You could be midway through a scenic run, nearing the finish line of a race, or just starting out on an early morning jog—and it hits you: the dreaded side stitch. The pain, which can appear on the left or right abdomen, can range from a dull cramp to a sharp stabbing sensation. Characteristics and etiology of exercise-related transient abdominal pain. Morton DP, Callister R. Medicine and science in sports and exercise, 2000, Mar.;32(2):0195-9131.
And though it may not make you feel better, you’re not alone in your discomfort. Around 70 percent of runners have experienced a stitch within the past year. Exercise-Related Transient Abdominal Pain (ETAP). Morton, D., Callister, R. Sports Medicine, 2015; 45: 23–35.
Luckily there are several strategies that you can implement mid-run to alleviate cramps, as well as steps to take before hitting the pavement to prevent them from happening at all.
Despite being extremely common, the cause of side stitches, or exercise-related transient abdominal pain (ETAP), isn't totally understood. “No one has come up with a definitive answer as to why it happens,” says Lewis Maharam, M.D., a.k.a. the “Running Doc,“ a sports medicine expert.
Though there are different theories, some experts think stitches are the result of a cramp in the diaphragm, perhaps due to ischemia (your diaphragm not getting enough blood). Exercise-related transient abdominal pain (ETAP). Morton D, Callister R. Sports medicine (Auckland, N.Z.), 2015, Jan.;45(1):1179-2035. As you run, you increase pressure on your abdominal muscles and breathe rapidly, expanding your lungs. Those two actions create a dual pressure: a push up from the abdominals, and a push down from your lungs—with your diaphragm getting pinched in the middle. That pinch can cut off the flow of blood and oxygen, causing the cramp, Maharam says. Another theory is that the stitches are the result of irritation of the parietal peritoneum, the membrane that lines the abdominal wall and helps support your organs.
And runners aren’t the only ones who get side cramps. Swimmers, basketball players, horseback riders, and cyclists also report being plagued by stitches.
Your Action Plan
Now for the good news: Side stitches typically go away the more you run. Though elite athletes aren’t immune, they definitely get them less often, says Debora Warner, running coach and founder of Mile High Run Club. Not elite-level yet? These expert-backed strategies can help prevent the pain.
Before a Run:
1. Avoid fatty and high-fiber foods.
“Food itself may add to the diaphragm’s distress,” Maharam says. A meal of less digestible, fatty foods—say, spaghetti and meatballs—could make the stomach heavier and increase that tug on the diaphragm. High-fiber foods are also associated with gastrointestinal issues, such as nausea, side cramps, or worse. Maharam also suggests spacing your meal and run several hours apart.
2. Skip fruit juice.
One study found that drinking fluids before exercise was associated with side stitches. Towards evidence based emergency medicine: Best BETs from the Manchester Royal Infirmary. BET 1: Is exercise-related transient abdominal pain (stitch) while running preventable? Pauwels N. Emergency medicine journal : EMJ, 2013, Apr.;29(11):1472-0213. Specifically, fruit juice seemed to cause them most often, while water and sports drinks had less of a negative impact. Effect of ingested fluid composition on exercise-related transient abdominal pain. Morton DP, Aragón-Vargas LF, Callister R. International journal of sport nutrition and exercise metabolism, 2004, Jul.;14(2):1526-484X. The study suggests that runners skip liquids that are high in carbohydrates and osmolality. (Osmolality is related to the concentration of a liquid. Liquids with an osmolality close to the body’s own fluids are easier for the body to absorb quickly. If you’re curious about where various sports drinks stand, one study tested several popular brands.)
3. Strengthen your core.
Another study found that strengthening your transversus abdominis muscles, which are located behind your ”six-pack” (the rectus abdominis), might reduce the incidence of stitches. The effect of transversus abdominis activation on exercise-related transient abdominal pain. Mole JL, Bird ML, Fell JW. Journal of science and medicine in sport / Sports Medicine Australia, 2013, Jul.;17(3):1878-1861. This can help minimize that parietal peritoneum irritation we mentioned earlier. The muscles run horizontally around your body to help stabilize your lower spine. You can activate them by sucking your belly button toward your spine and strengthen them through a number of abs exercises.
4. Stand tall.
Having proper posture might also prevent side cramps. One study found that individuals with kyphosis, a ”humpback” curve to the spine, were more susceptible to ETAP. Influence of posture and body type on the experience of exercise-related transient abdominal pain. Morton DP, Callister R. Journal of science and medicine in sport / Sports Medicine Australia, 2010, Dec.;13(5):1878-1861.
5. Don’t skip your warm-up.
While there aren’t studies proving that a warm-up can prevent side stitches, getting your heart rate up before a run is always a good idea. Try jumping jacks to open up your rib cage or simply run at a slower pace on the treadmill, Warner says.
During a Run:
1. Find a rhythm.
If you’re new to running, try counting your breaths and focusing on keeping them even and steady, Warner suggests. “People forget to breathe or don’t realize they’re constricting their breath,” she says. If you’re breathing erratically, you’ll be hit with a stitch in no time.
2. Exhale as your foot strikes the ground.
If you’re mid-race and don’t want to totally stop, Warner suggests slowing down and focusing on deep belly exhales as your opposite foot strikes the ground. So if the stitch is on your left, focus on breathing out as your right foot hits the ground.
3. Stop, breathe, stretch.
Take a long, deep breath and stretch your arms up to the sky, Maharam says. Next, bend at the waist toward the opposite side of the stitch with your arms extended above overhead. (If your stitch is on the right side, bend to the left.) “I call this the ‘swoosh’ stretch because you should look like a vertical Nike logo,” Maharam says.
4. Sprinkle some salt.
If you’re on a longer run, you may need to replace some of the electrolytes you’ve lost. Simply taking a salt packet and having a taste might make you feel better, Maharam says.
Maharam also has one word of caution: If the stitch travels all the way up your shoulder, especially on the left side, it could be a sign of a heart attack. Also, if you get side stitches all the time, there could be a problem with blood flow to your intestines. In either case, see a doctor. Otherwise, keep running and trust that as you get better, the frequency of your side cramps will decrease.