The Dreaded Side Stitch

Most runners know all too well the discomfort of the notorious side stitch. There's nothing worse than that sharp pain "under the ribs" creeping up out of nowhere to ruin what would otherwise be a perfectly great run or game.

The current term used to describe this side-ache is Exercise-Related Transient Abdominal Pain (or ETAP). It is defined as a well-localized pain that may occur in any region of the abdomen but is most common in the side of the mid-abdomen. Although widely recognized as a problem for runners, ETAP commonly occurs during a variety of other activities. Most people tend to experience ETAP in the same area every time and will usually experience pain in the upper or lower torso regions or either side of the mid-abdomen. However, pain most often occurs on the right side. ETAP is also occasionally accompanied by pain in the shoulder region and has been described as "shoulder tip pain." In fact, many people are forced to either reduce their activity level or stop entirely until the pain subsides, making a side stitch just as bad, if not worse, than any other injury. For this reason, the cause and best treatment of ETAP has become a hot topic for active individuals.

A study headed by Darren Morton, an exercise physiologist from the University of Newcastle and one of the leading researchers in this area, found that 61% of athletes reported experiencing ETAP in the past year while participating in their selected sport. This included a variety of team sports, swimming, and horseback riding. It is interesting to note that ETAP has not been found to be as prevalent in cycling and rowing, leading experts to believe that this condition is associated more with activities involving repetitive up-and-down or twisting torso movement.

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How to ditch the stitch:

1. Change breathing patterns

It is common for runners to step in time with their breathing. In fact, it has been found that many runners form an unconscious habit of breathing out on the same leg all of the time. One of the most popular striding-breathing patterns is two to one; meaning that two complete strides are taken for each breath in and each breath out. When you inhale, your lungs fill with air as your diaphragm contracts downward. This downward contraction increases pressure and stability in the abdominal cavity. This is a good thing. Conversely, when you exhale, the diaphragm relaxes and springs upward, leaving more room for the organs to potentially "bounce." 

TIP: When a stitch strikes, change your breathing pattern so that the leg on the opposite side of the body from the stitch is the one that hits the ground at the end of an exhalation.

2. Fortify your diaphragm with belly breathing

A stronger and more flexible diaphragm will be better able to withstand and move with the organs of the abdomen. Belly breathing can help do this.

TIP: To belly breathe, lie on your back on the floor and place a set of heavy books on your stomach. Try to raise the books when you breathe in and drop when you breathe out. After you are proficient with this exercise, try to use this method of breathing as you run. Note: it takes time to learn, so be patient.

3. What, when, and how much you eat or drink before activity

Drinking too much liquid too fast has been found to be a significant cause of ETAP. It is also important to note that while taking in larger quantities of water has been found to provoke ETAP, dehydration has also been shown to cause it as well. Since either drinking too much or too little can cause ETAP, it is important to hydrate within an optimal range. Beverages with high caloric content, high particle concentration, large volume (taken at once), and a high fluid acidity can all slow gastric emptying. 

TIP: Try to avoid fruit juices and beverages high in carbohydrate (sugar) concentration prior to and during exercise. Because symptoms associated with drinking carbohydrate beverages decrease with repetition, try practicing fluid ingestion during practice runs.

4. Increase core strength

Athletes with a strong core seem to have a much lower risk of developing a side stitch. Although it is not known why, it may be that increased trunk and pelvic muscle tone helps to support internal organs and keeps them from jostling up and down quite as much.

TIP: Focus on strengthening all the core musculature.

5. Ensure proper function of the thoracic spine

A regular visit to a local chiropractor for adjustments or mobilizations to the thoracic spine may decrease the frequency or severity of side stitch pain in some patients affected by thoracic spine pain referral.

6. Visit your physician

If symptoms still persist, visit a health-care professional to rule out a number of syndromes that may lead to symptoms similar to ETAP.

Typically, symptoms decrease the more you run. Keep the faith!