The Stitch When Running: Causes, Symptoms, Prevention, and Relief

What is the stitch when running?

A "stitch," medically known as exercise-related transient abdominal pain (ETAP), is a common, sharp pain felt in the side of the abdomen, typically below the rib cage, that frequently affects runners and other athletes during physical activity.

Understanding the "Stitch"

Exercise-related transient abdominal pain (ETAP), universally recognized as "the stitch," is a pervasive complaint among athletes, particularly runners. While its exact physiological mechanism remains a subject of ongoing research, ETAP manifests as a localized, sharp, stabbing, or cramping pain, most frequently experienced on the right side of the abdomen, just beneath the lower ribs. It can range in intensity from a mild ache to a debilitating cramp that forces cessation of activity. Despite its common occurrence, ETAP is generally benign and resolves shortly after exercise stops or intensity is reduced.

Proposed Causes and Contributing Factors

The multifactorial nature of ETAP means that no single cause has been definitively identified. However, several compelling theories, often acting in concert, are supported by current understanding of human physiology and biomechanics during exercise:

• Diaphragmatic Ischemia: One leading theory suggests that a stitch arises from reduced blood flow (ischemia) to the diaphragm, the primary muscle of respiration. During vigorous exercise, blood is shunted away from less critical organs and muscles (like the diaphragm) to the working skeletal muscles. This relative lack of oxygen to the diaphragm, especially when breathing patterns are shallow and rapid, could lead to cramping pain.
• Ligament Stress: The internal organs within the abdominal cavity, such as the stomach, spleen, and colon, are suspended by ligaments that connect them to the diaphragm and abdominal wall. Rapid, repetitive movements like running can cause these organs to pull downwards on their supporting ligaments. This repetitive tugging, particularly on the ligaments connecting the stomach and spleen to the diaphragm (gastrosplenic and gastrophrenic ligaments), is hypothesized to irritate the parietal peritoneum—the membrane lining the abdominal cavity—leading to pain.
• Peritoneal Irritation: The parietal peritoneum is highly innervated with pain receptors. Shearing forces and friction between the visceral organs and this sensitive lining during high-impact activities are thought to directly irritate the peritoneum, triggering the characteristic pain.
• Dietary Factors: What and when you eat can significantly influence the likelihood of a stitch. Consuming large meals, foods high in fat or fiber, or sugary beverages too close to exercise can delay gastric emptying and increase the volume of food and fluid in the stomach and intestines. This increased mass can exert more downward pull on the ligaments and potentially increase irritation of the peritoneum. Hypertonic drinks (those with a higher concentration of solutes than body fluids) can also draw fluid into the intestines, contributing to discomfort.
• Hydration Status: Both dehydration and over-hydration with hypotonic solutions (e.g., plain water in large quantities) can disrupt electrolyte balance and lead to fluid shifts in the body, potentially contributing to muscle cramping, including in the diaphragm.
• Inadequate Warm-up: Starting high-intensity exercise without a proper warm-up can shock the respiratory and circulatory systems, potentially leading to inefficient blood flow and unprepared muscles, including the diaphragm.
• Poor Running Form and Breathing: Shallow, thoracic (chest) breathing, as opposed to deep diaphragmatic breathing, can lead to over-reliance on accessory breathing muscles and less efficient oxygen exchange. Additionally, poor posture or a rigid torso can exacerbate the mechanical stresses on abdominal ligaments.

Symptoms and Characteristics

Recognizing the symptoms of a stitch is straightforward:

• Location: Primarily felt in the side of the abdomen, most commonly the right side, just under the rib cage. Less frequently, it can occur on the left side or centrally.
• Nature of Pain: Typically described as sharp, stabbing, cramping, or aching.
• Onset: Usually occurs during sustained aerobic activity, especially running, swimming, or cycling.
• Intensity: Can range from mild discomfort to severe, debilitating pain that forces a stop to activity.
• Resolution: Generally resolves quickly with rest or reduction in exercise intensity.

How to Prevent a Stitch

While not entirely preventable for everyone, several strategies can significantly reduce the likelihood of experiencing a stitch:

• Warm-up Properly: Begin your run with 5-10 minutes of light aerobic activity (e.g., brisk walking, slow jogging) followed by dynamic stretches. This prepares your respiratory system and muscles for the upcoming effort.
• Manage Pre-Run Nutrition and Hydration:
  • Timing Meals: Allow at least 2-4 hours after a large meal before exercising. For smaller snacks, 30-60 minutes may suffice.
  • Food Choices: Avoid high-fat, high-fiber, or very sugary foods and drinks immediately before a run, as these can take longer to digest.
  • Hydration: Stay well-hydrated throughout the day, but avoid gulping large volumes of water or sugary drinks right before or during your run. Sip small amounts of water or an electrolyte solution if needed.
• Focus on Breathing Techniques:
  • Diaphragmatic Breathing: Practice breathing deeply from your diaphragm (belly breathing) rather than shallowly from your chest. This ensures more efficient oxygen exchange and strengthens the diaphragm.
  • Rhythmic Breathing: Coordinate your breathing with your footfalls. Many runners find exhaling when their non-dominant foot strikes the ground (e.g., exhaling on every 2nd or 4th step) helps stabilize the torso and reduce stress on abdominal ligaments.
• Improve Core Strength: A strong core (abdominal and lower back muscles) helps stabilize the trunk during running, reducing the mechanical stress on internal organs and their supporting ligaments. Incorporate exercises like planks, bird-dogs, and Russian twists into your routine.
• Gradual Progression: Avoid sudden increases in running intensity or duration. Allow your body to adapt by progressively increasing your mileage and speed over time.

What to Do When a Stitch Occurs

If a stitch strikes during your run, these immediate actions can help alleviate the pain:

• Slow Down or Stop: Reduce your pace to a walk or stop completely. This reduces the mechanical stress and allows your body to recover.
• Deep Diaphragmatic Breathing: Focus on taking slow, deep breaths, pushing your belly out as you inhale and drawing it in as you exhale. This can help stretch the diaphragm and improve blood flow.
• Apply Pressure: Gently but firmly press your fingers into the painful area. This can help relax the localized muscle spasm or alleviate peritoneal irritation.
• Stretch:
  • Side Bend: While standing or walking slowly, raise the arm on the same side as the stitch overhead and lean away from the pain. For example, if the stitch is on your right side, raise your right arm and bend to the left. Hold for 10-15 seconds.
  • Arms Overhead: Interlace your fingers and raise your arms straight overhead, stretching your torso.
  • Forward Bend: If possible, bend forward at the waist while taking deep breaths.

When to Seek Medical Attention

While a stitch is typically benign, persistent or unusual abdominal pain warrants medical evaluation. Consult a healthcare professional if:

• The pain is severe, unrelated to exercise, or does not resolve with rest.
• The pain is accompanied by other concerning symptoms such as nausea, vomiting, fever, chills, or changes in bowel habits.
• The pain is in a different location than a typical stitch (e.g., upper abdomen, chest, or radiating to the back).
• You experience recurrent stitches despite implementing preventive strategies.

Conclusion

The "stitch" or ETAP is a common, often frustrating, but generally harmless phenomenon experienced by runners. While its precise cause remains elusive, a combination of diaphragmatic strain, ligamentous stress, and peritoneal irritation, often exacerbated by dietary choices and inefficient breathing, is largely implicated. By understanding these potential mechanisms and adopting proactive strategies such as proper warm-up, strategic nutrition, optimized hydration, and mindful breathing techniques, athletes can significantly reduce the incidence and severity of the stitch, ensuring a more comfortable and productive running experience.