Abstract Introduction Acute type 3b injuries of the hamstring muscle complex (HMC) are prevalent in sports, often lead to prolonged recovery, and demonstrate a high recurrence. Conservative rehabilitation is standard, and adjunct therapies such as radial extracorporeal shock wave therapy (rESWT) may offer additional benefits. Sources of data This randomized controlled trial, with blinding of patients and assessors, included 36 semi-professional athletes with ultrasound-confirmed acute type 3b HMC injuries. Participants received either real or sham rESWT in combination with an 8-week structured rehabilitation program. The primary outcome was time to return to sport; secondary outcomes included post-treatment muscle strength, patient satisfaction, and re-injury rate. Areas of agreement Progressive rehabilitation is effective for muscle injuries. rESWT is a safe, non-invasive modality with high therapeutic potential in musculoskeletal conditions. Areas of controversy Questions remain regarding the ideal rESWT protocol for acute muscle injuries, including optimal dosing, frequency, and timing relative to injury onset. Growing points The addition of rESWT resulted in a statistically significant reduction in return-to-sport time [25.4 ± 3.5 (mean ± SD) days with rESWT vs 28.3 ± 4.5 days with sham rESWT; P = .037]. In elite and semi-professional athletes, even modest reductions in downtime can carry meaningful performance and economic benefits. Furthermore, only the rESWT group avoided strength deficits in the previously injured leg, suggesting improved functional recovery. Areas timely for developing research Future studies should explore the comparative effectiveness of individualized versus standardized rESWT protocols and investigate its broader applicability across sports disciplines and levels of play.