Multisport: Beating the Side Stitch Witch

By Kirk Nordgren, CTS Expert Coach

Ask around at most any triathlon, running race or cycling event and you’ll likely hear tales of debilitating side-stitches that ruin otherwise amazing performances. And chances are, if you’re active in endurance sports, you’ve experienced these painful side-aches yourself. But if you’re frustrated by an inability to stop this side pain from hijacking your performances, don’t be too hard on yourself. Twenty-first century scientists can’t nail down the cause of side-stitches either.

Root of the Problem
While researchers are quick to point out that the cause of this Exercise-Related Transient Abdominal Pain (ETAP), as it is now referred to, is “poorly understood,” that hasn’t kept them from suggesting a plethora of theories. Many suggested causes of ETAP make great sense, but none have been definitively proven.

Traditionally, one of the most popular theories explains side-aches as the result of jarred digestive organs painfully pulling down on the ligaments supporting them. Another common theory blames the fact that directing blood flow to working muscles leaves the diaphragm in a cramp-inducing state of poor oxygenation. Both sound plausible right? But athletes in the jolt-free sport of swimming still get side-aches, and equestrians, while not typically associated with excess blood flow to working muscles, commonly experience pain as well. And these examples just touch on the holes existing in both suppositions.

Some newer theories also exist, like excess friction in the lining of the abdomen and impinged spinal nerves that radiate pain to the site of the side-stitch. These explanations also provide viable causes for the pain, but at this point, they haven’t been proven either.

Relief from Side-Stitch Pain
In spite of scientists’ failure to diagnose the specific cause, there are general methods that can usually alleviate side pain when it strikes. The first solution is to stop or reduce the intensity of your effort. And while slowing down in a race probably isn’t your first choice, it does effectively eliminate the pain, at least temporarily. Other methods that often work are variations of stretching the abdomen and applying pressure to the site of pain, usually on the right side near the bottom of the rib cage. Essentially, these techniques stem from the traditional theories of side-stitch causes and are aimed at either stretching the diaphragm or lifting the liver to relieve pressure on its supporting connective tissue. Belly breathing, or deep inhalations while pushing out the stomach, and breathing through pursed lips are also suggested solutions that accomplish similar goals of relieving cramping in the diaphragm and reducing organ pressure on ligaments. In most cases these solutions do eliminate side-ache symptoms. But in extreme cases involving reoccurring pain, athletes have undergone surgery to diagnose and eventually correct ETAP problems.

Prior Prevention
Since we don’t know what causes side-stitches and only have semi-effective solutions for when they do strike, it makes sense that there are not concrete measures to prevent side pain in the first place. We do know around 1/3 of runners experience ETAP during intense exercise and that a lower number of cyclists, swimmers, and team-sport athletes also deal with side-stitches on a regular basis. Some studies have shown that athletes with better fitness experience ETAP symptoms less frequently, but when side-aches do occur, the pain is similar to what novice athletes experience. Research additionally indicates that gender and body weight don’t affect side-ache prevalence, but eating too soon before exercise does lead to an increased likelihood of ETAP. Younger athletes also report more cases of side-aches then their older counterparts.

Since you can’t change your age, and you probably don’t want to switch sports, your best bets for preventing side-stitches from occurring are exercising without excess food in your stomach (by adjusting the amount of food you eat or eating further before your workout or competition), breathing deeply and evenly throughout your workout, and gradually increasing your sport-specific and core fitness. The more you participate in your favorite sport, the less fatigued your inspiration muscles will be while handling the effort, and there is anecdotal evidence that a strong core reduces the occurrence of sides-stitches.

Until the definitive cause (or causes) of side-stitches are determined, we won’t have a conclusive solution to the problem. But in the meantime, these remedies and preventions will allow you to perform side-pain free through your next workout or competition.

References

Dimeo, F C., J Peters, and H Guderian. "Adbominal Pain in Long Distance Runners: Case Report and Analysis of the Literature." British Journal of Sports Medicine 38 (2004): 24-26.
Morton, Darren P. "Exercise Related Transient Abdonimal Pain." British Journal of Sports Medicine 37 (2003): 287-88.
Morton, Darren P. "Factors Influencing Exercise Related Transient Abdominal Pain." Medicine and Science in Sports and Exercise 34.5 (2002): 745.
Morton, D P., and T Aune. "Runner's Stitch and the Thoracic Spine." British Journal of Sports Medicine 38.2 (2004): 240.

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