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Regular advice on running and RunCoach
A Stitch In Time - How To Prevent "Stomach" Cramps From Ruining Your Race
By Owen Anderson, Ph. D.
Posted: May 20, 2005
Runners who are prone to pains in their upper-abdominal areas (aka "stitches") usually develop the problems during the latter halves of their races, and they seldom have to endure stitch suffering during workouts, even when the sessions are prolonged and taxing. Why is this so, and what can you do to decrease your risk of developing a race-ruining stitch?
The fact that stitches prefer the late stages of competitions means that the disorders tend to occur when the respiratory system is stressed to its maximal level. In addition, since the pains appear in the upper-abdominal area, the key muscle of breathing - the diaphragm - must be involved in the often-agonizing discomfort. The diaphragm, which spreads over the top of the abdominal cavity like a dome-shaped hood, is producing its greatest-possible force near the end of a race, hoping to increase the rate at which oxygen is dragged into the lungs (and therefore enters the blood). At the same time, the diaphragm is experiencing its greatest-possible fatigue.
Those two factors - maximal force production and utmost fatigue in the diaphragm - do not explain the cramping phenomenon completely, however. In fact, the extreme forces and fatigue are permissive factors, opening a door so that stitches can occur but not producing cramps by themselves. To understand why this is so, we must first think about the natural history of cramping.
Although runners complain most loudly and most often about abdominal cramping, compared with other athletes, they are not the only individuals who suffer from the problem. Tennis players have been known to stitch up, and football players are prone to cramps, especially during spring drills. Somewhat surprisingly, equestrian competitors, camel riders, and even motorcyclists have to endure cramps, too, even though their respiratory systems do not seem to be especially stressed as they move along via hoof or wheel.
Indeed, acute demands on the respiratory system are not necessary for cramps to develop, nor do they even increase the risk of stitching, if another key factor is not present. For example, competitive skaters, cross-country skiers, and swimmers place huge demands on their respiratory systems and diaphragms - but seldom ever have stitches. The same is true for serious cyclists, some of whom keep their diaphragms humming for hours at a time without significantly enhancing their risk of stitching. What keeps skaters, skiers, swimmers, and cyclists away from stitches? Why do motorcyclists get cramps, while plain-vanilla, non-motorized cyclists do not?
One traditional view of abdominal cramping has been that it occurs when unwise individuals try to exercise strenuously too soon after consuming a significant amount of food or liquid. While this hypothesis has an intuitive appeal, it can be quickly rejected. After all, competitive cyclists are almost totally immune to stitches, even though they often imbibe rather large quantities of liquid before and during their longer competitions. Similarly, cross-country skiers have been know to drink copiously before and during their extended ski events, and yet such athletes remain inoculated against cramps. Motorcyclists develop stitches, even when their stomachs are empty and even though they are not really exercising. May we have the next theory, please?
A much-better explanation runs as follows: When we run (or ride a camel across the Sahara), the organs inside our abdominal cavity, relatively unanchored, bounce up and down like marionettes on strings (the "strings" are the extensions of our mesenteric system, which consists of strands of membranous connective tissue which infiltrate the viscera). In effect, our major abdominal organs, including the massive liver, the stomach, the small and large intestines, and the spleen, are hung like dirty laundry via cords connected to the dome-shaped diaphragm above. With each bounce (caused by footstrike in the cases of human runners, horses, and camels - and produced by bumpy roads and high speeds in the case of motorcyclists), the organs ascend in the abdominal cavity and then drop downward. Associated with each organ's impact-related plummet, there is a sharp tug on the diaphragm.
Of course, the diaphragm is an adaptable fellow, and it also has its own rhythm of movement. That is, the diaphragm can either be moving up when the organs crash downward, or it can be moving down, in synch with those organs. You get to choose which scenario of organ-movement is present when you run, and your choice will have an impact on whether you cramp or not.
As you can readily understand, if the diaphragm is moving downward along with the organs, the forces placed on the diaphragm will be comparatively small. On the other hand, if the diaphragm is moving upward as the organs accelerate toward the floor of the abdomino-pelvic cavity, the forces on the diaphragm will tend to be maximized. As the great Swedish exercise physiologist Finn Rost has pointed out, the tension created (when diaphragm goes north and organs head south) can force your diaphragm into a kind of spasm, creating all kinds of (stitch) pain and discomfort and reducing your chances of having a great race to nearly nil (1).
