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Side stitches – we've all had one (or 100), but they remain one of the most mysterious – and misunderstood – pains in sport. Here's an explainer that will help you avoid and treat that thorn in the athlete's side.
Everyone's had a stitch, but not many people know exactly what they are. It's not a cramp and it's not a diaphragm disorder, either. A study (Morton and Callister 1999) proved that during a stitch there is none of the intense electrophysiological activity that characterises a cramp, nor is there a change in lung performance before and during a stitch, which rules out a diaphragm issue.
Many athletes get their stitch low in the tummy, others right up under the ribs, while some even get it in the shoulder, but they all originate from the same place – the peritoneum. This is a two-layered membrane that separates the abdominal muscles from your guts. There's the visceral peritoneum and the parietal peritoneum, which is the layer closest to the muscles. In between these layers there's lubricating fluid, but sometimes the lube isn't enough to stop irritation, resulting in a stitch. The lube can run dry due to the reduction of blood flow to the abdomen or from increased movement of the diaphragm from exercise, or there could be friction from an organ such as the stomach being distended after a meal. Stitches can occur in the shoulder because the parietal peritoneum is supplied by the phrenic nerve, which refers pain to the shoulder tip region.
You're more likely to have a stitch if you're unfit or new to an activity, exercising very hard, dehydrated or have a full stomach. Stitches are common among newbie runners because the abdomen is not used to all the jostling (conversely, lack of torso movement is why stitches are a lot less common in cycling) or because of fast, shallow breathing. The ability to breath deeper and slower puts more pressure down through the peritoneum to stop organs jostling and creating friction. Most people find that stitches go away as fitness increases.
Here's the breakdown from a survey of 965 Australian athletes who had a stitch in the previous year:
Tennis fans might have noticed players sipping from two bottles, one with an isotonic or soft drink, and another with water in it. They know the score on stitches.
A study in Medicine and Science in Sports and Exercise showed that drinks high in sugar and/or salts are evil stitch-pedlars, whether drunk before or during activity. High-carbohydrate fluids pass slowly through the stomach, and it appears that high-carb drinks (e.g. fruit juice, soft drinks) can cause stitches more often and at a greater severity by both distending (bloating) the stomach and by slowing fluid absorption in the intestine.
Other foods and drinks that also take the blame are fatty foods, carbonated drinks, cold drinks, apples, bananas and chocolate.
Since the 1940s, it's been observed that people with increased curvature of the upper and lower spine seemed more likely to report pain from stitches. A study in 2001 (Morton and Aune) confirmed that the degree of kyphosis (forward rounding of the mid- to upper back) showed a direct and overwhelming relationship with stitch frequency. In people with scoliosis (abnormal sideways curvature of the spine), the level of their stitch pain was worth with a greater degree of spine curvature. The extent of lordosis (inward curvature of the lumbar and cervical spine) had no bearing on stitch frequency or severity.
This study indicated that it's likely spinal nerves that come from the thoracic (chest) region to innervate the abdominal area are involved in stitches.
There are lots of anecdotal remedies for a stitch, none appear to be scientifically proven. However, given what I've explained about how stitches work, here are two methods that will at least relieve some of the effects of the stitch (e.g. hard to breath because of pain around diaphragm).
Slow down and drop your intensity, bend forward 45-90° while squeezing firmly just under the bottom rib and half way across between the side and the belly button (thumb to the rear and fingers at the front) and breathe deeply. Slowly stand upright again. The pain will ease more quickly if you can stop exercise to do this or when you lie down with the hips elevated.
This is one for runners only and works on the idea of synchronising the movement of your organs with your diaphragm via your breathing. Slow your pace and exhale as the foot on the opposite side of the stitch strikes the ground (not every foot strike, though). When you exhale, really push down hard with the muscles of your diaphragm. The impact combined with the bracing of the diaphragm will help release the tension causing the stitch.