Overview

Contact sports such as ice hockey, rugby, boxing, wrestling and martial arts come with inherent risks. One of the most sensitive yet often overlooked contact sport injuries is testicular trauma. This type of injury, although less common compared to other sports-related injuries such as concussions or fractures, can have severe and lasting consequences. Testicular trauma can range from temporary discomfort and swelling to serious complications such as testicular rupture or even infertility. Despite the gravity, many athletes, coaches and even sports organisations do not prioritise preventive measures, leaving athletes unnecessarily vulnerable to largely avoidable injuries. This article aims to shed light on testicular trauma in contact sports, exploring associated consequences and presenting strategies to minimise risks and enhance safety. 

What is testicular trauma?

Testicular trauma refers to any injury to the testicles, which are housed within the scrotum (the sac of skin which hangs below the penis) and play crucial roles in hormone production and sperm generation. These injuries typically occur from blunt force, penetrating trauma, burns or degloving (when the top layer of skin is torn away from underlying tissue).¹ 

Types of Testicular Injury

• Blunt trauma: The most common form in sports, occurring from direct impact. More than 50% of testicular injuries are blunt force injuries.¹  Blunt trauma, which usually occurs on one side, can lead to bruising, swelling, twisting, dislocation or more severe conditions like testicular rupture
• Testicular rupture: A rare but serious injury where the protective covering of the testicle is torn, requiring immediate surgical intervention
• Degloving: Depending on the severity of the injury, treatment can range from sutures to surgical reconstruction
• Thermal: Rarely appearing as isolated injuries, isolated testicular burns are typically either industrial or chemical in nature.¹ This type of injury requires treatment similar to when any other part of the body is burned (more severe burns require more invasive treatment, i.e. surgery)

How are testicles protected by the body?

The scrotum lacks significant muscular protection, leaving the testicles more exposed than other vital organs. Despite the vulnerable position of the testicles (hanging outside of the body), serious injuries are rare.² The cremasteric reflex, mobility of the testicles and strength of the tunica albuginea surrounding the testicles all protect the scrotum from injury.² Nevertheless, the unique anatomical features (including minimal bony shielding and high nerve density) make injuries not only physically painful but also potentially damaging to reproductive health.³ With millions of people participating in contact sports globally, in the United States of America (USA) alone, sports-related testicular injuries account for approximately 3000 emergency department visits yearly, with no significant change in the rate of sports-related testicular trauma in the last decade.^4,5

Testicular trauma in contact sports

A contact sport is a sport where physical contact between competitors is an inherent part of the sport. Contact sports can also include sports where players frequently come into contact with objects or the environment. Examples of contact sports include:

• American football
• Rugby
• Ice and field hockey
• Basketball
• Baseball
• Cricket
• Soccer
• Lacrosse
• Wrestling
• Martial arts
• Boxing

Young individuals assigned male at birth (AMAB) are at greatest risk of testicular trauma associated with contact sports, whether they are playing recreationally or competitively.⁴ Several factors increase the risk of testicular trauma during sports activities:

• High-impact movements: Sudden collisions, kicks or hits
• Lack of protective gear: Inadequate or absent protective equipment leaves the genital region exposed
• Improper technique: Poor tackling or sparring techniques 
• Lack of awareness: Many athletes and coaches underestimate the importance of genital protection, leading to preventable injuries⁴

Prevention strategies

Selecting appropriate protective gear

The use of high-quality protective equipment such as:

• Protective cups: Rigid athletic cups (also known as ‘jocks’) are designed to shield the testicles from direct impact. Protective cups create not only a protective barrier, but also reduce the risk of severe injuries by distributing force over a wider area
  • Young AMAB athletes are advised to wear protective cups and supporters (also known as jock straps) as soon as they begin participating in sports that expose them to groin injuries, but it is estimated only 50% do^6,7
  • Global regulations for protective sports equipment exist through the American Society for Testing and Materials (ASTM) and in the USA through the National Operating Committee on Standards for Athletic Equipment (NOCSAE). Although athletic regulators exist in the United Kingdom (UK), there are no known regulations for athletic equipment to protect genitals. Some sporting organisations, however, recommend the use of protective cups, despite a lack of definitive scientific evidence supporting their effectiveness in preventing injury
  • Despite protective cup use, serious testicular trauma is still possible. 50 lb of force can rupture the testicles when they are trapped against the pelvic bone, inner thigh or protective cup⁶ 
• Jockstraps: A jockstrap or supporter is tight-fitting underwear worn by AMAB athletes, consisting of a waistband and a pouch to hold either the genitals and/or a protective cup in place
• Compression shorts with built-in cups: Intended for comfort, these tight-fitting shorts prevent protective cups from shifting during intense activity

Two factors affect the effectiveness of athletic gear for groin protection: 

• Material: Cups made from hard protective plastic offer superior impact resistance
• Proper fit: Athletic cups increase in size depending on the age of the athlete. Athletic cups should fit snugly against the body. Jockstraps and compression shorts should fit tight enough to prevent twisting or rolling. Ill-fitting gear may fail to provide adequate protection or cause discomfort, discouraging consistent use

Education and awareness

 Educating athletes, coaches and parents about the risks and prevention of testicular trauma can encourage a sporting culture which prioritises safety.

