I am a sub-Junior Wimbledon tennis player, and for several years have been plagued by stitches. Are they something I just have to learn to live with, or is there anything I can do to get shot of them?
(Jim Bledsoe replies:)
You may not know it, but you have something in common with camel riders and basketball players. All of you are likely to suffer from 'exercise-related transient abdominal pains' (ETAP), which are more popularly known as a 'side stitches'. Nor do you have exclusive rights to this unpleasant affliction: soccer, and rugby players, swimmers, horse riders, runners, aerobics participants, and even motorcyclists are at high risk of developing stitches.
Stitches can force even the toughest athlete to stop a workout or drop out of a competition, but exercise scientists have been at a bit of a loss to understand what causes stitches to occur - and how to prevent them. One popular view is that stitches occur when unwise athletes try
to exercise strenuously too soon after gulping down food
or fluid. Although this theory makes a certain amount of sense and corresponds with many athletes' real-life experiences with stitches, the reasoning falls apart on close inspection. After all, competitive cyclists have a low frequency of stitch problems, even though they often exercise very intensely while wolfing down large quantities of food and liquid. Likewise, cross-country skiers are relatively immune to stitching, despite the fact that they swallow large quantities of food and drink prior to long-distance treks.
Pain in the shoulder blade
To get a better purchase on how and why stitches occur, scientists recently studied 965 athletes is six different sports (running, swimming, cycling, aerobics, basketball, and horse riding). Over the course of a year of training
and competition, 75% of swimmers had trouble with stitches, 69% of runners were afflicted, 62% of horse
riders had ETAP, 52% of aerobics participants suffered,
47% of basketball players did so, and 32% of cyclists were affected ('Characteristics and Etiology of Exercise-Related Transient Abdominal Pain,' Medicine and Science in Sports and Exercise, Volume 32 (2), pp. 432-438, 2000).
A very interesting aspect of this research was that 14%
of the athletes indicated that they experienced shoulder-
tip pain (i. e., discomfort at the bottom tip of one of the shoulder blades). This is an important clue for understanding the origin of stitches, because the tip of the shoulder blade is a 'referred site' of pain for the diaphragm - the key muscle of breathing. In other words, pain which seems to emanate from the tip of the shoulder blade may actually have its source in the dome of muscle which separates the thoracic and abdominal cavities - the diaphragm. Similarly, much of the abdominally experienced pain which we call a stitch may originate in the diaphragm as well.
Why would the diaphragm call out in anguish (i. e., create a stitch) as we carry out our favourite sporting activities? When we ride a camel across the desert (or run across the soccer pitch, carry out an aerobics workout, shoot baskets, or pursue a cricket ball), the internal organs in our abdominal cavities bounce up and down. Those internal organs - like the liver, stomach, and spleen - aren't exactly riveted in place. Instead, they're supported by flimsy ligaments hanging down from the diaphragm, and with each bounce, the organs pull downward on the diaphragm.
That's no problem if the diaphragm is moving downward, too (as when an athlete is breathing in air). When the bouncing occurs as the diaphragm is moving up (when an athlete is breathing out), on the other hand, it creates a lot of strain on that ample muscle. As Swedish exercise physiologist Finn Rost has pointed out, the tension created can probably force the diaphragm into a spasm, creating all kinds of pain and discomfort ('Stitch', New Zealand Medical Journal, vol. 99, p. 469, 1986). Frequently, the pain is intense enough to force an athlete to stop exercising; unfortunately - as mentioned above - stitches are not rare occurrences.
Is it a stitch... or a heart attack?
How can you keep stitches from striking? Well, bear in mind that stitches appear on the right side of the abdomen about 65 to 70% of the time. This shouldn't be too surprising; as you know, your liver is located on the right side of your body and is by far the heaviest organ in your abdominal cavity. It therefore creates the greatest downward force on your diaphragm, far greater than the relatively weak forces produced by the stomach and spleen, for example, both of which are located on your left side. There is also ample opportunity for friction to occur between the diaphragm and liver, since the liver tends to 'mound up' on the upper right side of the abdominal cavity.
While the pain of a stitch is usually felt just below the ribs, some athletes report a stabbing sensation at the tip of the shoulder blade (as mentioned) or even as high as the shoulder. This latter type of pain can convince some athletes that they are having heart attacks, but a quick way to tell the difference between a stitch and an infarction is to lie down on your back with your hips and legs elevated (a move which takes pressure off the diaphragm). If you have a stitch, the pain should be relieved almost immediately; if you are having a heart attack, the pain will stay.
