Running Stitches: Causes, Prevention, and Relief Strategies

Why do you get stitches when running?

Stitches, scientifically known as Exercise-Induced Transient Abdominal Pain (ETAP), are a common and often sharp pain experienced in the side of the abdomen during physical activity, primarily due to irritation of the peritoneum or diaphragmatic stress, exacerbated by factors like breathing patterns, core instability, and recent food intake.

What Exactly is a "Stitch"?

A "stitch" is the colloquial term for Exercise-Induced Transient Abdominal Pain (ETAP). It's a localized pain, typically sharp or cramping, that occurs in the side of the abdomen during physical exertion. While most commonly associated with running, ETAP can also strike during other activities involving repetitive torso movement, such as swimming, cycling, or horseback riding. Despite its prevalence, the exact physiological mechanism behind ETAP remains a subject of ongoing research, with several leading theories attempting to explain its occurrence.

The Leading Theories Behind Exercise-Induced Transient Abdominal Pain (ETAP)

While no single theory fully explains all instances of ETAP, current exercise science points to a combination of factors, with some hypotheses holding more weight than others.

• Irritation of the Parietal Peritoneum: This is arguably the most widely accepted theory. The parietal peritoneum is a thin membrane lining the abdominal cavity and covering the underside of the diaphragm. During high-impact activities like running, the internal organs (stomach, intestines) can pull downwards, stretching the ligaments connecting them to the diaphragm and the parietal peritoneum. This repetitive friction and stretching, particularly when combined with shallow, upper-chest breathing, is thought to irritate these nerve-rich membranes, causing pain.
• Diaphragmatic Ischemia: The diaphragm, our primary respiratory muscle, works harder during exercise. Like any muscle, it requires an adequate blood supply. Some theories suggest that a stitch could be caused by temporary ischemia (reduced blood flow) to the diaphragm as blood is shunted to larger working muscles in the legs and arms. This lack of oxygen could lead to cramping pain.
• Ligamentous Stress: Closely related to peritoneal irritation, this theory posits that the pain arises from the stretching and pulling of ligaments that connect the internal organs (especially the stomach and spleen) to the diaphragm and the abdominal wall. Repetitive jarring motions, particularly after consuming food or drink, can increase the weight and movement of these organs, placing greater stress on their supporting ligaments.
• Gastrointestinal Distress: The timing and content of food and fluid intake before exercise are well-known risk factors. Consuming large meals, sugary drinks, or high-fat foods too close to a workout can lead to increased gas, fluid, or undigested food in the stomach and intestines. This can cause distension and increased pressure on the abdominal cavity, exacerbating peritoneal irritation or ligamentous stress.
• Core Instability and Poor Posture: A weak core musculature (abdominal and back muscles) can lead to poor posture during running, especially as fatigue sets in. Slouching or an exaggerated anterior pelvic tilt can alter the mechanics of the diaphragm and increase strain on the abdominal ligaments and peritoneum, making one more susceptible to stitches.
• Electrolyte Imbalance: While less supported as a primary cause, some researchers suggest that imbalances in electrolytes (such as sodium and potassium), which are crucial for muscle function, could contribute to muscle cramping, including potentially in the diaphragm. However, this is generally considered a secondary factor rather than a direct cause.

Common Characteristics and Risk Factors

Understanding the typical presentation of ETAP can help with both prevention and management.

• Location: Most commonly experienced on the right side of the upper abdomen, just below the ribs. However, it can occur on the left side or even centrally.
• Intensity: Ranges from a mild ache or sensation of pressure to a sharp, stabbing, or cramping pain.
• Activities: Predominantly associated with activities involving repetitive torso flexion/extension and high impact, such as running, swimming, and horse riding.
• Food and Fluid Intake: Eating a large meal, especially one high in fat or sugar, or drinking large volumes of fluid (especially hypertonic beverages) too close to exercise significantly increases risk.
• Age and Experience: Younger, less experienced athletes tend to report stitches more frequently. This may be due to underdeveloped core strength, less efficient breathing patterns, or less experience with pre-exercise fueling strategies.
• Breathing Patterns: Shallow, rapid breathing (chest breathing) rather than deep diaphragmatic breathing is often implicated, as it can limit diaphragmatic excursion and contribute to peritoneal irritation.

How to Prevent Stitches

Proactive strategies can significantly reduce the likelihood of experiencing ETAP.

• Optimize Pre-Exercise Nutrition:
  • Timing: Avoid large meals within 2-3 hours of exercise.
  • Content: Opt for easily digestible carbohydrates and limit high-fat, high-fiber, or very sugary foods immediately before a run.
  • Hydration: Hydrate adequately throughout the day. Avoid gulping large amounts of fluid just before or during exercise; instead, sip small amounts regularly.
• Master Diaphragmatic Breathing: Focus on deep belly breathing rather than shallow chest breathing. This allows for full expansion of the lungs and efficient movement of the diaphragm, which can help stabilize the abdominal organs and reduce peritoneal irritation. Practice this even when not exercising.
• Strengthen Your Core: A strong core musculature provides better support for the abdominal organs and promotes better posture during exercise. Incorporate exercises like planks, bird-dog, and Russian twists into your routine.
• Gradual Warm-up and Progression: Start your runs with a gentle warm-up to gradually increase heart rate and blood flow. Avoid sudden increases in intensity or mileage. Allow your body to adapt.
• Maintain Good Posture: Run with an upright posture, keeping your shoulders relaxed and back, and avoiding excessive slouching or arching of the back.
• Controlled Intensity: Listen to your body. If you're consistently getting stitches, consider reducing your intensity or duration until your body adapts.

What to Do When a Stitch Strikes

If a stitch catches you mid-run, these strategies can help alleviate the pain and allow you to continue, or at least recover comfortably.

• Slow Down or Stop: Reduce your pace to a walk or stop completely. This immediately lessens the jarring impact and reduces the demand on the diaphragm.
• Deep Breathing Techniques:
  • Pursed-Lip Breathing: Inhale deeply through your nose, then exhale slowly through pursed lips, focusing on emptying your lungs fully.
  • Forced Exhalation: When exhaling, purse your lips and push out all the air from your lungs, contracting your abdominal muscles.
  • Diaphragmatic Breathing: Focus on pushing your belly out as you inhale and pulling it in as you exhale.
• Stretch the Affected Area:
  • Side Bend: Raise the arm on the side opposite to the stitch over your head and bend towards the side with the stitch. Hold for 10-15 seconds. This stretches the intercostal muscles and the diaphragm.
  • Press and Release: Gently press your fingers into the painful area while exhaling, and release as you inhale.
• Change Breathing-Foot Strike Pattern: Some runners find relief by exhaling as the foot on the opposite side of the stitch hits the ground. For example, if the stitch is on your right, exhale when your left foot lands.
• Hydrate Slowly: If you're feeling dehydrated, take small sips of water rather than large gulps.

When to Seek Medical Advice

While stitches are usually benign and resolve on their own, there are instances where persistent or unusual abdominal pain warrants medical attention.

• Persistent Pain: If the pain does not resolve after stopping exercise and resting.
• Severe Pain: If the pain is unusually severe or debilitating.
• Associated Symptoms: If the pain is accompanied by other symptoms such as fever, nausea, vomiting, blood in stool, or changes in bowel habits.
• Pain at Rest: If you experience similar abdominal pain when not exercising.
• Recurrent and Unexplained: If you are consistently getting stitches despite implementing preventive measures, and they are significantly impacting your ability to exercise.

Understanding the multifactorial nature of stitches empowers runners and active individuals to implement effective strategies for prevention and management, ensuring a more comfortable and enjoyable exercise experience.