Injuries

Side stitch

Nov 6, 2019

The classic side stitch is also referred to as exercise-related transient abdominal pain – or ETAP. ETAP is a harmless, but nonetheless excruciating, often one-sided and localised sharp pain in the lower abdomen, just below or under the rib cage. 62% of people report always experiencing side stitches on the same side, and pain in the right side is twice as common as left-sided pain.

Side stitch

The side stitch is more common in running than in most other sports. It all comes down to motion. Running involves repetitive jostling of the abdomen while the torso is in an extended position.

This may be one of the causes of ETAP.

Causes of the Side Stitch

Frustratingly, most runners can’t point to a clear cause of the side stitch. And few can find a reliable remedy. There exist several theories about possible causes of the athletic side stitch.

External Factors: Food and Drink

Consuming any heavy food or drink close to exercise is likely to evoke a side stitch, even more so in athletes who don’t have an iron stomach. Your pre-race meal might make a big difference.

Respondents in a study of runners were more likely to report ETAP if they consumed a large mass of food in the one or two hours before the event. Quality and quantity seem to be just as important as timing.

Certain foods high in fat, protein, and fibre are likely to upset the GI tract and should be avoided too close to exercise. Best to eat small amounts of easy to digest food.

Excessive fluid intake before and during exercise is a known culprit for side stitches. This is particularly related to the carbohydrate content and the osmolality (concentration) of the beverage if it’s something other than water. Hypertonic beverages (those containing a higher amount of electrolytes and sugars) are more provocative of ETAP. However, a high-volume fluid ingestion of any kind, including water, is known to increase the incidence of ETAP.

While less-supported by experimental studies, improper warm-up and exercising in colder temperatures may lead to increased incidence of side-stitches.

A Side Stitch is Not a Muscle Cramp

Cramping of skeletal muscle is one proposed cause of side stitches. Incorrectly, side cramps are sometimes thought to be synonymous with side stitch.

While they may feel similar and both lead to a need to stop or slow down during exercise, the side stitch and muscle cramps are not the same condition. Classic wisdom says to treat muscular cramps with fluid, sports drinks, maybe even a banana–strategies that might actually provoke a side stitch.

Straighten Up

When Mom told you not to slouch, perhaps she was onto something. It turns out that the specific influence of posture may worsen symptoms of side stitch.

This hypothesis proposes an influence of the spine on the side stitch. Nerves from the spine also innervate parts of the abdomen. As a result of “jolting” during exercise and compression that may occur in the vertebrae, these nerves may invoke pain indicative of a side stitch. Improving posture and spinal alignment has been seen to improve symptoms related to ETAP.

Preventing a Stitch (Before it’s Too Late)

Many treatments and remedies for side stitch are anecdotal. You know runners. They’ll leave no rock unturned when it comes to improving performance, no matter how wacky. If it works, it works.

Hydration

A side stitch as a consequence of dehydration is unlikely, research says. Studies where subjects either abstained from or consumed fluid have shown that depriving yourself of fluids won’t prevent ETAP.

Drink to thirst before and during the race, taking smaller sips rather than large gulps all at once because, just as dehydration can cause a stitch, so can large quantities of fluid.

Time food and beverage intake strategically. It’s best to avoid large volumes of food and liquid for about 1 – 2 hours before exercise, or 3 – 4 hours if you’ve got more of a sensitive stomach.

Proper fluid concentration is just as important. Hypertonic beverages (a carbohydrate concentration of 8% and above) cause more GI symptoms by slowing gastric emptying, pulling blood away from the stomach, and leading to presence of fluid in the stomach and intestines. Avoiding sweetened beverages high in sugar/carbohydrates, such as fruit juice, can help prevent side stitch symptoms. Aim to consume a beverage in the range of 6% – 8% carbohydrates.

Physical Manoeuvres

You might look like a flash-mob participant, but research has shown that certain stretches and movements you can do while running may help to prevent a side stitch from worsening.

In a study designed to test the effects of various manoeuvres on side stitch intensity, it was shown that side stitches declined rapidly after runners contracted their abdominal muscles, modified their breathing, and tightened a belt around the abdomen. Remarkably, the side stitches disappeared within seconds.

Why do these actions work? Stretching the abdominal muscles reduces tummy tension. As for the belt? Similar to why power-lifters strap up before a lift, tightening the core using a belt while running could reduce abdominal movement, preventing the irritation that might lead to a stitch. (Yes, it’s unlikely that you will have a belt handy while on a long run, but it’s just something to keep in mind if you have a supporter on the route at the right time!)

Strengthen Your Core

Core stability may protect against some symptoms of the side stitch. Runners with stronger trunk muscles and a larger transversus abdominis muscle (which spans the abdominal wall) experience less side stitches.  Having a more stable core helps to prevent unwanted stomach motion during exercise.

Stop the Stitch

 Side stitches will happen, and if you continue to exercise in spite of the pain, they may only get worse.

At the first sign of a stitch, slow your pace, bend forward, and push your hand inward and upward on the area of pain. Tighten your abdominal muscles like you’re resisting a punch and breathe out through pursed lips.

If this doesn’t work, there are a few other tricks to try out.

Changing your foot-strike to match breathing patterns might help ease the pain. If your stitch is on the right side and you normally exhale when your right foot strikes the ground, reverse this pattern, exhaling on your left foot-strike. Vice-versa for a stitch on the left side.

Another common but unstudied technique may involve deep breathing. Take forceful inhales while contracting the stomach and forceful, full exhales while you distend your stomach. These movements are actually the opposite of the natural movements of respiration and stomach motion, one reason why they may help to relieve side stitches.

And sometimes, the best and only option is to stop running, massage the area, and pray to the running gods.

 

Originally published by H.V.M.N.


Scientific citations

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2. Morton DP, Richards D, Callister R. Epidemlology of exercise-related transient abdominal pain at the Sydney City to Surf community run. J Sci Med Sport. 2005;8(2):152-62.

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10. Morton DP, Aune T. Runner’s stitch and the thoracic spine. Br J Sports Med. 2004;38(2):240.

11. Morton DP, Callister R. Influence of posture and body type on the experience of exercise-related transient abdominal pain. J Sci Med Sport. 2010;13(5):485-8.

12. Institute of Medicine (US) Committee on Military Nutrition Research; Marriott BM, editor. Fluid Replacement and Heat Stress. Washington (DC): National Academies Press (US); 1994. 6, Gastric Emptying During Exercise: Influence of Carbohydrate Concentration, Carbohydrate Source, and Exercise Intensity.

13. Mole JL, Bird ML, Fell JW. The effect of transversus abdominis activation on exercise-related transient abdominal pain. J Sci Med Sport. 2014;17(3):261-5.

14. Spitznagle TM, Sahrmann S. Diagnosis and treatment of 2 adolescent female athletes with transient abdominal pain during running. J Sport Rehabil. 2011;20(2):228-49.

15. Eichner ER. Stitch in the side: causes, workup, and solutions. Curr Sports Med Rep. 2006;5(6):289-92.


 

Please note that information found in these articles does not constitute medical advice. If you are experiencing an injury or condition of any kind, it is always advisable to contact a medical professional for advice on your specific symptoms.

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