I think we have all witnessed the scene in which an athlete slows down tremendously during a marathon, stating they have a stitch in their side.  They are usually bent over or leaning to one side as they start to dig their fingers around and under their right rib cage.  They are trying anything in order to offer some relief to this unknown pain.  Many doctors, physiotherapists, athletic trainers and athletes alike have seen this scenario before, while others may have suffered from the mysterious “Stitch” themselves.  Moreover, statistics show that if you are physically active throughout your life, you probably have had at least one episode of a stitch before.  My Aussie friends call it a “Side Sticker”, or “Side Crampie”; the medical community calls it an Exercise Induced Transient Abdominal Pain or ETAP.  Either way, it can stop you dead in your tracks, inhibit performance in many sports and usually does not require any medical attention.  Stitches can be seen in a variety of sports like running, swimming, cycling, cross country skiing, basketball, equestrian and the performing arts.  Stitches seem to affect more men than women, can also affect the young athlete, and usually, one needs to cease exercise for a few minutes until the pain abates.  There are not many techniques available that have a direct effect on the ensuing pain.  Furthermore, while there are some known prevention skills, if we are unclear of the pain’s origin, we will be unable to have a direct effect on treatment or prevention.

What are the true physiologic origins of this side stitch?  There are so many theories, but which is correct? Are all stitches the same?  Why is a stitch always on the right side? Throughout this article, I hope to introduce you to a host of present theories from around the world, and explain which one seems to make the most sense.  Furthermore, I will explain some prevention theories and actual techniques that may reduce the severity of this benign and self-limiting injury we call a stitch.

Possible Causes

The first theory, known as the GI Theory, is related to the gut.  It has been stated numerous times that a stitch is simply lower or upper GI abdominal distension, otherwise known as gas.  The population of the medical community who adheres to this theory believes that during exercise, our body heat rises, expanding the gases in our body’s spaces.  The expanding gas during continued exercise exerts a pressure on the peritoneum.  It is believed that this increase in pressure in the abdomen gives rise to the side stitch.   Now, it is true that our body heat rises during exercise and gases do expand in heat, but this theory may not seem to hold up as the exact cause of the side stitch.  Abdominal distension can be felt anywhere around the gut, not just the right side, and upper GI issues usually correlate with other symptoms. To be clear, this does happen in the body and some athletes may have truly deep abdominal or epigastric pain.  Nothing is more important when dealing with this kind of pain than a thorough physical exam and medical history knowledge. In cases of extreme pain, remember the following facts when trying to diagnose its origin: Referred pain in the duodenum is known as the xiphoid process.  Pain in the cecum is felt four fingers below your navel, while the belly button itself draws sensations from the T10 area.  In addition, it is helpful to consider the famous McBurney’s point for referral patterns from the appendix.

The next theory is called the Diaphragm Spasm/Strain Theory.  As body heat increases with exercise, so does breathing rate or minute ventilation, as it is called in exercise physiology.  A normal breathing rate for a person at rest is about 12-15 breaths per minute, but during strenuous exercise, a person’s breathing rate can become as high as 50 breaths per minute.  Many health care practitioners believe this intense rate and depth of breathing can cause a spasm of the diaphragm muscle itself.  If the spasm continues and cannot keep up with the demands of the exercise, the diaphragm can become further ischemic, literally causing it to wrench for blood and potentially increasing the spasms.  The pain-spasm-pain cycle will begin to start.   Remember, the referred pattern from the diaphragm is the bilateral Acromion process or top of the shoulders.

Another theory is known as the Muscular Strain Theory.  The intercostal, abdominal or even serratus anterior muscles can be strained or pulled during any sport or exercise in many ways.  We know exercise causes an increase to both the depth and frequency of breathing.  Along with an increase in breathing rate, exercise challenges muscle of the thorax with many twisting and stretching positions.  These motions can overstretch the small muscle fibers in either the muscle of the abdomen or between the ribs. Similarly, pain coming from the costal fibrocartilage is more centrally based than the usual side stitch.  This pain is secondary to a history of some injury to the anterior chest, which actually shifts the way the ribs rest, causing the muscles in between to have a greater propensity to straining.

A second theory related to the ribs is the Stress Fracture Theory.  The ribs are subject to repetitive strain and are not the body’s strongest bones.  They carry the huge responsibility of protecting our vital organs, but are very thin.  Moreover, at any exercise level, the ribs can receive small accumulated stresses from breathing, over stretching muscles, or twisting motions.  This can possibly set up a platform for a rib stress fracture at a coastal angle.  Most of the ribs are located and attached to a part of the back called the thoracic spine.  Muscular imbalances in this region or any movement of dyskinesia can contribute to specific, deep spine pain that can wrap around the flank and can be thought of to be a stitch. I have no doubt this happens but I do not believe this to be the reasons for a stitch.

