We have all been there. Everything is humming along just fine on our run or perhaps, even in a race... Then it creeps in like a very unwelcome stranger. Denial is followed by alarm leading you to the conclusion that you are now the victim of a side stitch. Not me (!) you think to yourself as the reality descends upon your abdomen. You review your fitness, diet and pre-run ritual in a nanosecond, which only further compounds your disbelief. At last it is accepted as a mysterious occurrence and the thoughts shift to management of this performance debilitating condition.
Side stitch, side ache, side cramp are all names for the same frustrating ailment most runners have been stricken with one time or another. What exactly is this condition and more importantly, how do we prevent it?
Referred to in research as Exercise-related Transient Abdominal Pain (ETAP), the side stitches occurrence has been reviewed in research on large samples of athletes via questionnaires. Interviews with athletes from various disciplines, including running, has shown us that ETAP appears to be a single condition manifested in the right or left lumbar regions of the abdomen. The sensation was described by these athletes as cramping, aching, pulling or even with greater severity in sharp stabbing pains. The research questionnaires have also illustrated that with these athletes that have more frequent training, ETAP is less often experienced. Additionally it was revealed that the groups most frequently afflicted with this condition were runners and horse back riders! Unfortunately, all current research has been able to provide is hypotheses as to what it may be by what ETAP is not. It is hypothesized that the Parietal Peritoneum (surrounds the abdomen just inside of the abdominal wall) and the innervations of this with branches of the phrenic nerve may play a significant role in the onset of the side stitch. Simply stated; the theory is that the irritation of a nerve stemming from the facet joints on the spine (the joints made by the little 'arms' coming off each section of vertebra) may receive friction from an unknown source triggering the pain we know as ETAP or a side stitch. This hypothesis was developed out of the coincidence with shoulder tip pain in many suffers of the side stitch. So what do we do with this knowledge?
What to do
Given this investigative research yielding no hard conclusions to the cause of the side stitch, what are we to do to prevent its onset? Before you consider voodoo or other supernatural solutions, consider the recommendations of researchers and other doctors in the field of sports medicine. The relationship with the spine has been associated with the possible explanation of the aggravation of the phrenic nerve. Researchers found that people with kyphosis (a curvature of the spine) and certain palpations of the facet joints of the spine would reproduce ETAP. Morton, a leading researching in the causes of ETAP, concluded by suggesting that: "These findings may indicate that efforts to optimize spinal integrity may be important in the management of ETAP." There we have it; Morton has provided a new insight into a potential relief from the side stitch.
From this I have accumulated the current and comprehensive strategies for avoiding ETAP.
a. diet before run
b. diaphragm breathing
c. abdominal exercises prior to running
d. pressure when you exhale
e. adjusting the foot that falls on exhale
f. lying down elevate hips
Diet before the run
Long it has been thought that the pre-run diet is the culprit of the side stitch and this may be a contributing factor. Recent research on the association of fluids with ETAP saw an increased occurrence of ETAP with the ingestion of a variety of hypertonic fluids (concentrated solution: energy drinks, soda, etc.) directly before intense bouts of running. Therefore we can conclude one would be wise to avoid concentrated drinks and foods 2-4 hours prior to running.
Diaphragm breathing
Yoga or belly breathing is a technique that all runners should learn. In the Lore of Running by Tim Noakes, MD he describes this as "breathing with predominately the diaphragm, rather than with the chest muscles. With belly breathing the chest hardly moves at all. Instead, the abdomen (stomach) appears to be doing all the work, for as you breathe in, the stomach goes up, and when you exhale, the stomach retracts." A simple exercise for practicing belly breathing is to lie on the back and place a heavy book on your stomach. Inhale such that the book will rise then exhale allowing the book to come back down in a gradual manner. This takes the movement of the upper chest out of the breathing cycle and creates long fluid cycles of breathing like those practiced in yoga. If we are to embrace the possibility that the aggravation of nerves in the thorax play a role in the side stitch, I feel this breathing technique is instrumental in avoiding ETAP.
Engaging the abdominal and back muscles prior to running
If we accept that the position and movement of the spine may play a role in the occurrence of ETAP, then it is logical that ETAP may be avoided by development of the abdominal and back muscles. To maintain tone in these muscles and engage them prior to running, one can incorporate both pelvic stability and circuit training routines in to the training program before running.
What to do when ETAP appears
If, despite our best efforts, ETAP rears its ugly head during a run there are three strategies for managing it.
Forced exhale
When the location of the stitch is identified, exhale so as to produce pressure in the area of the stitch. With some practice this can be performed while running. This is an effective strategy when ETAP is first felt.
Switch the foot fall when you exhale
Whether you realize it or not, you likely have a series of breathing patterns that you engage while running. These breathing patterns may have you exhaling on the same foot fall with each breathing cycle. On your next run observe how many breaths you take for each footfall and on which foot you exhale. If find yourself exhaling on the same foot each time, then attempt to adjust the foot that lands on the ground during your exhale the next time ETAP appears. This may shift the jarring motion of your contact with the ground, adjusting pressure in the spine enough to squelch ETAP.
If all else fails, stop running
But not forever. If the above techniques prove ineffective at minimizing the effects of ETAP to allow you to run. Lie with your back on the ground and elevate your hips. This technique suggested by Noakes allows for rapid relief of the side stitch and for differentiation of the stitch from other ailments such as chest pain from heart disease.
Literally a pain in the side, the side stitch can seriously compromise your running. Although the exact origins of this trouble are still a mystery to researchers, armed with a regular routine of yoga style breathing, core stability training, and avoidance techniques to offset ETAP on the run, all runners should be able to keep ETAP at bay.
Long may you run,
Sean Coster
Complete Running Programs offers lactate threshold performance tests for runners and cyclists of various abilities. For more information check out this information on lactate testing.
For more writings on training, motivation and philosophies in distance running visit Sean's blog at www.seancoster.org/runningportland or www.crpusa.com
Copyright 2008 Complete Running Programs - May not be used without permission of the author.
