control exercises;
• Progressive resistance training;
• Functional movement patterns;
• Individualised home exercise programmes;

Depending on your needs, exercises can be performed using body weight, resistance bands, dumbbells or gym equipment.

I also consider your response between sessions, because the ability to recover is an important part of determining whether the programme is progressing appropriately.

My objective is not to make you exercise harder than you can tolerate.

It is to help you develop the physical capacity to move more confidently, improve your strength and maintain an active lifestyle.

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Conclusion: Move More, Live Well, Train smart, not only hard

In conclusion, living with lipoedema does not mean you should avoid strength training.

However, it does mean that your exercise programme deserves careful consideration.

You may need to spend more time establishing stability, motor-neural control, and breaking down functional movements before progressing to conventional resistance exercises.

You may also need to experiment with exercise volume and intensity to understand how much your body can tolerate and recover from.

There is no benefit in completing a demanding workout if the resulting symptoms prevent you from exercising consistently over the following days.

I believe the most effective approach is to build strength progressively, respect individual recovery and develop movement skills that translate into everyday life.

Lipoedema and Strength Training FAQ

Giovanni La Rocca
Clinical Myotherapist
Bachelor of Health Science (Clinical Myotherapy)
Melbourne Massage and Treatment Myotherapy and Lymphoedema Clinic – Coburg