Metacarpal Stress Fractures in Tennis and Racquet-Sport Athletes: An Updated Systematic Review

Metacarpal stress fractures are uncommon overuse injuries resulting from repetitive mechanical loading of bone. They are particularly relevant to racquet-sport athletes because repetitive gripping, impact transmission, training volume and technique may expose the metacarpals to repeated stress. Clinical presentation may be nonspecific, and early radiographs may be normal, potentially delaying diagnosis. A systematic review by Shaari et al., first published online in 2024 and subsequently included in the October 2025 issue of Hand, synthesized metacarpal stress fractures in athletes and identified 11 studies involving 29 cases. Tennis and badminton were among the most represented sports, and the review reported predominantly nonoperative management and a mean return to play of approximately 9 weeks. The present review is therefore designed as an updated and more sport-specific synthesis. The primary analytical focus will be tennis players, while other racquet sports will be included to provide a clinically relevant comparator group. The review will explicitly distinguish tennis-specific evidence from evidence arising from badminton, soft tennis and other racquet sports. The previous systematic review will be used for citation chasing and identification of primary studies, but it will not itself be treated as a primary eligible study and its cases will not be double-counted. Review objective To systematically identify, appraise and synthesize the available evidence on metacarpal stress fractures in tennis and other racquet-sport athletes, with particular emphasis on epidemiology, clinical presentation, anatomical distribution, diagnostic imaging, management, risk factors and return to sport. Specific objectives 1. To characterize the demographic and clinical profile of athletes with metacarpal stress fractures. 2. To determine the metacarpal distribution, particularly the second and third metacarpals. 3. To describe presenting symptoms, examination findings and diagnostic delay. 4. To evaluate the diagnostic contribution of plain radiography, MRI, bone scintigraphy, CT and other imaging modalities. 5. To describe reported biomechanical and training-related risk factors, including grip technique, repetitive loading and changes in training volume. 6. To compare conservative and surgical management when both are reported. 7. To characterize return-to-sport time, return-to-sport criteria and recurrence/complications. 8. To perform a tennis-specific synthesis and compare it descriptively with other racquet sports. 9. To update the evidence base after the search period of the previous systematic review and identify remaining evidence gaps. Review questions Primary question: Among tennis and racquet-sport athletes with metacarpal stress fractures, what are the reported clinical characteristics, diagnostic findings, management strategies and return-to-sport outcomes? Secondary questions: • Which metacarpals are most frequently affected? • Which imaging modalities detect the injury, particularly when initial radiographs are negative? • Which patient, training or technical factors are reported in association with these injuries? • What treatment strategies are associated with successful healing and return to sport? • How long does return to unrestricted sport take? • Are outcomes different between tennis and other racquet sports, between younger and adult athletes, or according to metacarpal location and treatment strategy?