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ObjectivesTo investigate the clinical and ultrasonographic changes associated with radial extracorporeal shock wave therapy (rESWT) in women with lipedema.MethodsThis prospective, single-arm study included 40 women with lipedema who completed six sessions of rESWT administered twice weekly to the index lower limb. Treatment consisted of 3000-6000 impulses at 15 Hz and 3-4 bar. Participants were evaluated at baseline (T0), immediately after treatment (T1), and at 4-week follow-up (T2). Outcomes included visual analog scale (VAS) pain scores, Patient-Reported Outcomes Measurement Information System (PROMIS) scores, pressure pain threshold (PPT), limb circumference, subcutaneous fat thickness (SCFT), and tissue echogenicity. Patient Global Impression of Change (PGIC) was assessed at T1 and T2.ResultsVAS scores decreased from 8.45 at T0 to 5.45 at T1 and 4.17 at T2, while PROMIS scores decreased from 25.3 to 16.2 and 14.3, respectively (both p < .001). PPT increased significantly at all four evaluated sites (p < .001). Calf and thigh circumferences decreased significantly over time (both p < .001). Medial calf SCFT decreased from 16.5 to 15.2 and 15.1 mm, and medial thigh SCFT from 21.0 to 18.2 and 18.1 mm (both p < .001). Median tissue echogenicity decreased from 3 at baseline to 2 at both post-treatment assessments (p < .001). PGIC scores also improved between T1 and T2 (p < .001).ConclusionsSix sessions of rESWT were associated with improvements in pain, quality of life, mechanical pain sensitivity, limb circumference, and ultrasonographic tissue characteristics in women with lipedema, with most improvements maintained at 4-week follow-up. These findings support further evaluation of rESWT as an adjunctive conservative treatment for lipedema in controlled studies with longer follow-up.Trial registrationClinicalTrials.gov, NCT07683559.