• Safety training sessions: Regular training sessions on proper tackling, blocking and defensive techniques can significantly lower injury rates⁸
• Emphasising the importance of protective equipment: Coaches should enforce mandatory use of protective equipment during both practice and games
• Athletes should learn and follow the rules of the game

Technique training 

Many sport-related injuries result from incorrect posture or technique. Athletes should:

• Be encouraged to learn the correct way to move and position the body during play to reduce strain and minimise the risk of injuries
  • For instance, proper tackling technique in rugby involves bringing your opponent to the ground with your arms around their torso in a controlled manner and ensuring feet are positioned to avoid dangerous leg positions, while keeping the body close to the ground. This is done to avoid hitting and kicking
• Promote situational awareness: Athletes can learn to anticipate and avoid potentially hazardous situations

Ensure fair and safe competition

To keep sports fair and reduce the risk of injury, competitors should be evenly matched. This is achieved through:

• Weight classes: In sports like boxing and wrestling, athletes compete against others of a similar weight (e.g. super heavyweight, featherweight)
• Age groups: Children are grouped by age to ensure fairness and safety. For example, a 15-year-old wouldn’t compete against a nine-year-old in contact sports
• Gender categories: In most sports, especially contact sports, those AMAB and those assigned female at birth (AFAB) compete separately for safety reasons and fairness
• Skill level: Encouraging athletes with relatively equal skill level and ability to participate in sports together not only promotes fairness, but also contributes to safety in certain sports

Rules and regulations

Sports governing bodies play a critical role in enforcing rules which protect athletes. By setting and enforcing rules, they create a safer environment for players. Key measures include:

• Penalising reckless behaviour that increases injury risks
  • When players engage in dangerous behaviour (such as intentional foul play or excessive aggression), it puts everyone at risk. Strict penalties for such actions not only promote safety but also encourage sportsmanship
• Mandating protective equipment across all levels of play
  • Across all levels of sports, athletes should be required to use protective equipment, such as athletic cups, to protect their genitals. These measures are particularly crucial for younger players who are still developing physically
• Reviewing and updating safety protocols based on emerging research
  • With advancements in sports science, new safety measures may be identified. Governing bodies should regularly update their rules and guidelines to reflect emerging research

Immediate response 

Despite preventive measures, injuries can still occur. Fast and appropriate responses are essential:

• Initial assessment: Recognise symptoms of severe injury, such as intense pain, swelling or discolouration and treat the situation as an emergency
• Seek medical help: Seek immediate care for suspected ruptures, torsion, or persistent symptoms to prevent complications
• Encourage rest and recovery: Not all injuries are severe, but even simple measures like rest and the application of ice packs to reduce swelling for minor trauma can prevent minor injuries from worsening

Sports medicine and technology

Advancements in sports medicine and technology play a significant role in improving the prevention and management of testicular trauma.

• Improved protective gear design: Innovations like shock-absorbing materials and ergonomic designs may make protective gear more effective and comfortable
• Diagnostic tools: Portable ultrasound devices may allow for rapid on-field assessments, facilitating timely interventions⁶
• Rehabilitation programs: Personalised recovery plans help athletes regain confidence and return to play safely
• Sports-specific innovations: Introducing specialised protective equipment tailored to the specific risks certain sports present. For example:
  • Cricket: Players use abdominal guards designed with extended coverage for enhanced protection

Psychological considerations

The psychological impact of testicular injuries is often overlooked. Athletes may experience embarrassment, anxiety or fear of reinjury, which can impact overall well-being. Addressing these issues through counselling or peer support, while creating supportive environments within teams, can reinforce the importance of safety practices while offering adequate support for those injured.

Summary

Preventing testicular trauma in contact sports requires a combination of proper protective equipment, education and adherence to safety protocols. Athletes should be encouraged to wear properly fitting athletic cups and/or compression shorts to reduce injury risks. Coaches and sports organisations play a key role in promoting safety by enforcing equipment use and teaching proper techniques. Rules which penalise reckless behaviour can further minimise danger to players. Additionally, regular medical check-ups and prompt treatment of injuries help prevent long-term complications. By prioritising safety measures and awareness, athletes can confidently participate in contact sports while reducing the risk of serious injury. Ultimately, a proactive approach ensures both player well-being and the integrity of the game.

Common myths

"Testicular injuries are too rare to worry about." 

While less common than other sports injuries, their potential severity makes prevention essential.¹

"Athletic cups are unnecessary." 

Athletic cups provide essential protection for AMAB athletes, especially in contact sports. Without a cup, players risk serious injuries to the groin area, which can be extremely painful and even lead to long-term damage.

"Only professional athletes need protective gear."

Injuries can occur at any level of play, from amateur to professional, highlighting the universal need for protection.

“Only direct blows cause testicular injury.”

Sudden pressure, falls or even awkward landings can cause testicular trauma, not just direct blows.

“Protective cups are uncomfortable and restrict performance.”

Advances in ergonomic design have led to contoured, ventilated and flexible cups that allow for movement without discomfort. The perception of restricted motion often stems from improper sizing.