What to do about it
Fortunately, there are sensible steps to take both to prevent stitches from happening and to get rid of them once they occur. If a stitch grips you during activity, one quick remedy is simply to change your breathing pattern. In athletes whose sports involve running, breathing and stitches are linked together because breathing and stepping patterns are coordinated. Specifically, most athletes breathe out - over and over again - on the same leg. An individual athlete might always exhale only when his/her right foot is on the ground, for example ('Running and Breathing in Mammals', Science, vol. 219, pp. 251-256, 1983).
Let's look at a specific example of this. In endurance runners, one of the most popular striding-breathing linkages is 2:1. That simply means that two complete strides are taken for each breathing cycle (a breathing cycle consists of an inhalation and an exhalation). To calculate strides, you count only when the left or right foot hits the ground, not both. So, a 2:1 striding-breathing linkage would mean that a runner might exhale when his right foot hits the ground and inhale the next time the right foot strikes terra firma (that's two strides and one breathing cycle). This pattern will be repeated over and over again, so the runner will exhale only when the right foot strikes the ground.
That can lead to problems, because the diaphragm springs upward when we breathe out, increasing the tension on those flimsy ligaments we mentioned earlier, the ones holding the liver, stomach, and spleen like fishes on lines. If we always breathe out when our right foot hits the ground, that means the jolting action of the foot will quickly lift the liver upward, but the massive organ will then fall back suddenly while the diaphragm is in its up position. That creates an immense pressure on the diaphragm, which can then go into the kind of painful spasm which makes you wonder why the athlete next to you has slipped a carving knife into your side.
The dictate to follow
Fortunately, this breathing-striding-stitching linkage permits the formulation of a solid rule of exercise, a dictate which can rescue a race or workout from imminent disaster. Here's the rule:
l when a stitch strikes, change your breathing pattern so that the leg on the opposite side of the body from the stitch is the one that hits the ground whenever you breathe out.
Implementation of this simple rule can frequently relieve the intense pain of stitching almost immediately. Strangely enough, loud grunting as you breathe out can also be helpful, possibly because the strenuous protestations force the diaphragm to move out of its hyper-tight position (both the rule and the enjoiner to grunt are suggested by Tim Noakes in his fine book, The Lore of Running, Leisure Press, p. 391, Champaign, Illinois, 1991).
Four ways to prevent stitching
To keep stitches from striking in the first place, use the following four techniques:
(1) Unkink and strengthen your diaphragm. As you make your diaphragm stronger and more flexible, you'll reduce your risk of stitching, since the diaphragm will be better able to both support and move with the liver's violent tuggings. To fortify your diaphragm, Noakes recommends 'bell breathing', in which the abdominal area moves out dramatically with each inspiration and plunges in on every expiration, while the chest moves relatively little. To learn how to belly breathe, lie on your back on the floor and place a set of heavy books on your stomach. Breathe so that the books rise significantly as you breathe in and move downward as you breathe out. Repeat this belly-out, belly-in action when you are standing (without the heavy books, of course). Concentrate on repeating a similar abdominal action whenever you run during your sporting activity. As Noakes points out, this is not necessarily easy to learn; it can require many months for some athletes to develop good belly breathing (op. cit, pp. 193-195).
2) Strengthen your abdominal muscles. It's not exactly clear why this helps, but athletes with strong abdominal muscles seem to have a much lower risk of stitching. Perhaps increased abdominal-muscle tone helps to support internal organs and keeps them from jostling up and down quite as much. To strengthen your stomach muscles, lie down on your back with your hips and knees flexed and the soles of your feet on the floor, and then simply raise your head and upper chest repeatedly by about 30 degrees or more. Don't just flop back down after each raise; lower yourself gradually so that you will get nice, controlled, eccentric contractions of your abdominal muscles.
(3) If you are stitch-prone, don't take in any food or water for a couple of hours before you exercise. Eating or drinking shortly before exercising does increase the chances of stitch, possibly because the increased weight of a full stomach creates a stronger downward tug on the diaphragm as the stomach is jolted with each footstrike (cyclists usually don't have to worry about this rule - unless they are riding on a bumpy road; uneven roads often give their internal organs enough jostling to increase the chances of stitching). Note, though, that if you are going to be exercising continuously for more than an hour, you will want to take in some sports drink 10 minutes before the beginning of your exertion (to begin moving carbohydrate toward your muscles). In this case, you'll have to rely on tips 1, 2, and 4 to keep you out of stitch trouble.