Of course, there is no organ bounce associated with swimming (unless you are swimming over a waterfall or through rough surf), and there is in fact no downward pull on the diaphragm, since swimmers' bodies are generally nearly horizontal during effort, making the risk of stitching during swimming quite small (skeletal-muscle cramps are another matter, especially in inexperienced swimmers); this is true even though diaphragm fatigue can be extraordinarily high during intense swim effort. Although cross-country skiing, skating, and cycling are all conducted with more-or-less vertical body positions and thus give the internal organs a nice chance to pull downward on the diaphragm, all three activities are gliding sports, with minimal impact forces, light bouncing, and reduced stress on the major muscle of breathing. Thus, the frequency of stitching is relatively small. Motorcycling ups the risk of cramping, even though it is a rolling sport like regular cycling, because motorcyclists ride on heavily traveled, often-bumpy roads, and motor-bikers also move along much more quickly, compared with regular bicyclists. Speed of course magnifies the impact forces transferred through the motorcyclists' bodies, raising their risk of cramping, compared to their cycling brethren (as mentioned, non-motorized cyclists tend to have a low risk of stitches; however, put a smooth-road cyclist in a mountain-bike race over rough terrain, and the risk of stitches goes up). The speed effect also helps to explain why runners are more at risk of abdominal cramping when they are running at very high speed; impact force with the ground is a direct function of velocity, and thus higher speeds produce higher stress on the diaphragm, at the same time the tent-shaped sinew is trying to work with all-out effort.
If you have ever suffered from a stitch, you are well aware that the pain associated with stitching can be intense enough to mandate a severe slow-down in running speed - and can even bring a complete halt to forward motion. You probably also know that stitches are not rare: One classic study carried out by Dr. J. D. Sinclair revealed that roughly 20 percent of well-trained runners develop stitches at some point during a cross-country season, while 33 percent of "moderately trained" harriers fall prey to the malady (2).
About two-thirds of the time, stitches appear on the right side of the abdomen, with the left side snaring the other third of the action (stitches are almost never centrally located, because the major organs of the abdominal cavity tend to be placed laterally, not in the middle of the gut). The right-side dominance for stitching should not be too surprising, since the liver, the heaviest organ in the abdominal cavity, is located on the right side of the body. Being more massive, the liver can create a greater downward force on the diaphragm, compared with the stomach or spleen, which are found on the left side. The liver is so large that there is also ample opportunity for friction to occur between the top of the liver and the bottom of the diaphragm.
While the pain of a stitch is usually felt just below the ribs on the right side, some runners actually report a "stabbing" sensation in the right (or even left in the case of a left-side stitch) shoulder. Such pain in the upper chest can sometimes convince a runner that he/she is having a heart attack. A quick way to differentiate between the two possibilities is to lie down on your back, with your hips and legs somewhat elevated, if possible (this takes the pulling stress off the diaphragm). If you have a stitch, the pain should diminish almost immediately; if you are having a heart attack, your heart won't care about your body position, and the pain will continue unabated. In the latter situation, you should of course seek medical attention immediately.
So how do you stop stitches from occurring? One key thing to remember is that stitches are a function of ground impacts and breathing. Stitches seem to occur because internal organs tumble downward while the diaphragm is in the up position. Since the diaphragm is in the up position when you are breathing out, this is another way of saying that stitch chances are maximized when footstrike and exhalation are synchronized on one side of the body. Breathe out when your right foot hits the ground, for example, and you are at risk of becoming one of the many right-side stitchers who populate the running community (since your diaphragm is up as your liver plummets toward your feet).
If breathing occurred somewhat randomly during exercise, independent of the actions of the legs, this would not be a problem, but in fact most athletes coordinate their breathing patterns with their striding. Worse yet, most runners always breathe out on the same leg, never giving the other leg an opportunity to enjoy the experience. And - it appears that the majority of runners are "right-leg breathers," exhaling only when the right lower appendage strikes paydirt (3).
As you can see, stepping and breathing are tightly linked, and the most commonly used striding-breathing pattern turns out to be 2:1. This simply means that two complete strides are taken for each breathing cycle (a breathing cycle consists of an inhalation and an exhalation). Strides are calculated only when the right or left foot hits the ground, not both. So, a 2:1 striding-breathing linkage would mean that you would most likely exhale when your right foot hits the ground and inhale the very next time your right foot struck terra firma; such a pattern would constitute two strides and one full breathing cycle (inhalation and exhalation). As you ran, this combination would be repeated over and over again, and you would exhale only when your right foot made impact with the ground.
