Why do I get stitches?

Side stitches have indeed been one of the more nagging and misunderstood pains in sport. In
fact, it was once believed that stitches were the result of the gods of sloth, such as Aergia
(Greek), Murcia (Roman) and Fegor the Overlord of Sloth (PlayStation Trillion: God of
Destruction), attempting to rip out your intestines from the inside as punishment for running,
swimming, etc. Strangely, this theory had more veracity than many other common explanations
for stitches.
First, lets look at what stitches are. After all, stitches are a bit like a one-night stand with an
attractive idiot while tipsy most of us have had one, we just didnt understand what it was at
the time.
Stitches are not cramps, and theyre not a diaphragm disorder, either. These were ruled out by
a study in 1999 (Morton and Callister) that proved that during a stitch there is none of the
intense electrophysiological activity that characterises a cramp, nor is there a change in lung
performance before and during a stitch.
Many athletes get their stitch low in the tummy, others right up under the ribs, while some even
get it in the shoulder, but they all originate from the same place the peritoneum. This is a
two-layered membrane that separates the abdominal muscles from your guts. Theres the
visceral peritoneum and the parietal peritoneum, which is the layer closest to the muscles. In
between these layers theres lubricating fluid, but sometimes the lube isnt enough to stop
irritation. In effect, you get a dry friction which result in the irritation we know and hate, the
stitch.
The lube can run dry due to the reduction of blood flow to the abdomen or from increased
movement of the diaphragm from exercise, or there could be friction from an organ such as the
stomach being distended after a meal. That all makes sense if you get stiches in your side, but
what happens if you get that sharp, knife-twisting pain in your shoulder? Well, its not that
youve eaten so much your guts have been squished up to your shoulder, its more about the
weird and obscure ways things get connected in your body, much like how Facebook will have
a hermaphrodite juggler at the Centre for Reformed Pedophiles in your People you may know
list. As it turns out, the parietal peritoneum is supplied by the phrenic nerve, which refers pain
to the shoulder tip region.

Who gets them?

Youre more likely to have a stitch if youre unfit or new to an activity, exercising very hard,
dehydrated or have a full stomach. Stitches are common among newbie runners because the
abdomen is not used to all the jostling (conversely, lack of torso movement is why stitches are
a lot less common in cycling) or because of fast, shallow breathing. This can mean that a
reasonably fit person can get a stitch when they do a new activity, because when we have a go
at something new we often take time to adapt to the breathing rhythm required or we are
distracted (by nerves or the need to coordinate our muscles), which can make our breathing
fast and shallow. The ability to breath deeper and slower helps because it puts more pressure
down through the peritoneum to stop organs jostling and creating friction. Most people find that
stitches go away as fitness increases and they have some familiarity with the activity they are
doing.
Some actions or sports are more prone to stitches than others. Heres the breakdown from a
survey of 965 Australian athletes who had a stitch in the previous year:
swimmers - 75%
runners - 69%
horse riders - 52%
aerobics class participants - 52%
basketballers - 47%
cyclists - 32%

Foods, drinks and stitches

Tennis fans might have noticed players sipping from two bottles, one with an isotonic or soft
drink, and another with water in it. They know the score on stitches.
A study in Medicine and Science in Sports and Exercise showed that drinks high in sugar
and/or salts are evil stitch-pedlars, whether you drink them before or during activity. High-

carbohydrate fluids pass slowly through the stomach, and it appears that high-carb drinks (e.g.
fruit juice, soft drinks) can cause stitches more often and at a greater severity by both
distending (bloating) the stomach and by slowing fluid absorption in the intestine.
Other foods and drinks that also take the blame are fatty foods, carbonated drinks, cold drinks,
apples, bananas and chocolate.

Is your spine stitching you up?

Even if none of the reasons for stitches above apply to you, theres a chance your posture and
spine could be causing your stitches. Since the 1940s, its been observed that people with an
excessive curvature of the upper and lower spine seemed more likely to report pain from
stitches. A study in 2001 (Morton and Aune) confirmed that the degree of kyphosis (forward
rounding of the mid- to upper back) showed a direct and overwhelming relationship with stitch
frequency. In people with scoliosis (abnormal sideways curvature of the spine), the level of
their stitch pain was related to a greater degree of spine curvature. The extent of lordosis
(inward curvature of the lumbar and cervical spine) had no bearing on stitch frequency or
severity. This study indicated that its likely spinal nerves that come from the thoracic (chest)
region to innervate the abdominal area are involved in stitches.

Avoiding stitches
If stitches are pretty common to you, then heres a checklist of steps you can take to cut your
chances of them occurring:
Make sure youre well hydrated for 24 hours leading up to an event or the hours before
heavy training. This will minimise the risk of dehydrating the parietal peritoneum
Skip solid food in the hour before activity
Avoid drinks with lots of salt or bubbles
Avoid high-carbohydrate drinks such as fruit juice and soft drinks before and during
exercise. The ideal carb level is about up 6% and certainly no more than 8% Coke is
11%, unsweetened apple juice about 12%. If you must, take small sips alternated with
water
Drink small amounts frequently before and during exercise
Warm-up a bit indoors if its very cold outside. When its cold, its less comfortable to
take deep breaths if you do a lot of shallow breathing while exercising, the diaphragm
remains in a consistently high position and never lowers enough to allow the
peritoneum to relax
Strengthen your core tighter muscles in the mid-section will allow less movement of
those internal organs
Where possible, avoid excessive torso movement when exercising
If you often have stitches, get your thoracic spine checked out by a physiotherapist or
chiropractor for abnormalities such as joint hypermobility.

If you still get a stitch

There are lots of anecdotal remedies for a stitch, none appear to be scientifically proven.
However, given what Ive explained about how stitches work, here are two methods that will at
least relieve some of the effects of the stitch (e.g. hard to breath because of pain around
diaphragm).
Method 1
Slow down and drop your intensity, bend forward 45-90 while squeezing firmly just under the
bottom rib and half way across between the side and the belly button (thumb to the rear and
fingers at the front) and breathe deeply. Slowly stand upright again. The pain will ease more
quickly if you can stop exercise to do this or when you lie down with the hips elevated.
Method 2
This is one for runners only and works on the idea of synchronising the movement of your
organs with your diaphragm via your breathing. Slow your pace and exhale as the foot on the
opposite side of the stitch strikes the ground (not every foot strike, though). When you exhale,
really push down hard with the muscles of your diaphragm. The impact combined with the
bracing of the diaphragm will help release the tension causing the stitch.