(4) Relax! Stitches occur much more frequently in tense athletes. Before a competition or strenuous workout, spend some time taking deep breaths, and make sure your stomach is moving out expansively as you breathe in. Continue to breathe deeply until your diaphragm feels loose and free. Visualise yourself exercising with non-tightened abdominal muscles and relaxed but forceful breathing. As your competition begins, monitor your abdominal area for tightness and concentrate on maintaining good belly breathing.
And another problem
The four steps outlined above should go a long way toward reducing your risk of stitches, but we should mention one other aspect of the stitch problem. In 1982, a British physician named A. M. W. Porter developed a severe case of diarrhoea as he ran his first marathon. This was hardly an earth-shaking event, but the bowel troubles did cause Porter to reevaluate what was happening to his internal organs during running. Porter eventually decided that his caecum, which is the first part of the large intestine, had been rubbing against the inside of his abdominal wall. This friction might have produced an inflammation of the caecum, precipitating the diarrhoea and causing stitch-like pain in the right side of the abdomen (where the caecum is located). Porter coined the term 'caecal slap' to describe the knocking of the caecum against the abdominal wall ('Marathon Running and the Caecal Slap Syndrome,' British Journal of Sports Medicine, vol. 16, p. 178, 1982).
Caecal slap may indeed be an additional source of stitches. Fortunately, the way to keep it from ruining your workout or competition is clear: breathe out when your left foot hits the ground, not during right footstrikes. If you breathe out when your right foot hits the ground, your abdominal wall will move inward at the same time that your caecum, which is also on the right side of the body, is jostled, maximising friction between the two body parts. In general, being a 'left-footed exhaler' is a good idea if you know that you are a right-sided stitcher. Left-footed exhalations should also help to minimise the tension between liver and diaphragm which we described earlier.
And yet another
To make things a little more complicated, Tim Noakes contends that any part of the upper colon can actually slap against the bottom of the diaphragm, potentially producing digestive upset and the pain of a stitch (Lore of Running, p. 391). Fortunately, if you just remember to shift your exhalations to a different foot, you can probably minimise problems with this slap-happy-colon type of stitch, too.
It's possible, too, that marathon-type endurance runners could reduce the risk of developing a colon-slapping stitch (and perhaps stitches of all kinds) by deliberately changing their breathing patterns every now and then. The idea would be to use left-footed exhaling most of the time but to shift over to right-footed exhalations for five- to 10-minute periods during races and long workouts. This should lead to more equal 'bruising rates' on each side of the colon and diaphragm and might help thwart stitches by reducing the possibility of a significant irritation on one side of the body.
Other things to consider
There are many other factors which increase the risk of stitching. Fast running is more likely to start a stitch than slow, because fast running features higher ground-reaction forces and more dramatic and quicker movements of the diaphragm. Running on rough, hard ground also raises the risk of stitch, compared with pacing along on even, softer surfaces.
Being out of condition can dramatically hike your risk of stitching, as can starting out too fast in a competition. For some reason, stitches occur more frequently on cool days than during warm weather. Stitches are also very likely to show up when you are running downhill; downhill running increases the jolting forces inside the abdominal cavity and also pushes your internal organs forward, forcing the caecum into contact with the abdominal wall. For these reasons, it's important to exhale only when your left foot hits the ground whenever you run downhill.
Stitches can be prevented by following the simple rules outlined above. If a stitch does happen to strike you suddenly, change your exhalation foot immediately. If this doesn't help, lie down on your back with your hips and legs elevated. Since stitches generally strike on the right side of the abdomen, learning to become a left-footed exhaler can go a long way toward eliminating the problem (if, however, you have a history of left-sided stitches, try to work on breathing out during right footstrikes). Avoidance of chest-only breathing and an overly tight diaphragm is also extremely important; your diaphragm should feel like a large flap of rubber, and your stomach should move outward like a balloon when you inhale. If you strengthen and relax your diaphragm, breathe properly, fortify your abdominal muscles, warm up
thoroughly prior to workouts and competitions, and refrain from dining and drinking more than you can handle before you exercise, it's very unlikely that stitches will limit your training or performances.