When the intensity of your effort picks up, things do not get any better from the standpoint of the striding-breathing linkage. Most commonly, as effort level rises runners tend to shift from 2:1 directly over to 1:1, which means that once again exhalation is synchronized with the landing of a specific foot, often the right one. A common pattern, for example (with 1:1), is for a runner to breathe in "off" the left foot and breathe out "off" the right trotter - over and over again. This is 1:1 (one stride with one complete breathing cycle), and again repetitive stress hammers away, stride after stride, on one particular side of the diaphragm.
Let's review for just a moment: When you breathe out while running, your diaphragm springs upward, increasing the tension on the cords which hold the liver, stomach, intestines, and spleen like fish on a line. If you always breathe out when your right foot hits the ground, the jolting action associated with impact will quickly bounce the liver upward, but the massive organ will then fall back quickly while the diaphragm is at its peak position. That creates an immense pressure on the diaphragm, which can then go into a painful spasm, making you wonder how the runner next to you managed to slip a knife into your side as part of his strategy to overtake you as you both gallop toward the finish line.
Fortunately, this breathing-striding-stitching linkage permits the formulation of a solid rule of running, a credo which can rescue a race from imminent disaster:
When you feel a stitch beginning to strike (often stitches give small, slightly uncomfortable warning signals in advance of the tidal flood of pain which can subsequently occur), change your breathing pattern immediately so that the leg on the opposite side of the body from the impending stitch is the one that hits the ground whenever you breathe out. If the stitch is on the right side, start breathing out "off" your left leg, and vice-versa.
Implementation of this technique can frequently stop a stitch from becoming full-blown or else can relieve the intense pain of a stitch which has shown up, uninvited, in your abdominal area. Strangely enough, extremely loud grunting, uttered with each exhalation, can also be quite relieving, perhaps because it forces the diaphragm out of a tight, crampy spasm and because it puts downward pressure on the vast muscle of breathing (ref. 4, p. 391).
Of course, it is always better to prevent stitches from occurring at all, instead of merely waiting until they occur and then seeking remedial action. So, we have assembled a list of rules for keeping stitches from happening in the first place. Bear in mind that there is little scientific research to guide us in this effort; there are simply no controlled, prospective studies to lead the way. As we created this listing, we simply used logical thinking, using as a starting point the close-to-unassailable principle that abdominal cramps are caused by downward pulling on the diaphragm by internal organs, in concert with extreme effort on the part of the diaphragm and runners' perverse tendencies to rigidly coordinate their striding with their breathing.
Here are the six rules of stitch-fighting:
(1) Alternate your striding-breathing pattern when you train intensely and race. Be aware of which foot you are using for exhalations, and deliberately exhale with your other foot for significant periods of time. A reasonable strategy is to exhale on your right foot for a couple of minutes, shift over to your left pied for a few minutes, move back to your right for awhile, and so on. This does not have to be done in a rigid fashion (don't bother to use your watch to time how long you are exhaling with each foot - you already have enough to think about when you race); as long as you are changing the pattern every now and then, your risk of stitching should decline appreciably.
(2) If you are stitch-prone, tell jokes before the beginnings of your races, and get in some good, solid belly-laughs before the starting gun sounds. We are serious about this merry-making. The logic here is that many runners are tense before their races - and "hold" a good portion of this tension in their muscles of breathing. A tight diaphragm probably increases the risk of stitching, since it creates more strain and pulling in the connective-tissue cords running between the diaphragm and the suspended internal organs. Lots of laughing can relieve the tension which is the ultimate source of the problem and can specifically relax and loosen the diaphragm, which heaves and hos in response to each pronounced chortle. Incidentally, the use of humor is not antithetical to the overall focus and self-affirmations which are a normal part of the pre-race psychological process.
(3) Use techniques which decrease the tone of your diaphragm, stretch your diaphragm out, and make it less tight. In theory, the more you can make your diaphragm move downward (which it does during inhalation), the lower your risk of stitching will be, because less average pulling force will be present between your innards and your key muscle of breathing. To accomplish this, noted sports-medicine expert and running author Tim Noakes recommends the use of "belly breathing" during running, in which your abdominal area moves out dramatically with each inspiration and plunges inward with each expiration, while the chest moves less dramatically. To learn how to belly breathe properly, simply lie on your back and place every back issue of Running Research News, along with Webster's New International Dictionary (unabridged), on your tummy, and then breathe so that the books and back editions rise significantly when you breathe in and plunge downward as you exhale. Repeat this belly-out, belly-in form of breathing when you are standing (without the heavy books and back issues anterior to your abdomen, of course), and concentrate on repeating a similar abdominal action whenever you run. This is not necessarily easy; Noakes believes that it can take many runners several months to develop this optimal breathing pattern (pp. 193-195).
