“Clank.” A screaming fastball strikes the groin of Claude Berry, a professional baseball catcher from 1905 to 1915. Astonishingly, he is unfazed. Having secretly fashioned a piece of molded steel to wear in his pants, this novel piece of protective equipment permitted Claude to be comfortable and composed while crouching behind home plate, an otherwise dangerous position on the baseball diamond.^1,2 Eventually seen as a competitive advantage amongst athletes, manufactured athletic cups grew in popularity over the years to come.

Playing catcher myself, I learned to wear a protective cup behind home plate, especially given the frequency of baseballs flying by. In one terrifying instance, I witnessed an umpire struck in the groin with a foul ball, resulting in significant trauma and testicular loss. Despite my regular use of a cup for baseball, I used one much less frequently for other at-risk sports, such as football. Having not personally witnessed a football-related genital injury, and with few teammates wearing cups, there was less motivation to implement the extra protection. Reflecting on my urology interest and personal sports experiences, I wondered: should I have worn a cup for other sports? Did I put myself at risk? And possibly more importantly, are athletes still wearing cups today?

On review of the literature, the short answer is that it appears most athletes are not. A 2014 survey of high school and college athletes by Bieniek and Sumfest found that only 14.7% of high school athletes and 7.2% of college athletes across all sports wore cups.³ Both groups self-reported similar incidences of prior testicular injury (17.2% and 18.4%, respectively). Baseball and lacrosse players had the highest rates of cup usage (40.6% and 51.5%, respectively), with less than 10% of athletes from other sports wearing cups.³ Thankfully, sports-related genitourinary injuries requiring medical attention remain relatively rare in adolescent populations.^4-6 There have been no formal studies investigating athletic cup use or groin injury incidence at professional levels.

This begs the question, why aren’t athletes wearing cups? The previously mentioned study found that among high school and collegiate athletes, reasons cited for not using a cup included not owning one, lack of knowledge, and social image. To get a sense of the cup culture at professional levels, online interviews with various athletes and coaches were reviewed. Kevin Greene, former 15-year National Football League (NFL) defensive end, noted, “I didn’t know anyone on the 4 teams I played for who wore a protective cup.” In the same piece broadcasted nationally on ESPN’s NFL Countdown, current NFL players Christian McCaffery and Austin Ekeler cited comfort, mobility, and a risk they were “willing to take” as reasons for not wearing groin protection.⁷ While originally viewed as a competitive edge, a cultural shift has occurred with some of today’s top athletes seeing athletic cups as a disadvantage. Major League Baseball managers have estimated that only 25% of their players wear cups. Former Minnesota Twins 5-time All-Star Torii Hunter reports the cliché and potentially risky “I just take it like a man” approach to protection.⁸ Speaking personally, I witnessed this sentiment firsthand, which played a role in some teammates foregoing genital protection. As such, further efforts are needed to engage professional athletes to endorse the importance of genital protection and shift the culture back towards athletic cup acceptance.

Though the use of an athletic cup remains logical to reduce sports-related testicular injuries, the data, or lack thereof, do not provide a definitive answer. There are currently no studies demonstrating the effectiveness of athletic cups in reducing the incidence or severity of testicular injury. Future studies on this topic could include strict enforcement of protective cups for one group of athletes, with no enforcement of cups in a control, followed by analysis of genital injury incidence and severity. Challenges for such a study would include compliance and the need for a large sample size, given the relative rarity of significant testicular injuries.

According to the AUA, boys competing in contact sports should be wearing a hard protective cup as soon as one properly fits them.⁹ Similarly, the American Medical Society for Sports Medicine encourages all male athletes to wear a cup when participating in sports that have a “significant risk for testicular injury,” including lacrosse, soccer, baseball, ice hockey, rugby, football, boxing, and mixed martial arts.¹⁰ Like batting helmets or shoulder pads, male athletes of all ages should be wearing a protective cup when playing a contact sport. Health care providers need to emphasize and educate athletes on the importance of genital protection until the data say otherwise. If not for injury risk reduction, just point out the competitive edge it gave to Claude Berry.