Here is an all-too-common scenario: You go out to do a little jogging, and once again you’re grabbed by a stitch in your side. You try running through it but it takes you out of your rhythm and you end up either slowing down or holding your side, hoping the pain will dissipate. The frustrating thing is that it always seems to happen about the same distance into your run. You have tried changing the time of day you run, the terrain you run on and the amount of liquid you drank beforehand.
What is this mysterious phenomenon often referred to as a “side stitch,” and what can be done to alleviate it?
First, the technical name for a side stitch is “exercise related transient abdominal pain,” or ETAP. Somehow, having a technical name associated with something always seems to validate its annoyance. An article in Medicine and Science in Sports and Exercise, Volume 32, 2000, found that out of 965 athletes studied, 75% of swimmers, 69% of runners, 62% of horseback riders, 52% of aerobics participants, 47% of basketball players and 32% of cyclists were afflicted by ETAP over the course of a year of training.
The symptoms of the side stitch were generally an intense stabbing pain under the lower part of the rib cage. In 65%-70% of the cases, the stitch occurred on the right side. In 14% of the cases, the pain was located at the bottom tip of the shoulder blade. The location of the side stitch, at a large muscle called the respiratory diaphragm, gives some clues about the origin of the pain.
A dome-shaped muscle, the diaphragm separates your chest from your abdomen. The diaphragm attaches in front to the zyphoid process, which is the little bone at the very tip of the sternum or breastbone between the left and right lower rib cage. It also attaches on the sides of the bottom 6 ribs and attaches in back to the upper vertebrae of your low back. This large muscle is the main muscle for breathing. The muscle contracts when you inhale and the dome descends, drawing air into the lungs. As it descends, it also pushes downward on the stomach and liver, pushing them forward. As you exhale, the diaphragm relaxes back up, enabling your lungs to expel air.
The most widely accepted theory in the cause of side stitches is that they result from a spasm of the diaphragm. This may occur during impact activities, like running, through this mechanism: As you exhale, the diaphragm relaxes upward, but if you land on the left or right foot, the organs forcefully descend on that side, causing a tension between the diaphragm and the ligaments that hold the organs in place.
Since the liver, which is located on the right side, is a solid heavy organ, it has been speculated that the tension is greater on the right side, explaining why the stitches are more common on the right. With this is mind, one suggestion to decrease side stitches is to check if you always exhale while landing on the same foot. If, for example you start developing a side stitch on the right side, and you notice that you always exhale when your right foot hits the ground, try switching your breathing pattern to exhale when your left foot hits the ground.
Running on soft surfaces, which lessen impact, may also help. You can strengthen and stretch your diaphragm by performing diaphragmatic or belly breathing. Since a deep diaphragmatic breath displaces your organs slightly forward, you can monitor your success in belly breathing by placing your hand on your stomach area just under your ribs and allowing your stomach to push out as you breathe in. Then, as you breathe out, your stomach should go back in. This is opposite of how people often forcefully breathe when they raise their chest and pull their stomach in with an inhalation. Diaphragmatic breathing is not only an excellent exercise for side stitches, it is also very helpful for general stress reduction and to increase lung capacity.
If you find diaphragmatic breathing difficult and you have no known lung issues, you may have some postural imbalances, which can hinder diaphragmatic movement. Often, manual physical therapy can help this situation.
Lastly, minimize large amounts of food and water intake immediately before any strenuous activity because the additional weight in the stomach may pull on the diaphragm. You should, however, be well hydrated before any exercise.
With a little awareness, you can often get to the root of those pesky side stitches.