(4) Strengthen your abdominal muscles. If stitches are caused by organs tugging away on the diaphragm, it's not exactly clear why abdominal-muscle strengthening should be helpful, but runners with strong abdominal muscles seem to have a lower risk of developing stitches, and - anecdotally, of course - stitch-prone runners who shore up their abs seem to get into stitch troubles less often. It is possible that increased abdominal-muscle strength helps to support internal organs and thus keeps them from jostling up and down so much during running. One way to strengthen your stomach muscles would be to lie down on your back with your hips and knees flexed and the soles of your feet on the floor; you would then simply raise your head and upper chest repeatedly by about 30 degrees or more. A key with this exercise is that you should not just flop back down to the ground after each "crunch"; lower yourself gradually so that you will get a nice, controlled, eccentric activation of your abdominal muscles (the work of the abdominal muscles is decidedly eccentric during much of the gait cycle of running). As an alternative, you could also perform abdominal crunches on a Swiss ball? or some other such inflated sphere; EMG studies indicate that the abdominal muscles are most completely activated during such effort.
(5) Combining techniques 3 & 4, you could practice yoga twice a week. Yoga is relaxing and fun, and it can probably enhance whole-body flexibility and coordination for running. With its emphasis on full and proper breathing, yoga can also strengthen the diaphragm and make it more flexible, and certain yoga routines can have a dramatically positive impact on the strength of the abdominal muscles. There are many great yoga books, VHS recordings, and DVDs available to the public, but RRN is particularly fond of Rodney Yee's "Abs Yoga for Beginners." It is great for runners who have never tried yoga before, it improves breathing techniques, and it is tremendously strengthening for the abdominal sinews.
(6) If you are a runner who is stitch-prone and you tend to have stitches on your left side, try cutting back on food and water intake during the two hours or so before you run. Cyclists can usually get away with eating and drinking before their hard rides (unless they are working on a very bumpy road or trail), but eating or drinking shortly before running can increase the chances of a stitch, probably because the increased weight of a food- or liquid-laden stomach pulls downward on the left side of the diaphragm with fuller force. Of course, if you are going to be running for over an hour, you will need to consume some sports drink just before you start your exertion (5). The good news is that drinking before a fairly lengthy (greater-than-an-hour-long) effort is usually not a problem, since such long runs occur at reduced speeds which are less likely to produce stitches.
These six rules should go a long way toward reducing your risk of stitching, and the sextet can easily be incorporated into your training and racing, with modest inputs of time and effort. The stitch case is not quite closed, however, for it would be seriously remiss of us not to mention one other aspect of the stitch problem. Another type of stitch-like abdominal pain may have nothing to do with the diaphragm at all; it may result from the slapping of a rather bizarre pouch against the inner wall of the abdomen!
To understand this aspect of the stitch phenomenon, it is first necessary for you to know that in 1982 a British physician named A. M. W. Porter ran his first marathon - and developed a significant case of diarrhea during the event. That was hardly an earth-shaking development, but Porter's bubbling bowels did cause the medical man to reevaluate what was happening to his internal organs during running (prior to the emergence of the excess excrement, the healer had assumed that the stomach and intestines bounced along happily and uneventfully during the gait cycle).
After considerable pondering, Porter decided that his cecum (a pouch-like structure at the origin of the large intestine, present in all normally endowed runners and not just Porter) had probably been rubbing against the inside of his abdominal wall. Porter believed that the resulting friction produced an inflammation of the cecum, which we might call cecumitis but certainly not cecumosis, precipitating the diarrhea which forced him repeatedly to the side of the road (inflammation is oft accompanied by an increase in fluid flow) and causing stitch-like pain in the right side of his abdomen (where the cecum is located). Porter went so far as to coin a new athlo-medical term, cecal slap, to describe the knocking of the cecum against the abdominal wall during running (6).
It is not unreasonable to think that Porter might have been right - and to accept the idea that other runners might be similarly plagued during rather prolonged efforts. In effect, cecal slap could be another legitimate source of stitch-like pain. Fortunately, the way to keep cecal knocking from ruining a race is clear: You should always breathe out when your left foot hits the ground, not during a right footstrike (the same strategy you would use to avoid a right-side diaphragmatic stitch). If you breathe out when your right foot strikes the ground, your abdominal wall will move inward at the same time that your cecum, which is also on the right side of the body, is jostled, potentially maximizing friction between the two body parts. If you breathe out when your left foot hits the street, your abdominal wall will sag inward while your cecum is napping, producing considerably less irritation.
