Side Stitch Solutions for Runners: Understanding, Managing, and Preventing
Picture this: you’re having a great run and you feel strong—you are almost flying. Suddenly, this sharp pain starts stabbing at your side and you feel like you can’t breathe. Sounds familiar?
If you’re a runner, you most likely have experienced this; a cramp or a stitch in your side. It’s incredibly annoying and frustrating—it can make or break your run. But knowledge is power, my friend. Knowing what to do when this pain arises can save your run.
This article aims to clarify what exactly is happening in your body when this pain shows up and what actionable tips you can try to get ride of and prevent side stitches as a runner. Let’s dive in!
Understanding Abdominal Pain in Runners
Defining the “side stitch”
Let’s start by defining this “side stitch” that can happen when we exercise; including when we run. It can also be referred to as “side cramps”.
The scientific term for the side stitch or side cramp is exercise-related transient abdominal pain (ETAP). This means that this pain is located in the abdomen area, is related to exercise, and isn’t permanent.
Side stitches will typically occur with activities that involve repetitive torso movements with a vertical or rotational component. This is exacerbated if the torso is also in an extended position (Morton & Callister, 2015).
This is exactly the position that runners are in which makes them susceptible to the dreaded side stitches! In fact, Morton & Callister (2015) report that 70% of runners will experience the side stitch within a one-year time frame.
How does it feel?
It’s important to note that side stitches will usually feel like very localized pain–not the pain that is “spreading”. That means you would typically be able to point and put a finger on the area of pain.
The sensation will either be a sharp, stabbing pain if it is severe; or a cramping, aching pain if it is less intense (Morton & Callister, 2015).
Read my article “Running with Pain: When to Push and When to Rest” if you need some guidance on whether or not you should run with pain.
Where is the pain localized?
As mentioned above, side stitches are located in the abdominal area. Although they can be anywhere in the abdomen, the most common localization is on the lateral side of the mid portion of the abdomen near the ribs.
Morton & Callister (2015) report that it is typically more common on the right than on the left in runners.
Here is a figure from their article published in Sports Medicine that illustrates the different locations of the side stitches in runners based on percentage.
Figure 1. The location of exercise-related transient abdominal pain (ETAP). From "Exercise-Related Transient Abdominal Pain (ETAP)" by Morton & Callister, 2015, Sports Medicine (Auckland, N.Z.), 45 (1), p. 28.
Who is more at risk?
Morton & Callister (2015) who have done significant work on the topic of side stitches, found that this pain typically happens in younger runners rather than older ones (more common below 40 years of age). They also stress that it can still happen in highly trained runners, but that it seems to be less frequent. Their research didn’t find that women are more affected than men.
Key Points to Remember About the Side Stitch:
Very localized pain in the abdomen area—more often on the lateral mid portion below the ribs
Happens with exercise involving repetitive movement of the torso
It is not permanent
More common in younger runners
Can still happen to highly trained runners, although less frequent
Feels sharp and stabbing when intense
Feels crampy and achy when more mild
The Possible Causes of Side Stitches in Runners
Now that we know how to recognize the side stitch, let’s discuss what might be causing it. If we know what causes it, then we are better able to treat and manage it.
This is where it gets a bit tricky. Like a lot of things in health and fitness, there is still a lot of uncertainty as to what causes this abdominal pain. Although there has been more research in recent years, there is still no definite cause for it.
Here is a list of the possible causes of side stitches that have been studied:
Ischemia of the diaphragm (restriction of blood flow to the main breathing muscle)
Stress on the ligaments that link the abdominal organs to the diaphragm visceral ligaments that attach the abdominal organs to the diaphragm
Gastrointestinal distension (stomach and intestines get full and swollen)
Cramping of the abdominal muscles
Irritation of the spinal nerves (the same nerves that link the torso and the diaphragm)
Irritation of the parietal peritoneum
The last cause is underlined because it is currently the one that is most probable and that makes the most sense with the research we have available to us.
What is the parietal peritoneum?
The peritoneum is made of fibrous tissue and has two layers.
The deeper layer is called the visceral peritoneum and it surrounds our organs. The more superficial layer–the parietal peritoneum—surrounds the walls of our abdomen, pelvis, and diaphragm which is our main breathing muscle.
These layers act as a lubricant and decrease the friction between the different organs.
Why does this layer of tissue cause pain?
When this layer of fibrous tissue–the parietal peritoneum–gets irritated, it becomes more sensitive to movement. It can then cause some very well-localized sharp pain, i.e. the runner’s side stitch (Eichner, 2006).
The parietal peritoneum can get irritated by stomach distension, also known as a full or swollen stomach. The nerves that give the parietal peritoneum sensation are the same ones that give the sensation to the abdomen walls. Therefore, we might feel the pain in the abdomen when this layer of tissue is irritated. Are you still with me?
There have also been associations made with the thoracic spine (vertebras in the torso area) and the abdominal pain we might feel. Morton & Aune (2004) recruited runners who sometimes experienced side stitches. Once the pain had gone away, they were able to reproduce the side stitch pain in 47% of runners by touching specific vertebrae in the thoracic area (T8-T12).
The nerves that give the sensation to that part of the spine are the same ones as the parietal peritoneum and the diaphragm, so they all link together nicely! This just reinforces the point that the spine also plays are role in the side stitch in runners.
Management Strategies
It’s nice to know what the side stitch is and what causes it, but what can we do when we are enduring this pain?
Disclaimer: I have to mention that there is very little high-quality research on the management of the side stitches in runners. The following solutions are mostly based on case studies and anecdotes.
