Essential Sports Nutrition


How to avoid a painful side-stitch

Over the past few weeks, I've had several athletes reach out regarding painful side-stitches while running and if they are nutrition related. Well, the answer is yes and no. I thought it would be helpful to go into the details behind the dreaded side-stitch and how to minimize the chances of one occurring while you are exercising (primarily running). 

What is a side-stitch? 
Also known as ETAP (Exercise-related transient abdominal pain), a side-stitch is a localized pain, typically sharp or stabbing, that occurs in any region of the abdomen but typically on the right quadrant of the abdomen. Most athletes experience side-stitches during running and the intense pain typically resides when at rest. Athletes of all fitness levels experience side-stitches, however, fitter (more trained) athletes may experience them less frequently. 

What causes a side-stitch? 
That's a good question! Research is unclear of the exact mechanism that causes a side-stitch, however, a few things may contribute to its occurrence: 
  • Diaphragm ischemia (decrease oxygen supply to diaphragm)
  • Pressure or stress on the visceral ligaments that attach abdominal organs to the diaphragm
  • Abdominal musculature cramping
  • Irritation of the parietal peritoneum (the portion that lines the abdominal and pelvic cavities)
  • Posture 
  • Jostled organs
  • Rapid or short breathing
  • Weak core
How to quickly reduce or eliminate the pain when experiencing a side-stitch? 
  • If the stitch is not severe, it's ok to keep running. Try to pair your gait with your breathing so that you exhale when your left foot hits the ground. If exhaling when the right foot strikes, the liver is dropping and the diaphragm is rising with exhalation, which may stress the ligaments, causing pain. This may prevent the stitch from getting worse. 
  • Slow down your pace, walk or stop completely. Take the time you need to massage the stitch, take deep inhales and exhales (balloon breathing) and try slightly bending over and tightening abdominal muscles.  
  • Pursed lip breathing may reduce the pain of the stitch. 
Tips to avoid or minimize a side-stitch from occurring: 

  1. Sport nutrition - Drinking large amounts of fluids (at once or per hour) or consuming high carbohydrate content (hypertonic) drinks (or food) may stress the visceral ligaments due to increased gastric mass. Drinking in small, frequent intervals (ex. 4-5 sips every 10 minutes) and using a sport drink with a lower (iso or hypotonic) carbohydrate content may increase gastric emptying, absorb faster and reduce weight in the gut.
  2. Pre-workout nutrition - Avoid eating a high fat/fiber meal in the 3 hours before exercise as it takes longer to empty from the gut. Avoid eating quickly or eating too much food too close to your workout (ex. 20 min before).
  3. Proper breathing - Respiration plays a huge role in reducing stitch pain. Instead of shallow upper chest breathing, inhale and exhale as if you are blowing up a balloon. This is very important when you start running (ex. off the bike in a triathlon or in the first few miles of a running race) as well as in the later miles of running when you try to pick up the intensity. It's also recommended to avoid straw-based hydration systems (ex. bike) which require "sucking" in fluid which can cause excessive air swallowing.
  4. Psychological factors - Stress, nerves and anxiety may increase the risk of abdominal pain and GI issues. To reduce sympathetic activity, focus on muscle relaxation and mental skill techniques.
  5. Stay well-hydrated (but not overhydrated) - During intense or long-duration activities, blood flow to the gut and diaphragm is reduced so that blood can go to the working muscles (especially in the heat). This can cause pain in the abdomen area. It's important to have a hydration protocol that's easy to apply and implement when training (ex. wearing a hydration belt/pack).Remember, staying hydrated doesn't simply mean drinking a sport drink when you feel thirsty but taking action to prevent dehydration during workouts and also doing a great job of proper hydration in the hours and days before and after your workouts.
  6. Warm-up - Take your time when you run. Get your breathing and form controlled before you try to increase the effort.
  7. Biomechanics - Running causes intestinal jarring so it would be wise to strengthen your diaphragm and abdominal muscles to help you run more efficiently and to reduce the jostling of organs. Focus on running light and fluid and when form falls apart, don't be afraid to stop, reset the body and mind (neuromuscular control) to help you keep running with good form. If you find that you experience side-stitches in the later miles of training/racing, this could be a result of fatigue and form falling apart (requiring more effort and heavier breathing to move yourself forward).
If you experience abdominal pain at rest, consult with your doctor as there may be an underlying issue going on that needs immediate attention.