E3 TRAINING SOLUTIONS Exercise Related Transient Abdominal Pain (Side Stitch) By Jorge Martinez USAT/USAC
What is a Side Stitch? Exercise related transient abdominal pain (ETAP) commonly known as a side stitch or side cramp, is an intense stabbing pain under the lower edge of the ribcage that occurs usually while exercising. ETAP is widely believed to be due to spasm or irritation of the diaphragm muscle. The diaphragm muscle is used during breathing; it is a dome shaped muscle that separates the chest cavity from the abdominal cavity. When we inhale, the diaphragm moves downwards; assisting in filling the lungs with air. When we exhale the diaphragm springs back upwards. This is important because a number of organs are attached to the diaphragm by ligaments. The liver is attached on the right side of the diaphragm. So when we run and exhale while landing on the right foot, the liver will pull down on the diaphragm while it is trying to spring upwards. What Causes a Side Stitch? The two causes of ETAP that have traditionally featured in the literature are diaphragmatic ischaemia (blood restriction of blood flow through diaphragm) and stress on the sub‐ diaphragmatic ligaments supporting the abdominal viscera. Still, there is no one known reason as to what causes ETAP, more so when ETAP can occur when horse riding when there is not a ‘hard’ level of exertion or when swimming when there is not a lot of ‘jolting’ movements to cause strain on diaphragm. Still, for activities like running, there is anecdotal evidence which indicates spasms of the diaphragm occur because of the movement of the internal organs as they jolt up and down while running, thus pulling down and straining the diaphragm as it moves up while exhaling. The liver, being the heaviest organ attached to the diaphragm, is thought to cause spasm or irritation to the diaphragm hence most people experience stitches on their right side, immediately below the ribs and in a greater recurrence when runners exhale when the right foot hits the ground. (Not so much when exhaling when left foot hits the ground). Another probably cause seems to be the timing of the pre‐event meal. There is evidence reported that consuming energy dense hypertonic fluids like reconstituted fruit juices and beverages high in carbohydrate and osmolality (the measure of concentration), too close just before the activity or during usually triggers ETAP, particularly in susceptible individuals. It seems the timing is more important than the quantity. How to Prevent Side Stitches? AS mentioned above, there is no one single cause for ETAP hence the suggestions below might or might not work for you. A common sense approach at figuring out what is causing your stitches would be to take the information provided and try indentifying if something like your run breathing pattern, timing of food consumption or the type is causing it. WWW.E3TS.COM
Techniques that might help prevent stitches: 1. Practice your breathing pattern – if when running you usually exhale when your right foot hits the ground then try changing this to the opposite side. 2. Time your meal – consume your pre race/long training meal 2‐3 hrs before. This will allow your body to absorb it for fuel and avoid irritation. Within the hour before the race/long training try avoiding highly concentrated drinks and try sticking to water. With a proper meal 2‐3 hrs before you’ll have enough fuel to get your going. 3. During the race/long training, try different sports drinks, try diluting it mixing it water to reduce the carbohydrate concentration or try other products like gels and water. 4. Breathing – if you usually inhale through your mouth, try learning to inhale through your nose and exhaling through you mouth. 5. Stretching may help preventing a stitch ‐ Raise your right arm straight up and lean toward the left. Hold for 30 seconds, release, and then stretch the other side. Repeat this 2‐3 times 6. Breathing exercises‐ Lie down on the floor, place a hand on your belly and breathe deeply. You are belly breathing correctly if you feel your hand rise slightly. If only your chest moves up, you are not breathing deep enough. (You can place a book on your belly to see this). Do this 15‐20 inhaling inflating the belly and holding your breath for 2‐ 3 seconds and then exhaling until your belly is completely deflated. 7. Core resistance training 8. Warm up before racing/long training. Techniques that might help getting rid of sides stitches in training or racing: 1. Switch your breathing pattern – if you are exhaling when your right foot hits the ground switch the pattern to the opposite leg or vice‐versa. 2. Breathe shallow – allow your body to get into a shallow breathing to help the abdominal muscle relax. 3. Take a deep breath in as quickly as you can, to force the diaphragm down. Hold your breath for a couple of seconds and then forcibly exhale through “pursed” lips. 4. If the above fails, slow down walk (or even stop) – slow down your pace for a few seconds/minutes (to a jog or walk), breathing shallow letting your body to relax. Once the pain fades away, resume running and pay attention to your breathing pattern. 5. If drinking highly concentrated fluids (i.e. Gatorade), stick with water instead and try something easy/fast to digest such as gels always mixed with water.
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