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The Informed Parent

The Dreaded Stitch

by Louis P. Theriot, M.D., F.A.A.P.
Published on Feb. 26, 2001

I was doing a sports physical for a 16-year-old cross-country runner one morning and was amazed at just how physically fit he was. He couldn’t have had more than 7% body fat, and his resting heart rate was 56 per minute. Anticipating that there were no other problems I was surprised when he said, “Oh, doctor, there is one thing. Often times when I run I get a “stitch” in my left side, and it really bothers me. What causes it, and what can I do for it?”

The nasty and dreaded STITCH….the bane of all runners. I, too, am a runner, having logged six marathons in my relatively short running career. I certainly have first hand experience with the stitch. It is a sharp, stabbing pain, almost paralyzing, that attacks most unexpectedly…invariably at the inopportune time. One can be running at a comfortable clip, without a care in the world, and totally “in the zone”, when it hits. Now comes a searing pain in your side that literally takes your breath away. As one tries to compensate for it you realize that your concentration is shattered, and, as a result, so is your stride. Your minute-per-mile pace has decreased dramatically and there’s nothing you can do to correct this. Finally, after a few blocks, it passes, almost as quickly as it started. Once again you are back in the groove.

The funny thing about the stitch is that it is well described in literature. Almost all runners have experienced it. But little is known as to the cause. A smattering of articles have been written describing the stitch in 1932, 1941, 1957, and 1985. Each article offers certain theories as to the cause of the stitch, but there have been no controlled studies.

The latest issue of RUNNER’S WORLD features an article about the stitch which referenced a report published by a team of researchers from New Zealand and was published in the JOURNAL OF MEDICINE AND SCIENCE IN SPORTS AND EXERCISE (1999). These researchers looked at the stitch in a controlled and scientific study, and drew some interesting and important conclusions.

It is widely accepted that the pain from the stitch comes from the diaphragm, a muscle that is positioned between the lungs and abdomen. When the diaphragm contracts, the lungs expand and we are able to take in a breath.

Two differing opinions were being offered as to the exact nature of the pain from a stitch. One theory stated that the pain was caused by a mechanical pulling of the diaphragm from ligaments within the abdomen that attached to the diaphragm. Hence, when we ran with a full stomach (especially if we had loaded up on fluids), the jostling caused the stomach to pull, or tug, on these ligaments, and as a result pulled on the diaphragm.

Another theory suggested that after eating or drinking a high-energy, high-carbohydrate sports bar or drink, blood was directed to the stomach to aid in digestion. Consequently, as the theory goes, this blood was diverted AWAY from the diaphragm, causing the diaphragm to “cramp”. Thus, it was this brief decrease in blood flow to the diaphragm that was the cause of the stitch.

Until this article from New Zealand was published, these two competing theories were bandied about, and both were credible. The team from New Zealand studied ten college athletes who were asked to run on a treadmill under controlled settings. The researchers recorded the stitches as to time of onset, severity and duration. They studied four groups: one that had no fluids, one that drank water, one that drank Exceed (a sports drink), and one that drank a hyper tonic solution of a non-absorbable sugar (lactose). Basically they found that the stitches occurred with similar frequency in each group that was given fluids before running, but not in the group that received no fluid. Their conclusion was that the pain resulted from the mechanical tugging on the diaphragm and NOT from a selective diversion of blood away from it.

They took it a step further. If their theory was correct, proof was needed to show that any maneuver supporting the stomach should reduce the frequency and intensity of the stitch. The athletes were directed to 1) contract the abdominal muscles, lean forward when the stitch started, push in on the sight of the pain 2) breathe at a faster and more shallow rate when the stitch began (this was to keep the lungs more expanded; thus, lowering the diaphragm) 3) breathe through pursed lips which would facilitate step 2, and 4) wear a broad belt around their waist and tighten it at the first sign of a stitch. All of these maneuvers greatly reduced the severity and frequency of stitches; thus, lending credence to their conclusion.

What advice can be given to runners who are inconvenienced with stitches? First of all, they should wait at least two hours after eating a meal before running. Secondly, when taking fluids before running, it is best to take small and frequent amounts. If a stitch should start tighten your abdominal muscles and lean forward a little while firmly pressing in the area that hurts. Regulate your breathing to a slower and shallower rate while breathing through pursed lips. Hopefully these tips will give some relief.

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