Once you get the side stitch, I would recommend slowing down your pace. After you have done so, here are some actionable tips you can try when you get a side stitch on a run:
Try pushing on the affected area
Locate the pain that you are feeling and apply gentle pressure on the area. This shouldn’t make the pain worse. If it does, you are pushing too hard.
2. Try to modify your breath
You can start by taking deeper breaths. Inhale deeply through your nose and exhale deeply through your mouth. Try to focus on “belly breathing’’, don’t keep all the breathing up into the shoulders and upper torso.
Dr Eichner, an internist and researcher affiliated with the University of Oklahoma Health Sciences Center, also suggests modifying the footstrike-to-breathing cadence. For example, ff the side stitch is on the left, you would exhale when your right foot hits the pavement (Eichner, 2006).
3. Try to stretch the affected area
You could try to stretch the side that has the side stitch by lifting your arm on the same side up in the air (it might look silly, but we’re in pain here!). You can also, pause for a little while and stretch. If the stitch is on the left, for example, you could lift your left arm overhead and side bend to the right. Take deep breaths, breathing into your left side. Start again slowly and see if that makes a difference.
4. Try to bend forward
Some runners may find relief by bending forward when they get a side stitch, although the results of this technique are not always consistent across studies (Morton & Callister, 2015).
According to a survey conducted by Morton & Callister (2000) on 600 side stitch sufferers, 18% said the bending forward technique helped to relieve the pain.
5. If all else fails, stop running
If you have tried all these tricks, and nothing is helping, stop running. You can keep walking and try the above tricks. The pain should resolve quickly. Try again, starting slow, and see if you can continue without pain.
To summarize the treatment options for side stitches in runners:
Push on the affected area
Modify your breathing (deeper breaths)
Stretch the area
Bend forward
Stop if all else fails (try the above techniques and start again slowly)
Preventative Measures for Side Stitch in Runners
Is there anything we can do to prevent this annoying pain from happening in the first place?
Again, just like the treatment options, there is a lack of research when it comes to preventative measures. These are mostly tips and tricks, but there is no gold standard yet.
Here are some actionable tips that can potentially help reduce the likelihood of getting a side stitch (Morton & Callister, 2015):
Avoid having large amounts of food at least 2 hours before your run
This ties into the irritation of the parietal peritoneum that we talked about earlier. We don’t want a full and bloated stomach to avoid putting extra pressure on this layer of tissue which could bring on the abdominal pain.
2. Avoid hypertonic drinks (fizzy drinks)
These types of drinks slow down the emptying of the stomach and also increase the volume of substances in the stomach. Once again this can contribute to irritating the parietal peritoneum and lead to a side stitch.
3. Hydrate in a different way
Hydration is super important before, during, and after your run. To avoid side stitches, it is suggested to take smaller sips and more frequent ones while you are out on your run.
4. Improve posture of the thoracic spine
Earlier in this article we talked about the link between the thoracic spine and the abdomen which are innervated by the same nerves. If there is a lack of mobility or even too much mobility in an area of the spine, this could trigger to some pain in the abdomen.
This is when seeing a physiotherapist to get a proper assessment of your spine and a targeted intervention could be useful.
5. Improve core strength
There might be a link between poor functional core stability and getting side stitches. This doesn’t mean you need to start doing 100 sit-ups every day.
However, it is a good idea to keep up with your strength training routine as a runner. Even if you are not doing specific core exercises, your core will still get some engagement in strength training exercises such as squats and deadlifts, for example.
6. Wear a supportive belt
Lastly, wearing a supportive belt has been suggested to help with side stitches. In my opinion, this preventative method should be a last resort.
I think it could be a temporary measure used for more severe cases. It shouldn’t replace the active methods such as improving core strength which will pay off long term.
To summarize the preventative measures for side stiches in runners:
Avoid large amounts of food at least 2 hours before a run
Take smaller and more frequent sips when hydrating
Avoid fizzy drinks before and during your run
Improve thoracic spine posture
Improve core strength
Wear a supportive belt (last resort)
Last Words on Side Stitches for Runners
You now have the knowledge to recognize side stitches in runners and a few tips and tricks to manage them if they happen to you on a future run.
Trying to incorporate preventative measures like improving core strength and taking smaller sips during your run is a good place to start in the hopes of avoiding the pain altogether.
Just remember that, although quite painful and annoying, side stitches are very common and not dangerous per se.
If you do find, however, that you have abdominal pain while you run and it keeps happening and getting worse, don’t hesitate to consult a healthcare professional to get additional guidance.
Let me know in the comments if you have ever experienced this kind of pain and what your tricks were to get rid of it.
Happy running,
April
References:
Eichner E. R. (2006). Stitch in the side: causes, workup, and solutions. Current sports medicine reports, 5(6), 289–292. https://doi.org/10.1097/01.csmr.0000306432.46908.b3
Morton, D. P., & Callister, R. (2000). Characteristics and etiology of exercise-related transient abdominal pain. Medicine and science in sports and exercise, 32(2), 432–438. https://doi.org/10.1097/00005768-200002000-00026
Morton, D. P., & Aune, T. (2004). Runner's stitch and the thoracic spine. British journal of sports medicine, 38(2), 240. https://doi.org/10.1136/bjsm.2003.009308
Morton, D., & Callister, R. (2015). Exercise-related transient abdominal pain (ETAP). Sports medicine (Auckland, N.Z.), 45(1), 23–35. https://doi.org/10.1007/s40279-014-0245-z
