June 27, 2006 -- I am hoping your superior doctor skills can help me with this problem. I have been developing a side stitch on my right side for the last three weeks. Three weeks ago I did a pretty tough brick, and on the run I had a hard time catching my breath until mile two, and then I felt good. No problems that day but when I got up the next morning and tried to run I developed a side stitch pretty early on and felt terrible the rest of the day.
It has been three weeks now and I am still unable to run. Swimming and cycling don’t seem to bother it so much unless I am really pushing it. I am in the military and my doc can’t figure it out. He sent me for an ultrasound that revealed no abnormalities and the lab says my blood work is normal. I really miss those runs; can you help please? Thanks for your time
Thanks,
Doug
Doug,
The short answer: The side stitch is a common problem and, although annoying, it is benign. Preventing the side stitch can be accomplished for many with some basic adjustments to the running routine.
The long answer: Among the myriad of aches and pains that runners suffer, the side stitch may be the most common and annoying. At some point, most runners will suffer from this problem, which manifests as a sudden, intense stabbing pain just below the rib cage, frequently on the right side. Theories abound as to what causes the side stitch, but two in particular have received the most widespread acceptance: diaphragmatic ischemia and ligamentous stretch.
The diaphragm is a concave muscle that lies beneath the lungs and separates the chest and abdominal cavities. When the diaphragm contracts it flattens and causes the volume of the thoracic cavity to enlarge. A vacuum is created and results in air being drawn into the lungs for respiration.
Diaphragmatic ischemia, or a decrease in oxygen supply to the diaphragm, may arise during running when the diaphragm contracts so forcefully and the lungs inflate so dramatically that the blood supply to this muscle becomes compromised and oxygen delivery falls. Lactic acid buildup within the muscle cells may then be produced, and this causes pain.
The alternative theory currently enjoys the most support and has to do with ligaments running from the abdominal organs, specifically the liver, to the diaphragm becoming stretched during exercise. During running, the organs within the abdomen are jostled with each step and the ligaments that tether them in place may be subjected to significant stresses. Exacerbating this tension is the fact that, when running, the diaphragm contracts frequently and forcefully and this puts added strain on those ligaments. The end result is pain.
Treating a side stitch when it arises is fairly easy. Most of the time, a reduction in pace while simultaneously placing a hand over the area of pain and pushing or massaging is all that is needed. Occasionally, this is inadequate and walking or stopping completely is required. While walking, raise your arms over your head and focus on deep and easy breathing. After a brief period the stitch will resolve.
Of course, the best treatment of the side stitch is to prevent its occurrence altogether. There are several recommendations on how to accomplish this:
· Focus on the pairing of your gait and your breathing. Most runners breath every two to four steps and do so when one particular foot strikes the ground. Those who exhale when their right foot strikes tend to be most at risk of developing a side stitch. As the liver is dropping secondary to the force of the right foot hitting the ground, the diaphragm is simultaneously rising with exhalation. The result may be excess stress on the ligaments, causing more pain. By modifying your technique to exhale when the left foot strikes the ground you may be able to prevent the stitch.
· Pacing is very important. Ensure that you start slow and warm-up appropriately prior to pushing the pace.
· Side stitch is more common when running after eating. Allow two hours after eating to ensure that the stomach is empty before you run.
· Deep breathing with forceful exhalation may help.
· Ensure adequate hydration.
Hopefully a combination of these measures will help Doug return to running and avoid that nefarious pain in his side.
Train hard, train healthy.
Dr. Jeffrey Sankoff, MD, FRCP(C), is a two-time Ironman triathlete and ER physician based in Denver, Colorado. To learn more, visit Sankoff’s Web site.
If you have a question for Dr. Sankoff, please e-mail Triathlete Magazine Interactive. Please include “Dr. Sankoff” in the subject line.