Recently I saw the mom of a patient of mine while working out at the gym. She was concerned about her 6th grade son who had just joined the school track team.

 

Several times the past week he reported a sharp pain in his side while running just below the ribcage. It was enough to make him stop. She was worried and asked if she should have him seen. Talking more about his symptoms I assured her it sounded like he was having a runners stitch. Discussing this in detail I told her that if his symptoms were in any way NOT consistent with a stitch, I needed to see him.
 

Anyone who has done any type of running has probably had a stitch at least a few times in their career. It is not just reported in runners…swimmers, motocross riders and horseback riders have been afflicted with this benign but bothersome condition. A stitch is an intense, sharp stabbing pain that occurs just below the ribcage on the right or left side and occurs during vigorous activity. The medical name for a stitch is exercise related transient abdominal pain (ETAP). While it has been reported throughout literature for centuries there is still no consensus of opinion as to its actual cause. Although there are a couple of popular theories.

 

One theory is that the weight of the inter-abdominal organs (stomach, liver and spleen) pulls on the ligaments that connect to the diaphragm causing a strain from the internal jostling while running.

This has been disputed because ETAP occurs in swimmers where there is no such “jostling”.
 

Another theory is that a stitch is caused by ischemia, or lack of oxygen to the diaphragm during vigorous exercise.

However, stitches are seen in horseback riders and motocross riders where there is low respiratory demand when compared to a runner or a swimmer. Further evidence against this theory was shown in the lab whereby fluoroscopy studies during an ETAP event showed completely normal function of the diaphragm with free and unrestricted movement.
 

A more accepted explanation for ETAP has to do with friction that occurs between the peritoneum.

 

The peritoneum is a lining within the abdomen. It has two layers. The outer layer lines the abdominal cavity and also covers the diaphragm. The inner layer covers the abdominal organs. There is typically a tiny space between the two layers allowing for natural lubrication. This theory is that pressure from the stomach decreases the natural space between the two layers. This causes friction which then causes the pain of a stitch.

While the exact cause of a stitch is not yet known, certain conditions trigger it. Eating a large meal before running is a common cause. The theory is that a full stomach can bring about irritation of the peritoneum. Drinking sugary beverages before running has also been implicated. This may be due to the fact it delays gastric emptying which in turn causes the stomach to be more full and irritated. While it is important to “hydrate” before running, it is recommended to take small but frequent sips of water rather than chugging a large volume which fills the stomach. It has been reported that stitches are more likely to occur in “chest breathers” than in “belly breathers” .Therefore it is recommended to try to belly breathe while running which puts the diaphragm through more of a full range of motion.
 

Stitches are benign and in no way dangerous.

 

If a person gets one while running, it is safe to continue running through it. Some potentially helpful tips are to take a deep breath in and hold it for 2-3 seconds. Tighten the abdominal muscles and then exhale through pursed lips. Putting direct pressure with your hand on the site of the stitch, pressing in and upward, then bending from the waist to the opposite side may be helpful. Changing the foot strike-breathing pattern may also help. If the stitch is on the right side we typically exhale when the right foot strikes the ground. Try exhaling when the left foot strikes the ground or vice versa.
 

Other things that are helpful to prevent stitches are to take the time to properly warm up before running. It is also important to strengthen the core muscles. One should dress appropriately if running in the cold. As stated above, stitches are benign and not of any concern. BUT they should only occur while running and should resolve within minutes after stopping the exercise. If this is not the case the athlete should see their doctor ASAP to rule out any other more serious condition.
 

I saw my friend/patient a few days later at the gym. She said that she did read more about stitches and it fit her son’s complaints to a tee. When she discussed it with her husband and her son’s coach they both laughed and said that they remembered getting them when they were younger.