How to prevent a runner’s side stitch… maybe

I still remember my worst stitch. I was 12 years old. Our school class had trooped off to a local park late in the autumn term to do one of those British weather-inflicted cross-country runs that teachers think are fun, and that kids think are stupid. We were deployed like mini Marines on manoeuvres and on this day the overused paths were peppered with deep puddles and cloying mud from frequent rain; our activity was more of an obstacle course than an afternoon jog.

I quickly worked out the secret sauce for success in these activities; the technical name is called being bothered. At 12 years old most kids couldn’t be. If you were in the ‘Not Bothered Brigade’ you had two tactics for keeping for your feet dry: hug any tree holding the high ground either side of the obstacle and then jump when necessary, or carefully pick your way through brambles. The NBBs would invariably return from their exertions with chests covered in verdant moss, and with tiny red rivulets on their arms and legs. Apparently, the possibility of blood was better than the inevitability of mud.

I was looking forward to getting back to the showers early and was squelching along, feet caked in mud, minding my own business, when an invisible knife pierced my side just below the ribs. My phantom running buddy pushed the blade in further, and then twisted it. I like to think I didn’t scream, or at least yelp. I probably did. I paused for a time and recall looking back; the blood warriors were still out of sight and I was on my own. I eventually began walking again, ever more briskly, but the stitch remained. In fact it didn’t even get better until some time after the end of the run, and as is the case for many things in life I simply learned to live with it for as long as I had no choice.

The next time it happened I had a teasing warning, as though my hidden tormentor was playing with me. I tensed in anticipation, waiting, waiting, until the blade finally made its way through the side door and just sat there, inside me, like the dodgy relative who turns up on your doorstep unannounced, eats all the best cookies, and who can’t take a hint that it’s time to leave… not realising it was never even time to arrive.

Looking for a cure

A stitch is what I always called it but the name doesn’t really matter. Others might call it the runner’s stitch, side stitch, side cramp, ‘ETAP’ (exercise-related transient abdominal pain), etc. We could call it Fluffy Bunnykins and it wouldn’t make it any less annoying or painful. It can happen when I am running fast, and even when I’m running slowly and it feels like a knife or a needle, although I understand others can experience it differently, perhaps a dull ache. It was of no relief to eventually learn it had affected Olympians and marathon greats like Haile Gebrselassie and Deena Kastor.

From time to time I’d research causes and solutions. I tried all of the preventative measures, with varying levels of enthusiasm:

don’t eat too close to a run
don’t drink orange juice before a run
don’t eat too much before or during a run
don’t eat spicy food the night before or on the day of a run
don’t have too much sugary food before or during a run
build up your tolerance to sugary drinks (woo hoo!)
develop your core strength
develop your flexibility
warm up properly
become fitter
get older

All of these are good advice anyway, apart from avoiding sugary drinks bullet point. (It’s hard to do a long run with no carbohydrate.) The getting old thing is also to be avoided where possible, unless you’re as ageless as Audrey Hepburn. Audrey Hepburn has nothing to with stitches or running, at least as far as I know, but any blog post is going to seem a little classier with a light sprinkling of Audrey. She’s awesome! Just saying.

I am now older, fitter, stronger, less spicy, and after all my sugary runnning I’m also a damn sight sweeter. The stitches are coming less frequently than they used to but Fluffy Bunnykins still keeps turning up unannounced, expecting a cup of tea and wanting to eat my Chocolate HobNobs and Jammie Dodgers. (The UK has some of the best names for cookies and biscuits.)

If prevention wasn’t working, could a cure be the solution? I have tried those too:

Carrying on running while pushing my fingers into the side that hurts (Which sadist…!?)
Carrying on running and timing my breathing so I breathe out when my foot on the side of the stitch hits the ground (before, presumably, deducting my date of birth and dividing by the number I first thought of)
Slowing down my run, or walking
Stopping the run to fold myself over at the waist and breathe slowly and deeply
etc.

The only things that have worked for me are slowing or stopping.

I think I found the problem

In his book, Born to Run, Christopher McDougall notes that unlike most animals the breathing of humans is disconnected from our running pattern. Contrast this with a cheetah, whose leg motion acts like a bellows for its lungs. I.e. its lung activity is directly connected to its leg activity. A cheetah is fast, but it cannot last long. Homo sapiens, however, can take long deep breaths or short sharp breaths, mixing up the pattern as and when needed, regardless of our pace or the motion of our legs. We can’t outrun a cheetah over short distances, but we can outlast a cheetah over long ones. This flexibility in the way we breathe, which should be an asset, was also my problem. Periodically I would do it all backwards, sometimes when I was running quickly, sometimes when I was running slowly.

Yoga practitioners and freedivers will be familiar with the three part breath, which emphasizes the importance of breathing not just into the top of your chest, but also into your belly. When I was running, I was doing two things wrong:

I wasn’t breathing deeply enough into my belly, and so I was reducing the amount of oxygen taken in with each inhalation and
When I did breathe into my belly, I was squeezing in my tummy just as I was trying to fill it with air, and pushing it out when I was trying to exhale.

That second point is really important… and it makes no logical sense. I was putting my internal organs under strain by asking them to make the space inside my abdomen smaller just as I was trying to fill it, and to make the space bigger just as I was trying to empty it. The Far Side’s “Middle School for the Gifted” sprang to mind.

Somehow, over the years of being more bothered than most 12 year old kids, I had developed this totally incorrect habit. Audrey would be horrified.

Learning how to breathe

My solution for addressing my stitches, other than becoming older, wiser, more sweet, less spicy, etc. is now to focus on my breathing, and to incorporate breathing into a mental checklist that I go through every mile or so on my run:

am I relaxed?
how is my nutrition and hydration?
how is my cadence?
am I landing mid-foot?
am leaning?
am I belly breathing?
am I pushing out my belly as I breathe in /squeezing in my belly in as I breathe out?

Credit for the above image to: https://yurielkaim.com/belly-breathing/

I still catch myself breathing incorrectly but at least I’m aware, and I hope that if I keeping checking in with myself the new habit will eventually become engrained.

A final word

The latest word on stitches is that the issue is not Fluffy Bunnykins at all but rather the parietal peritoneum. (If only I had known this earlier in the article.) The connection between the parietal peritoneum, a membrane around your abdomen, is… going into too much detail. Instead I think it’s safe to say that when it comes to stitches, lots of things can bring it on and the trigger can vary from person to person because we’re all individuals.

Endurance runners know there is no one size fits all solution. In much the same way that one form of nutrition is great for one person and by hated by another, we all need to find our own path when we suffer discomfort. I’d advocate addressing whatever will bring most benefit quickly. If poor eating just prior to a run is your kryptonite, then that’s what I’d focus on first. However, if you walk around stiff as a board all day then I’d focus on your flexibility. If you’re not sure then you might need to hit a few tactics all at once.

This article says breathing is the solution. Well, it’s my solution. I think I had slowly eliminated the larger risks until I reached the point where breathing was simply the next big thing to address. Even now, as I reflect, it may not address the issue for the reasons I believe. Maybe going through that breathing check just reminds me to address poor form. Maybe the focus on breath distracts and relaxes me – a breathing, running meditation of sorts. Maybe it’s not down to breathing at all but rather because I just got even older. Maybe I don’t need to understand why it works at all; right now I only care that it seems to be doing the job.

Cool books:

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