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What Causes a Side Stitch?

Tips and advice for a side stitch or side ache when running

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Updated April 07, 2014

Most runners have experienced a side stitch or side ache at one time or another during exercise. That sharp, localized twinge of pain just below the rib cage that usually occurs on the the right lower abdomen. It is particularly common in runners and has been known to slow some athletes down to a walk until the pain subsides.

Today, researchers refer to this nagging abdominal pain by the much more technical and scientific term, "exercise-related transient abdominal pain" (ETAP). Regardless of what you call it, the pain is often enough to stop runners and swimmers in their tracks and hold their sides in agony.

What Causes a Side Stitch

While there is still no definitive explanation for the cause of a side stitch, there are several very convincing theories. The majority of the researchers believe that it has a lot to do with what we eat before we exercise.

Several studies agree that ETAP is most common in running and swimming. The pain is described as well-localized in the right or left lower abdomen. The pain of the side stitch often interfered with performance, but wasn't related to the athlete's gender or body mass index. ETAP was far less common in older athletes.

The most important factor in developing ETAP seems to be the timing of the pre-event meal. One study reported that consuming reconstituted fruit juices and beverages high in carbohydrate and osmolality (a measure of concentration), either just before or during exercise triggered the onset of a stitch, particularly in susceptible individuals. The symptoms didn't seem to be related to the amount of food eaten (gastric volume). See: Proper Hydration for Exercise

A more complicated explanation put forth by some researchers is that a side stitch is caused by stretching the ligaments that extend from the diaphragm to the internal organs, particularly the liver. The jarring motion of running while breathing in and out stretches these ligaments. Runners tend to exhale every two or four steps. Most people exhale as the left foot hits the ground, but some people exhale when the right foot hits the ground. It is the later group who seem more prone to get side stitches.

Exhaling when the right foot hits the ground causes greater forces on the liver (which is on the right side just below the rib cage). So just as the liver is dropping down the diaphragm raises for the exhalation. It is believed this repeated stretching leads to spasms in the diaphragm.

What to Do for a Side Stitch

If you develop a side stitch when running, stop running and place your hand into the right side of your belly and push up while inhaling and exhaling evenly. As you run or swim, try to take even, deep breaths. The stretched ligament theory would argue that shallow breathing tends to increase the risk of a stitch because the diaphragm is always slightly raised and never lowers far enough to allow the ligaments to relax. When this happens the diaphragm becomes stressed and a spasm or "stitch" is more likely.

Some other ways to alleviate the pain of a side stitch include:

Tips for Preventing a Side Stitch

  • Time your pre-race meal to allow it to digest prior to the event
  • Avoid drinking reconstituted fruit juices and beverages high in carbohydrate and osmolality before and during exercise
  • Stretching may relieve the pain of a stitch. Raise your right arm straight up and lean toward the left. Hold for 30 seconds, release, then stretch the other side.
  • Slow down your pace until pain lessens.
  • Massage or press on the area with pain. Bend forward to stretch the diaphragm and ease the pain.
  • * If you continue to experience pain, see your doctor.

Source

Eichner ER. Stitch in the side: causes, workup, and solutions. Curr Sports Med Rep2006;5:289–92.

Morton DP, Callister R. Factors influencing exercise-related transient abdominal pain. Medicine and Science in Sports and Exercise. 2002 May.

Morton DP, Callister R. Characteristics and etiology of exercise-related transient abdominal pain. Med Sci Sports Exerc2000;32:432–8.

Morton DP, Richards D, Callister R. Epidemlology of exercise-related transient abdominal pain at the Sydney City to Surf community run. J Sci Med Sport2005;8:152–62.

Morton DP, Aragon-Vargas LF, Callister R. Effect of ingested fluid composition on exercise-related transient abdominal pain. Int J Sport Nutr Exerc Metab2004;14:197–208.

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