A Stitch in Time

     While not a 'true' injury, a side stitch can be one of the most debilitating problems an athlete can face during a race.  They can literally bring you to your knees and leave you unable to continue racing.  The good news is that in many cases they are easy to get rid.  Read on to find out how!

The Anatomy

     A 'stitch' is a spasm of the diaphragm - a large, flat muscle that separates the abdominal cavity from the thoracic or lung cavity. The diaphragm is involved in breathing. During light breathing (that which we do unconsciously, for example) it's really just the diaphragm moving up and down to expand and contract the lungs. When we start breathing harder, the rib cage and surrounding muscles also get involved. Now, because the diaphragm forms the ceiling of the abdominal cavity it also serves as an attachment for many organs. The liver, for example, hangs from the diaphragm. In fact, the liver is often the culprit in a side stitch. The liver is a large organ and the heaviest one that is suspended from the diaphragm. When we run, the vertical motion of running causes the liver to tug downwards on the diaphragm (you may have noticed that we rarely get a stitch when we swim or bike, and that's because there is little or no vertical motion involved with these two activities, therefore the liver isn't getting jerked around). Combine that with the extra effort of heavy breathing and the diaphragm will often spasm, giving you pain. A stitch will sometimes refer pain to the shoulder region. This is because the diaphragm is innervated (i.e.- get is it's nerve supply) from the Cervical Nerve Roots 3,4, and 5 and these also supply pain and sensation to the shoulder area so there can be some reflex pain to that area.

Signs and Symptoms

  • Pain which is often sharp and stabbing in nature, which affects the side of the rib cage
  • Pain usually begins with heavy breathing, but may continue even after normal breathing resumes
  • Most common on the right side but it may also affect the left side
  • When severe, a stitch will often refer pain to the shoulder or neck region
  • More common while running than with swimming or biking

What To Do About It

     So, what do you do? Well, most (but not all) stitches occur on the right side because that's where the liver typically resides. The trick to fighting off a stitch is to change your rate and pattern of breathing. When you get a RIGHT sided stitch you need to EXHALE (breath out) when your LEFT foot hits the ground. It is difficult to consciously breathe, so you will have to think about this while you're running. Once you start to breathe in this pattern, the stitch should subside. It works in the majority of runners. If the stitch is on the left, you can try the opposite but left sided stitches can be a bit more difficult to abate for some reason. If the above breathing pattern doesn't work, then try other breathing patterns such as breathing twice as often (lots of smaller breaths), or taking deeper breaths, running faster, or slower, anything you can do to change your rate of breathing is advisable. That's your best bet to get rid of them.

Now, you may have found that certain situations are more likely to trigger a stitch, in which case you should take precautions to avoid those scenarios. For example, I've had really bad stitches in races where the swim is followed by a long run uphill. I'd go from horizontal in the water to vertical and bouncing on land and then by running hard my breathing rate went sky high and I'd spend most of the bike dealing with a stitch which only got worse when the run started. In cases like that, I now know to take it a bit easier on the run to transition after the swim and breath deeply in the early part of the bike. If you find, for example, that drinking liquids before running will affect you, you should make sure that you don't drink too late in the bike leg so that there isn't any water sloshing around in your stomach during the run. Also, you may need to walk on the run while you drink because if you are swallowing too much air with each gulp of water it may contribute to the stitch.  Remember, everyone is different so you may have to find a solution which is unique to you.

Finally, a one-time stitch is usually nothing more than a bother, but if they become recurrent or chronic (i.e.- they linger long after the offending event has subsided) you should consider visiting a massage therapist who has experience with athletes and diaphragm problems.  He or she should be able to massage part of the diaphragm and show you how to stretch to help loosen it up so that it doesn't keep returning. 

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