Since it may take awhile for the cecum to be rubbed enough to become inflamed and produce discomfort (clearly 180 hard slaps to the abdominal wall by the cecum are nothing to worry about, as any good 800-meter runner knows, but 16,000 hits - the number in a three-hour marathon - are something else again), it is possible that cecal-slap pain is associated primarily with marathon and ultra-marathon (and perhaps half-marathon) running. Indeed, the frequency of diaphragm-related stitching should be low during marathon efforts, since the intensity of effort is relatively moderate - at about 80 to 85 percent of VO2max (remember that stitches are most likely to occur when exercise intensity soars above 90 percent of VO2max and the diaphragm is flapping wildly up and down like a tent flap in a Manitoba windstorm). Thus, one might reasonably argue that marathon runners should always be left-footed breathers, since such a respiratory pattern would leave the cecum becalmed and would not hike the probability of a left-side stitch calamity.
Just to make things slightly more complicated, the venerable Noakes argues that any part of the upper colon can actually be abraded by the bottom of the diaphragm or the abdominal wall, potentially producing an upset of the large intestine and stitch-like pain (ref. 4, p. 391). Fortunately, as long as such discomfort is not located dead-center in your abdomen, you can probably minimize any painful colon-related problems which develop during prolonged running by shifting your exhalations to a different foot (by law, this must be the foot on the other side of the body from the source of the pain). If you are a marathon runner dedicated to left-foot breathing for the major portion of your race, you could shift over to right-foot breathing every now and then (for about a mile at a time). The basic idea here is that such a pattern would protect the cecum but would also better equalize bruising rates between the right and left sides of the colon, downgrading the likelihood of developing a huge irritation on one side of the body.
Before we finally draw this article to a close, we should mention that you should be very serious about your stitch precautions if you are running a race on very hard, uneven ground, which will augment the jolting forces experienced by your internal organs. Stitches also occur more often on cold days, compared with balmy conditions, so practice stitch prevention more fervently when the temperature dips below 45 degrees or so. Note, too, that stitches are more likely to show up after you have run very fast downhill. This may be because your internal organs accelerate downward within your body to a greater extent when you are running downhill, compared with flat-ground running, or because downslope running tends to push your internal organs forward into contact with your abdominal wall. It would appear to be prudent to relax your breathing as you careen down hills and to exhale "off" your left foot to the greatest extent possible (since the right-side liver, the heaviest organ in the abdomen, will be the least-well-restrained collection of tissues during your downward assaults).
The causation of stitching is usually multi-factorial, so we can't end this article with a brief one-liner. However, if you develop a preference for left-foot breathing, if you convert your diaphragm into a pliable flap of rubber, and if you move your stomach in and out, balloon-like, when you run, your chances of suffering a stitch will be slim. Similarly, if you strengthen your abdominal muscles, eat and drink reasonably before your races, warm up thoroughly and properly in advance of competitions, and become a bit of a 10-K humorist, abdominal pains will become something rather strange which other runners experience; you can empathize with them after the race while discussing your PR. Don't forget that if a stitch does strike, you can usually instantly relieve the pain by lying down quickly and elevating your hips and legs (this works best, of course, during a non-crowded marathon, when you can afford to lose a few seconds and there is little risk that someone will trample you; don't try the technique when you are in the lead in a hotly contested, 1500-meter track competition). Once the pain subsides, jump up, begin breathing "off" a different foot, and you will keep the stitch from ruining your day. ?
(1) "Stitch" (Finn was a stickler for being as brief as possible), New Zealand Medical Journal, Vol. 99, p. 469, 1986
(2) "Stitch: The Side Pain of Athletes," New Zealand Medical Journal, Vol. 50, pp. 607-612, 1951
(3) "Running and Breathing in Mammals," Science, Vol. 219, pp. 251-256, 1983
(4) Noakes, T. (1991). The Lore of Running. Champaign: Leisure Press.
(5) "Sports-Drink Update: Beginning with Bolus Better than Slurping Small Samples," Running Research News, Vol. 7-4, p. 1, 1991
(6) "Marathon Running and the Caecal Slap Syndrome," British Journal of Sports Medicine, Vol. 16, p. 178, 1982
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