During exercise of any type, as stated earlier, breathing rate increases.  The Pleural Rub Theory states that the sheaths, or the pleural linings of the lungs in which they are housed, may be dry and dehydrated, causing some frictional force during normal respiration.  The sound of this rub is like the sound of packing a snowball.  Each and every breath causes pain and directly comes from the nerves of the lungs.  The pain is derived from behind the sternum and can refer pain anywhere throughout the flank, specifically, the tops of both shoulders.  A stitch is not pleurisy, a medical condition which is associated with pneumonia, causes the lining to rub, and only happens in severe dehydration.  People also mistake a stitch for Pericardial Friction Rubs or a condition called Precordial Catch Syndrome (PCT).  PCT or Tex’s twinge is a pain emanating from cartilage and bones of the ribs and sternum.  The one main difference from the traditional stitch is that this twinge is felt primarily behind the chest on the left side, and stitches are usually seen on the right.  Remember, referred pain from any liver is directed to the right sides of the throat, shoulder, upper trapezius and lower back (quadratus lumborum muscle).  The heart, on the other hand, mainly refers pain to the left side of the upper body, face and neck, as well as thoracic levels T1-4.

The reason and theory for the predominately right sided pain led me to the following theory.  This theory, the Visceral Ligament Theory, concerns stress on the visceral ligaments of the body.  During fast walking and running, exercising or playing sports, the body and its internal organs get jostled.  The actual ligaments that connect these organs to the core of our body get stressed by this downward force.  The right sided pain is directly related to the liver being the heaviest organ, meaning that the hepatic (liver) ligaments get stressed to a greater degree than other organs.  I had come to believe this theory, which I had adopted for years, was flawed, when I spoke to an Olympic swimming coach.  He questioned my present theory, stating that swimmers get stitches too, though there is less jostling in the water from the hydrostatic pressure and no downward forces stressing the visceral ligaments.   In essence, this revealed that my favored theory might not be totally correct.  At this point, I needed to dig deeper to elucidate what truly is the origin of the side stitch. Or, could it be a combination of the theories? Probably not.  I have felt it myself and it’s not gas in my gut or a pulled muscle.  I was confused and had realized that any of these scenarios can happen to anyone exercising, but the true reason was still slipping through my hands!

Finally, the last theory I uncovered was called the Liver Hypoxia Theory, an organ ischemia.  Exercise causes a huge demand for the redistribution of blood flow to the body.  Blood circulation must accommodate the working muscles, but cannot ignore other main organs.  When there is a fight for blood in the body, the working muscle usually wins.  All of this happens in central circulation.  The shunt of blood may affect other struggling organs, but a normal working system redirects blood to the working muscle and balances out the rest of the blood volume for other organs like the brain, liver and spleen without problems.  The Liver Hypoxia Theory posits that exercise exerts increased internal organ pressures and that during the fight of blood, the blood flow to the liver does not win, causing an acute organ hypoxia. A plausible mechanism for the pain is that high or changing internal pressure in the liver results in a lack of oxygen to the cells of the liver.  Could this be the true cause of the stitch?

It is obvious that many of theories circulating are completely wrong, and I must admit I am still pretty confused, as I am sure you are too.  The explanations that truly make sense are the Visceral Ligament Theory and the Liver Hypoxia Theory.  Knowing that pain does pass without any medical attention is probably the reason people never truly discovered what this was.  From my experience, I believe the Liver Hypoxia Theory to be the most correct.  We know the pain is always right sided; whether it’s the ligaments or the hypoxia, the liver is the culprit.  If the ligaments of the liver are the culprit, then why does it happen in swimming, which requires a person to be horizontal, and exerts less force on the body? That’s why my current explanation of the mysterious side stitch must be the Liver Hypoxia Theory.

Possible Treatment Methods

  1. While running, exhale when the left foot lands.
  2. Proper hydrationProper warm-up for muscles.
  3. Strengthen respiratory musculature for increased demand with (F,I,D,M)
  5. Use acupressure on the spot of pain, under the fibrocartilage. Place 5 fingers down and lateral from the xiphoid.
  6. Slow down pace.
  7. Run-on softer surfaces to minimize jarring.
  8. Use of the Trendelenberg position.

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